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Transsexuals, as a client group, are increasingly coming to the attention of mental health professionals. This paper offers a general discussion of gender dysphoria and sex-reassignment, including an examination of their psychosocial aspects. The role of psychotherapy in relation to this client group is explored, and reactions of the therapist to the transsexual are considered.
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After a review of the historical development of ideas about transsexualiam and the discussion of possible somatic and psychological causes of this condition, the results of explorations of 12 male and 6 female transsexuals who desired a hormonal and surgical approximation to the opposite sex are reported. Two of the nine patients whose chromosomes were examined were found to suffer from Klinefelter's Syndrome. From the personal history it was apparent that 8 of the 12 male transsexuals had difficulty in identifying with an absent, alcoholic or brutal father. The wish to be a member of the opposite sex could be traced in 10 of the 12 male and all 6 female transsexuals to the first five years of life. 7 of the 12 male transsexuals and 3 of the 6 female transsexuals were found to have attempted suicide or to have had suicidal tendencies in the past. In 9/12 male transsexuals and 5/6 female transsexuals the "change of sex" operation was considered to be indicated. The average age at operation was 28 for the male transsexuals and 26 for the female transsexuals. The follow-up studies were done 2 months to 3 years after operation for the male transsexuals (average 1, 7 years) and 2 to 3 3/4 years post operatively (average 2, 9 years) for the female transsexuals. 7/8 of the male transsexuals from whom we have katamneses and both female transsexuals reported that they felt subjectively better than before the operation. The present legal situation concerning the registration of change of name and sex in various countries is described.
Twelve male transsexuals were found to have acquired a successtion of gender roles from childhood to adulthood-ambivalent, homosexual, drag queen, and transsexual. Thse roles constituted different stages of their livers during which they were clarifying their psychosocial gender role as transsexuals. Their transition through these roles suggests that these individuals are a subset of the transsexual phenomenon, for many--probably most--other transsexuals do not adopt these roles prior to becoming adult transsexuals. The social interaction of these transsexuals with significant others differed from the ways in which sociological role theories view this process: the significant others in their lives (apart from their mothers) primarily influenced their role changes by withdrawing from and/or rejecting these individuals--not by inducing them to conform to their role expectations. As permanently cross-dressed transsexuals, these individuals continued to associate with the institutions of the gay world, which alone was tolerant of them and where they could draw on the emotional support of other transsexuals in this last presurgery role. At this point they had become their own reference group.
Transsexuals are concerned with being accepted in straight society, that is, "passing" successfully. Ninety-one undergraduates were shown a videotaped discussion of interracial dating by five heterosexual biological females and one cross-dressed male transsexual. Experimental subjects, who had been previously informed of the presence of the transsexual, were all able to identify her, significantly more than control subjects who had not been given this set. Ratings were obtained on eight personal attributes of the transsexual and the five biological females prior to the subjects' attempts to identify the transsexual in the group. The results of these ratings indicated that detection of the transsexual was related to perceived femininity and happiness. Based on these findings and subjects' reports of how they correctly identified the transsexual, suggestions were made for a therapy package to assist transsexuals in minimizing the probability of their detection.
Transsexualism is an extremely uncommon disorder of gender role. This article describes the backgrounds, modes of life and management of transsexuals. "The transsexual believes him(her)self to be a female (ormale) in the body of a male(female)." The name is given to a very small number of men (and an even smaller number of women) who, although they are outwardly physically male (or female), are irrevocably convinced that their entire personality and identity are those of the opposite sex. They therefore feel that they ought to have their bodies changed to agree with the intensity and conviction of their feelings. Because this condition is so uncommon (having a prevalence of about one in 20,000 of the population), very few doctors ever meet any transsexuals, particularly as most of them live in only a few areas. In this article I will be mainly discussing the male transsexual, and will mention the female transsexual briefly afterwards. Transvestites and transsexuals are sometimes confused but can usually be differentiated. Basically the difference between them is that transvestites merely dress in female attire, whereas transsexuals feel that the sex organs are objects of hatred or disgust; they therefore persistently request a sex reassignment (sex change) operation in order to rid themselves of these organs.
