As mentioned earlier, the patients' histories as they told them were checked with their parents, or other close relatives who had known them when they were young. The relatives were.asked to relate the histories in the same way as the patients had done, without any leading questions being asked. This could only be done in 19 of the cases. In all except 2 of these 19 the relatives' histories corroborated those of the patients, the exceptions being cases 2 and 38. The relatives of the remaining 24 patients could not be asked for various reasons.

The most frequently occurring -feature before puberty was a feeling of belonging to the opposite sex. It was only lacking in 3 cases, numbers 6, 11 and 15, in which the transsexualism did not start till the age of 21, 16 and 23, respectively.

The next most common feature was behaving and playing like members of the opposite sex. For the boys, this meant that they played with dolls, that they chose to be the mother when playing house, that they sewed and embroidered, that they helped their mother with the house work, and so on. It also meant that they refused to do what other boys did-that they refused, for example, to spend any time on things of mechanical nature, play ball, play Indians and cowboys, or climb trees. The figures were about the same for preference for opposite-sexed pl*_% mates younger than themselves. By this preference I do not mean that the subjects occasionally played with younger children of the opposite sex; I mean that they did so consistently. This feature is undoubtedly strongly correlated with the foregoing-which would explain the similarity in frequency.

Sixty per cent of the men and 46 per cent of the women had been embarrassed when they had to undress in front of their own sex, for instance, for the gymnastics hour at school. Many said that it seemed much more natural to change clothes in front of a person of the other sex. Other authors rarely mention this characteristic. The patients often said it was hard to say exactly what they were embarrassed about, or what troubled them most-that it was not only a question of genitals or secondary sex characteristics. I got the impression that they were embarrassed about their body as a whole. One could perhaps speak of a tendency to dysmorphophobia which had reached the level of consciousness but had not acquired any specific character. This hypothesis is supported by the fact that before puberty only 3 of the 30 men and none of the women were discomfited or disgusted at the sight of their own genitals, but after puberty they all were.

Many began to cross-dress very early, sometimes before the age of 5, but then only because it was fun or felt better that way. From the age of 10 or so on, it became more purpose, by that time most of the patients feeling that they belonged in every respect to the opposite sex, and feeling extremely uncomfortable in the clothes of their assigned sex. Before puberty, none of the men dressed in clothes of the opposite sex all the time, but 46 per cent of the women did.

Two of the men never dressed in the clothes of the opposite sex, even after puberty (cases 22 and 24), being prevented by the kind of work they did or their social position, though they felt just as strongly as the others that they belonged to the opposite sex. After puberty, all the women dressed either sporadically or consistently as men.

The women also differed from the men in that a number of them (cases 39, 40 and 42, and probably 41) often wore clothes of neutral character, not specific of either sex, before they changed over to wearing the clothes of the opposite sex. None of the men did so.

All the patients felt as though they belonged to the opposite sex at the time I interviewed them. But they did not all want to cross-dress all the time. Thus 6 men (cases 1, 2, 6, 11, 16 and 17) said that they got attacks every few weeks for no apparent reason when they felt they must dress in women's clothing; if they could not do so when the attack came on, they became overcome with anxiety; as soon as they put on women's clothes they calmed down and felt at peace with the world. Other cases of this kind have been described, for example, by Bürger-Prinz et al. (1966) but not much attention has been paid to them.

Together with the feeling of belonging to the opposite sex and disgust at their own sex characteristics, particularly their own genitals, transsexuals are often extremely envious of the sex characteristics shown by the other sex. This is particularly true of the male transsexual. The young male transsexual is stricken with envy when the girls of his age begin to show the characteristics of the female sex. He becomes overcome with a longing to get these signs of womanhood on his own body. This desire to look like the other sex anatomically generally develops in connection with puberty, judging by the present series. The transsexual woman, on the other hand, though she feels the same aversion to her own body, does not seem to be so envious of the sex characteristics of the other sex. Thus all the men in the present series said of their own accord that they envied women their bodies, but only a few women said that they envied men their bodies. Thirteen of the 30 men had tried to make themselves look feminine by shaving their pubic hair to give it a straight upper line, by plucking out their facial hair, by shaving their eyebrows, and other measures, and one-third of the men urinated in the sitting position. One patient (case 9) had tried to castrate himself, and one (case 11) had threatened to do so.

All my patients said that they wanted a "change in sex" the first time I 'interviewed them. They wanted it done both legally, by having their name and sex changed officially, and anatomically, by having their body changed so as to look like that of the other sex. Only 7, all men (cases 4, 7, 11, 16, 21, 23, 28) said that they wanted this done mainly for erotic purposes. Thus only I out of every 6 subjects wanted to be changed so that they could take the place of the other site in physical sexual relations.

The age at which the patient comes to a physician asking for a change in sex can be taken as the age at which the patient comes into such conflict with society that he or she cannot carry on by themselves. It may also be said to be the age at which the patients are most troubled by their anomaly. It is true that if they do succeed in getting some form of surgery performed, they often come back for more. But this does not seem to be because of the transsexualism. growing worse; it seems to be only a further manifestation of the transsexualism as it was before (Bürger-Prinz & Weigel, 1940).

The ages at which the patients first consulted a physician in my series were as follows:

The mean age was 24.5 years for the men and 22.5 years for the women, the difference not being significant. The corresponding ranges were 14-41 years and 13-38 years.

Delay et al (1954) pointed out that, because the anomaly seldom diminishes in strength, transsexuals are often cut off from other people, and often grow to hate their fellow-men and society as a whole. Six of the 30 men in the present series, or 20 per cent, felt that they were being persecuted, though their ideas did not reach the psychotic level (cases 4, 6, 11, 15, 21 and 25). None of the women seemed to feel persecuted.

In addition, transsexualism. sometimes leads to depressive reactions, thoughts of suicide and attempts at suicide. Before going on I shall explain what I mean by these terms.

By a depressive reaction, I mean general despondency, a feeling of hopelessness and despair, sometimes combined with loss of vitality, objectively manifested by psychomotor inhibition, and loss of faith in one's own abilities, a feeling of inferiority, and in the extreme case, the desire to die; the reaction may be of any degree. By thoughts of suicide I mean a feeling that life is so unbearable that suicide is the only way out. By attempts at suicide, I mean, like Stengel (1963), "any act of self-damage undertaken with the apparent intention of self-destruction, however half-hearted and ineffective. The patient may have been only vaguely aware of his intention, which sometimes has to be inferred from his behavior". The following are the figures for these three characteristics in the present series, in the 207 cases I assembled from the literature and in Pauly's (1965) 100 cases from the literature. The figures for my cases are based on my own observations or on information in the records of psychiatric institutions, thus not on what the patients themselves said.

Six of the men in the present series had attempted to commit suicide (cases 2, 14, 16, 23, 27 and 28) and I of the women (case 43), judging by the records from the mental hospitals and psychiatric departments to which the patients might have been admitted. Probably many more attempts had been made than the foregoing figures indicate, for they only cover the ones leading to hospitalization.

The difference between the figures for the three series may have been due to the fact that, whereas Pauly's and the present series contain only cases of distinct transsexualism, the cases I collected from the literature also contained transvestites with only mild features of transsexualism.

Parkin & Stengel (1965), analyzing the about half million population of a city, found 400 and 420 verified attempts at suicide for the years 1960 and 1961; reasoning that more attempts had been made than those revealed by their method, they concluded that the incidence amounted to about one per thousand -or 0. 1 per cent as opposed to 16 per cent in the present series. Although they did not use the same method to get their figure as was used here, the two figures indicate a large over-representation of suicidal attempts in the present series.