T R A N S S E X U A L S: fall into two groups: primary and secondary. The former are transsexuals throughout the course of their development; the latter are effeminate homosexuals and transvestites who become transsexuals under stress. In this chapter we delineate the syndrome of primary transsexualism. We present clinical examples and discuss gender identity, family history, childhood development, clinical course, and personality structure. In the following chapter we discuss secondary transsexualism.

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In a previous paper (Ovesey and Person, 1973 [Chapter 5 in this book]), we. established a theoretical framework in which we demonstrated the psycho-dynamic interrelationships between gender identity and sexual psychopathology in homosexuality, transsexualism, and transvestism.

In this chapter, we examine male transsexualism in more detail. We define transsexualism as the wish in biologically normal persons for hormonal and surgical sex reassignment. We demonstrate, first, that the transsexual wish is the nucleus of a
transsexual syndrome, and, second, that the transsexual syndrome in males is not a unitary disorder but a final common pathway for patients who otherwise differ markedly in family history, developmental history, psychodynamic patterning, personality structure, and clinical course. The differentiation of these patients is not of solely academic interest; it is of crucial importance for the psychiatrist who must evaluate applicants for sex reassignment.

 

PRIMARY TRANSSEXUALISM 1968,1970; Golosow and Weitzman, 1969; Gershman, 1970; Weitzman, Sha-
moian, and Golosow, 1970) that transsexualism, transvestism, and effeminatehomosexuality have their origin in the preoedipal period. We proposed in our initial paper (Ovesey and Person, 1973) that all three disorders stem from unresolved separation anxiety during the separation-individuation phase of in infantile development.

In point of time, we suggested that they originated along a developmental gradient: transsexualism first, transvestism and effeminate homosexuality later. The symptomatic distortions of gender and sex in the three disorders reflect different ways of handling separation anxiety at progressive levels of maturation.

Thus, as we see it, in male transsexualism, the child resorts to a reparative fantasy of symbiotic fusion with the mother to counter separation anxiety. In this way, mother and child become one and the anxiety is allayed, but the cost
is an ambiguous core gender identity (sense of maleness). We infer that this fantasy is laid down before the child is three years old (normally, core gender identity is firmly established by that age). The ambiguous core gender identity
also impedes sexual development and in most transsexuals leads to relative asexuality.
In contrast to transsexualism, separation anxiety in transvestism and effeminate homosexuality is allayed not by symbiotic fusion with the mother but by resort to transitional and part-objects. These mechanisms are not as primitive as symbiosis and do not become available to the infant until he has moved further along on the separation-individuation gradient. The mechanisms may become operant before the age of three, but their major effects come later, since there is little ambiguity about core gender identity either in the transvestite or in the effeminate homosexual; to the contrary, core gender identity in both is predominantly male. Gender role identity, however, is markedly disturbed.          2

 

The stages of maturation along a developmental gradient are not neatly compartmentalized but overlap. In consequence, under conditions of stress;

1. See Mahler (1972) for an excellent summary of the separation-individuation process. Mahler dates the
principal psychologic achievements of this process to the period from about the fourth or fifth to the
thirtieth or thirty-sixth month of age.
2. In transvestism, the female clothes represent the mother as a transitional object and hence confer
maternal protection. They are also used sexually as fetishistic defenses against oedipal anxiety. In effemi-
nate homosexuality, the boy would like to maintain the dependent tie to the mother but fears engulfment
and annihilation. In the Oedipus complex, this fear is eventually transferred to the vagina, and the
homosexual solves both his sexual and dependency problems by changing the sexual object. In his case,
therefore, the separation anxiety is allayed through the pseudo-homosexual components (Ovesey, 1969) of
the homosexual act. His partner's penis is equated with the mother's breast and is incorporated orally or
anally as a part-object.

 

Transsexual impulse may arise defensively as a regressive phenomenon in some effeminate homosexuals and transvestites. Clinically, therefore, there are three prototypic histories in patients who seek sex reassignment, and transsexuals can be classified in accordance with these prototypes. We have divided them into two groups, which we have designated primary and secondary transsexuals.