The case described is that of a man raised in the Vietnamese peasant countryside who clearly fits the transsexual syndrome. On physical examination he appears to be a normal male, yet he insists that he is a female. He dresses as a woman and is able to successfully "pass" in society. He relates that he felt he was a female from earliest childhood. He prefers nonhomosexual men, denies any heterosexual experience, and has an all-consuming desire for the sexual transformation operation. This paper focuses on the social aspect of transsexualism and the manner a society, particularly the Vietnamese, may handle transsexual behavior. These ways can be seen to fall into a continuum. On one end, sexual role reversal is institutionalized and transsexual-like behavior is carried on according to a prescribed cultural pattern. The Vietnamese "hermaphroditic witch" could be included in this category. In the middle of the continuum, the idiosyncratic transsexual is provided an acceptable cultural role, and he therefore should be visible when he occurs. The Vietnamese young person who cross-dresses could perhaps be in this category. On the other extreme, the transsexual role is not conceivable or, at best, is very marginal. Here, the transsexual remains hidden in the general culture and can only be detected, as the person described in this paper, by accident.
The study's goal was the examination of the hypothesis that transsexualism develops on a diminution of sexual drive which itself is a result of temporal lobe dysfunction. 28 transsexuals were examined. More than 30% of this group showed pathologic findings in EEG recordings. Most of the pathological findings were situated in the temporal region. Four transsexuals with pathologic EEG findings mentioned a brain injury in their personal history. In all but one case this injury had taken place after manifestation of transsexual behavior. There was no correlation between depressed sexual drive and pathologic electroencephalographic changes. Generally genetic male transsexuals showed a diminuation of sexual drive only by taking estradiol. This is interpreted as a hypogonadotropic hypogonadism. The electroencephalographic findings in 9 or 28 cases of transsexualism with an increase of epsilon-waves mostly in the temporal region are discussed in the context of single case studies and regarded as a reference to temporal lobe dysfunction. This dysfunction is interpreted as a biologic factor in the etiology of transsexualism.
An analysis of postoperative data obtained from 42 male-to-female transsexuals showed them to fall into three distinct categories: homosexual transsexuals, asexual transsexuals, and heterosexual transsexuals. Additonal data covering the areas of gender vs. sexual dysphoria, surgical details, background characteristics, sexuality-related behaviors, and postoperative adaptation further differentiated these groups and suggest that the categorization is theoretically meaningful and relevant to understanding the causes and course of the transsexual phenomenon. An extensive developmental theory is suggested to account for both differences and commonalities among the different subgroups of transsexuals, as well as among these and related groups, such as effeminate homosexuality and transvestism. The theory is sufficiently specific for making empirical predictions.
Body image has come to mean not only the way one perceives his body but also how one feels about these perceptions. It is an important part of one's total self-concept. As such, it can present a significant problem for many individuals. For individuals with gender identity problems, such as transsexuals, body image dissatisfaction and distortion are a fundamental aspect of their condition. It is possible to more fully understand this condition by appreciating the distinction between the reality of the transsexual's body and his preferred body image. The Body Image (BI-I) scale presented here representa an effort to quantify the transsexual's body attitude. It consists of 30 body features which the subject is asked to rate on a 5-point scale of satisfaction. This test, as part of a larger seven-test battery, was administered to 16 male and 16 female transsexuals. The data have been analyzed for comparisons between males and females, for the effects of endocrinological and surgical treatment on body attitude, and for the common denominators which characterize the transsexual's body attitude. This instrument is being used as an additional tool in evaluating the transsexual's request for sex-reassignment surgery and in following those individuals who have been accepted for treatment as they progress through the evaluation and treatment program.
The present research introduced standardized psychological measurement into the clinical assessment of the male transsexual. Thirty-one males with a presenting complaint of gender dysphoria were carefully screened as to their correspondence with current nosological conceptions of transsexualism, and administered the Derogatis Sexual Functioning Inventory (DSFI) as part of their clinical psychometric work-up. The DSFI is an omnibus self-report scale providing measurement in the primary domains of sexual information, sexual experiences, sexual drive, sexual attitudes, psychological symptoms, affects, gender role definition, and sexual fantasy. Transsexual profiles were contrasted with those of a comparison group of 57 normal heterosexual males. Results of the comparisons revealed the transsexuals to show a significant decrement in accurate sexual information, and a marked reduction in the variety of sexual experiences they have been involved in. They also revealed a reduction in drive levels; however, this was qualified by which indicator of drive was used. Significant elevations in psychological symptoms and dysphoric affect were also noted, particularly of a depressive nature. Gender role definitions were markedly polarized in the feminine direction for male transsexuals, and their fantasy endorsements revealed some of the classic transsexual themes. The ability to develop this quantified and standardized psychological profile is viewed as an important step in accurately assessing the nature of these complex individuals, and developing a more accurate understanding of their condition.
