Summary

An attempt was made to penetrate the nature of transsexualism by attacking the problem from several different angles.
First the literature on transvestism. and transsexualism was reviewed. Transvestism was included as many authors believe that the two conditions overlap, and many do not distinguish transsexualism. from transvestism, though transvestism. may be a component of several abnormal conditions.
Next, an analysis was made of 207 cases of transvestism/transsexualism from the literature, mostly taken from single case reports, as only a few series over 10 have been reported. This revealed: (1) that about 90 per cent of the subjects began showing signs of cross-gender behavior before the age of 15; (2) that they were apparently distributed along the normal curve of intelligence; (3) that about 37 per cent had suffered from. some form of parental deprivation in youth; (4) that in about 27 per cent of the cases the parents had dressed them in clothes of the opposite sex when they were children, or had wanted a child of the opposite sex; (5) that in about 6 per cent other members of the family had cross-dressed; (6) that between 10 and 15 per cent of the men showed some form of abnormality in their morphologic sex attributes; (7) that about 33 per cent of the EEG's were abnormal, and that epilepsy was over-represented in comparison with the general population.
Analysis was also made of 43 personally examined transsexuals, 30 men and 13 women, all over 15 years old, and none showing any signs of psychosis when they were interviewed. Data on the subjects were collected from personal interviews and clinical and laboratory examinations, from their relatives, from hospital records concerning their birth and illnesses for which they had been hospitalized, from the records of child welfare bureaus, social welfare bureaus, temperance boards, state insurance offices, and every form of psychiatric institution in the districts in which the subjects had lived. This revealed the following:
In all except three cases, the subjects became conscious of their transsexual feelings before they reached the age of 15 years.
The men first consulted a physician about their anomaly at a mean age of 24.5 years and the women at a mean age of 22.5 years.
Neither the men nor the women differed much from the general population in physical characteristics, including morphologic signs of sex. A few of the women had the wide shoulders and narrow hips of the young man, but on the whole they did not differ from the normal in any of the body dimensions measured.
Cross-dressing was not a consistent feature and was never done for sexual excitation or satisfaction. More women than men cross-dressed, both before and after puberty.
As children, 72 per cent of the transsexuals had preferred to play with members of the other sex, 74 per cent had acted like and played the games of the other sex, and 56 per cent had been embarrassed when they had to undress in front of members of their own sex.
As adults, all were disgusted by the morphologic and other signs of their sex, were convinced that they really belonged to the other sex, and wanted an operation to make their bodies took like that of the opposite sex or to be re-registered officially as belonging to the opposite sex.
Many had attacks of depression, and 16 per cent had attempted to commit suicide. About 37 per cent showed mental signs of a cerebrolesional syndrome. A probably significantly greater number of them than of the controls had needed social assistance for more than two years and they were more often sick-listed than the controls. A larger percentage of them were antisocial than the controls, but the difference was not statistically significant.
Fifty-three per cent of the men and 61 per cent of the women had had chiefly or only homosexual contacts, and 20 and 8 per cent chiefly or only heterosexual contacts; the rest claimed to have had no sexual activity at all. Ninety-three per cent of the men and all the women were, and had always been, sexually aroused mentally only by members of their own sex. About every fourth to fifth patient had only a weak sexual urge, or little interest in sex on -the whole.
The men were more often hysteroid and asthenic than the women, and also more often psychoinfantile, the last trait occuring much more often among these transsexuals than in series of other nature. Schizothymia was also over-represented among the transsexuals.
The men and women showed the reverse relationship in their scores on verbal and nonverbal tests of masculinity-femininity to that shown by normal men and women.
The transsexuals did not differ from the general population in IQ distribution or mean.
No convincing evidence was found of a disorder in steroid metabolism.
About 28 per cent had abnormal EEG's, one patient had epilepsy, and another got a grand mal seizure on photic Stimulation and may also have suffered from attacks of petit mal.
All the patients had a normal sex chromatin pattern.
All were apparently normally delivered. Their histories from childhood mention a number of nonspecific signs and symptoms that might have meant involvement of the central nervous system, but they did not allow any definite conclusions on this. In one case the transsexualism developed after a severe cerebral concussion at adult age.
The transsexuals did not show more than the usual amount of nervous disease in childhood.
The parents of the transsexuals showed no more than the average amount of mental and physical disease.
No other members of their families had shown any signs of transsexualism or any other form of sex deviation. In 4 cases there was reason to suspect a genetic background for a number of nonspecific signs of cerebral lesion.
Significantly more of them than of the controls had suffered from parental deprivation before the age of 15 and had had their homes reported to the child welfare bureaus as unsuitable for children, and probably significantly more of them had fathers who had been repeatedly reported for drunken misconduct.
Half the transsexuals deprived of their parents through death, divorce of illegitimacy suffered this loss before the age of 3, and the other half after the age of 3. The same was true of the controls, In 3 cases it was said that the parents might have wanted a child of the opposite sex, but no clear proof was forthcoming of psychologic conditioning in early childhood.
The transsexuals did not differ from controls in their parents' social standing or in parental age and they were randomly distributed by birth rank.
It was estimated that not less than I out of every 40,000 males is a transsexual and I out of every 100,000 females.
  

Conclusions

(1) Transsexualism is a separate disease entity, at least in the great majority of cases.

(2) Its three essential characteristics are (a) a conviction of belonging to the other sex, (b) abhorrence of the sex attributes given by nature, (c) and an overwhelming longing for a "change in sex". These features are specific of the anomaly, and make it easy to distinguish from other forms of sexual aberration.

(3) Transsexualism is more common than generally assumed.

(4) More attention than hitherto should be paid to the risk of transsexuals committing suicide.

(5) Sex, in the usual sense of the term, does not play a prominent part in transsexualism.

(6) The most consistent variable in the sex history of transsexuals is that they are mentally aroused only by members of their own anatomic sex.

(7) Many transsexuals have a psychoinfantile personality.

(8) More attention than hitherto should be paid to the possibility of brain damage.