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Developmentally, the primary transsexuals progress toward a transsexual resolution of their gender and sexual problems without significant deviation either heterosexually or homosexually. Behaviorally, therefore, they are primarily transsexuals from the beginning and throughout the course of their development. In them, the transsexual impulse is insistent and progressive, and usually they cannot rest until they reach their objective. In the second group are those patients who gravitate toward transsexualism only after sustained periods of active homosexuality or transvestism. Behaviorally, there-
fore, they are primarily homosexuals or transvestites, and only secondarily do they become transsexuals. In them, the transsexual impulse may be either transient and fluctuating or insistent and progressive. In the latter case, it may
eventually become a full-blown transsexual syndrome. In summary, then, we can classify transsexualism clinically under the following headings:
  I. Primary transsexualism
  II. Secondary transsexualism
  A. Homosexual transsexualism
  B. Transvestitic transsexualism3

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In our clinical experience, the great majority of male transsexuals will fit easily into this classification. A few patients, however, will straddle two, or even all three of the categories, and in their clinical course be mixtures of transsexualism, transvestism, and homosexuality. They will have transitory episodes of each, shifting from one to the other, before they ultimately embark on the final transsexual resolution. We have concluded from a study of female transsexuals that there is no female equivalent of primary male transsexualism. In our opinion, the transsexual syndrome in women develops only in homosexuals with a masculine gender role identity. Female transsexualism, therefore, can be classified as another form of secondary (homosexual) transsexualism.

This chapter is based on a psychiatric study of twenty transsexual patients in various stages of hormonal and surgical treatment. Ten were primary and ten were secondary transsexuals. The latter broke down into five homosexual
and five transvestitic transsexuals. All the patients were volunteers referred by Dr. Harry Benjamin's office and The Erickson Educational Foundation, both, clearing houses for patients seeking sex reassignment. The patients were studied in psychiatric interviews. Five patients were seen in single interviews only; fifteen were seen approximately once a week for several weeks, then irregularly for periods ranging from a few months to as long as two years. All patients were first seen by Dr. Person, who also conducted all ongoing interviews. Selected patients in each category were seen in consultation by Dr.
Ovesey.

 

The numerical breakdown of our sample is not statistically significant. We chose to study more primary transsexuals than either homosexual or transvestitic transsexuals because we wished to establish beyond a doubt that primary transsexualism is a distinct diagnostic entity, separate from both homosexual and transvestitic transsexualism. Sulcov (1973), in a study of sixty-five consecutive applicants for sex reassignment, classified them as follows: homosexual transsexuals 52 percent; "asexual isolates" (primary transsexuals in our classification) 18 percent; transvestitic transsexuals 18 percent; unclassified 12
percent. The median age of those classified as transsexuals was the following: homosexual transsexuals twenty-two, primary transsexuals twenty-four, transvestitic transsexuals forty.

 

 Gender Identity in Transsexualism

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The presenting complaint of the transsexual, both primary and secondary, is usually a variant of the plea, "I am a female soul trapped in a male body." The patient claims that this was a lifelong conviction, although he at no time denies
the anatomic reality of his maleness. Stoller (i968a) accepts this claim and attributes the patient's conviction to a female core gender identity laid down within the first three years of life. We find ourselves in disagreement with Stoller. We question the transsexual's conviction of femaleness, as well as its life-long duration. We also question Stoller's hypothesis that transsexuals have a female core gender identity.