The literature concerning the relationship between transvestism and transsexualism is briefly reviewed. Some workers consider the two conditions to be on a continuum, whereas others feel that they are independent clinical entities. To clarify the relationship between the two syndromes, biographical data were collected and penile volume changes recorded in 29 subjects who identified themselves as transsexuals and 35 who identified themselves as transvestites. In comparison to the transvestite subjects, significantly more transsexuals were younger, were single, cross-dressed fully, and reported homosexual interest, a feminine gender identity, and a desire for a sex-change surgery. In comparison to the transsexual subjects, significantly more transvestites reported heterosexual interest, cross-dressed partially, and had shown fetishistic arousal. It is concluded that transvestism and transsexualism are separate clinical entities.
A pair of male monozygous twins of gynandromorphic habitus but normal male body hair and genitalia, who appear concordant for transsexualism and explosive personality disorder but discordant for schizophrenia, is presented. No evidence of specific family dynamic factors, imitative learning or folie a deux was found in the twins' history. A constitutional aetiology of their transsexualism and one twin's schizophrenia is suggested. The relationship between transsexualism and schizophrenia is briefly reviewed. No evidence can be found that the modal transsexual is suffering from a schizophrenic disorder, florid or attenuated. A more subtle relationship is possible of transsexualism occurring as a schizophrenic spectrum disorder. This twin pair appears to illustrate such a relationship.
The nature of the relationships of 29 male homosexuals, 34 male transvestites and 29 male transsexuals with their parents, during childhood, was assessed on the basis of the subjects' reports, and on their responses to two tests, namely the Childhood Family Relationship test and a Semantic Differential. If the subjects' reports are valid significantly more mothers of transvestite and transsexual subjects hoped for a girl prior to the subject's birth. During childhood there was a trend for homosexual, transvestite and transsexual subjects to report that their fathers lacked interest in them or were absent from home. There was little evidence to support the view that homosexual, transvestite or transsexual subjects had pathological relationships with their mother. Intrafamilial childhood environmental factors reported by homosexuals, transvestites and transsexuals appear to be non-specific.
The literature concerning the relationships between transsexualism and transvestism and their association with fetishism is reviewed. Sexual activity, including sexual arousal to women's clothes, is frequently reported in histories of transsexuals. Characteristics are reported of 12 male subjects who have shown sexual arousal to women's clothes and who have a sustained cross-gender identity combined with a desire for a change-of-sex operation. Diagnostic categories alternative to transsexualism for subjects who cross-dress are inadequate to classify at least some of the 12 subjects reported. Restricting the definition of transsexualism so as to exclude those who have shown fetishistic features is considered premature.
Clomiphene was administered at a daily dose of 100 mg for 5 consecutive days to two groups of male subjects. There were three uncastrated male transsexuals (Group A) and nine castrated male transsexuals (Group B). In the uncastrated subjects Clomiphene enhanced the secretion of follicle-stimulating hormone (FSH), luteinizing hormone (LH) and testosterone (T) starting from day 3 of treatment. The magnitude of the increment ranged from 150%--250% over the mean basal plasma level for LH, 113%--262% for FSH and 12%--68% for T. In contrast, Clomiphene suppressed both FSH and LH in the castrated subjects. Equal suppression of both the gonadotrophins were observed. The levels of FSH and LH in plasma on day 3 were suppressed to 66.4% and 66.2% of their respective mean basal levels. Two days after the termination of treatment, suppressions were maintained. These results suggest that Clomiphene acts as an anti-oestrogen in uncastrated male transsexuals and in castrated male transsexuals who have subphysiological levels of oestradiol it acts as a weak oestrogen.
The parental contact reported by 12 biologically male and 12 biologically female transsexuals was compared with that reported by control subjects (109 conscripts in the Swedish Army; 101 pregnant nulliparous women). Parental contact was estimated for three different periods: 1) childhood, 2) adolescence, 3) the year before investigation. Transsexual patients generally reported less satisfactory relations to both parents than same-sexed control subjects. A pattern characterized by warm and intense contact with the cross-sexed parent and poor contact with the same-sexed one was observed in about half of the male transsexuals, but not in the female ones. Our findings suggest that disturbed emotional relations to the parents may be one contributory cause in the development of transsexualism and are in accordance with the hypothesis that gender identity grows out of an interaction of biological and environmental factors.
Gender discriminating vocabulary tests administered to a consecutive series of 53 male transsexuals show different results. The Slater Selective Vocabulary Test, Cohen's factors and the Terman-Miles Attitude Interest Analysis Test (M-F) show male transsexuals to have a higher degree of feminization than normal controls. The Wechsler-Bellevue Vocabulary Test and the Wechsler M-F Test are difficult to interpret, and do not show a clear trend of feminization in transsexual males. The investigation has shown that male transsexuals have a vocabulary which differs from that of normal males in the direction of greater feminization.