Whether or not the transsexual's conviction of femaleness is truly a conviction is, of course, a matter of interpretation. Clinically, he appears confused about gender identity, and his conviction seems an attempt to resolve this confusion rather than a true conviction. (In this chapter, we use the term "conviction" to express the patient's representation of his feelings, not our interpretation of them.) In our opinion, the transsexual does not succeed fully either in denying that he is male or in accepting that he is female. On this basis, we believe it would be more accurate to say that transsexuals have an
ambiguous core gender identity. The ambiguity derives from the unconscious fantasy used by transsexuals to allay separation anxiety: namely, symbiotic fusion with the mother. Our hypothesis is bolstered by the fact that the conviction has an evolutionary history; that is, it does not spring ready-made into the child's head. Furthermore, the evolutionary process is not the same in all transsexuals. Its course in primary transsexuals is very different from that in secondary transsexuals, and the ambiguity is far greater in the former than in the latter.

 

The primary transsexual in childhood has no major defense against separation anxiety other than this fantasy, which markedly inhibits masculine behavior; hence, the primary transsexual has undiluted gender discomfort that becomes progressively more severe as he grows older. Not until late adoles-cence or early adulthood, when he learns of the existence of transsexualism, does he get any relief. Only then does he resolve the ambiguity through a transsexual identity and sex reassignment. The secondary transsexuals, on the other hand, are perhaps more successful in alleviating gender discomfort.
They usually resolve the ambiguity somewhat earlier by dealing with the separation anxiety either as transvestites or as homosexuals. The defenses in these disorders tip the ambiguity toward a male core gender identity. As long as these defenses work, the patients maintain some semblance of emotional balance. However, under conditions of severe stress, when their tenuous masculinity is threatened, they may regress to transsexualism and seek a reversal of core gender identity.

 

It would be helpful here to review the autobiography of Christine Jorgensen (1967), the "ur" transsexual. Emotionally withdrawn, Jorgensen as a child was asexual but was regarded as a sissy. In our classification, he was a primary transsexual. At the termination of his army service, Jorgensen speculated on his initial confusion about gender identity: "I was underdeveloped physically and sexually. I was extremely effeminate. My emotions were either those of awoman or a homosexual. I believed my thoughts and responses were more often womanly than manly. But at that point, I was completely unaware of the many combinations of masculinity and femininity, aside from homosexuality, that exist side by side in the world" (1967, p. 43).

 

 In 1948, at the age of twenty-two, he read a newspaper article about the work of a prominent endocrinologist who had experimented with the masculinization of a chicken and the return to vigor of a castrated rooster. At first, Jorgensen considered masculinization, but he finally opted for feminization. He described himself at the time to a doctor: "I've tried for more than twenty years to conform to the traditions of society. I've tried to fit myself into a world that's divided into men and women... to live and feel like a man, but I've been a total failure at it. I've only succeeded in living the life of a near recluse, completely unable to adjust" (p. 73).

​

In The Male Hormone by de Kruif*, Jorgensen read a statement that profoundly impressed him: "Chemically, all of us are both man and woman because our bodies make both male and female hormones, and primarily it's an excess of testosterone that makes us men and an excess of female hormones that makes us women; and the chemical difference between testosterone and estradiol is merely a matter of four atoms of hydrogen and one of carbon" (1945, p. 79).

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            "For myself there was a brief time frame (1980-85) I attempted to be like a Real Man, however I by then

            had been so sexually feminized by males (me performing fellatio and getting "bred" by males) I simple had to be

            female sexually roled, there just was no desire to take the male role sexually" -me

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 He began to medicate himself with estradiol. Soon thereafter he found a sympathetic physician with whom he discussed "certain historical cases" of sex conversion reported in medical journals, presumably of pseudohermaphrodites. The quotes above reveal that Jorgensen's conclusions about his gender identity (pseudohermaphroditic, but truly female) were achieved via a perusal of the medical literature and not simply from some inner process. Jorgensen's ingenuity lay in forging his identity; the term "transsexualism" was subsequently coined by Benjamin (1953). Today, many transsexuals conclude as did
Jorgensen that there is some chemical imbalance that causes their problem, but this has become a much easier conclusion since Christine Jorgensen did the spadework for them.

 

Primary Transsexualism

Case  A. appears as a tall, quiet, shy, striking-looking blonde woman in her early twenties. In fact, she is a thirty-year-old transsexual. She has been taking hormones for two years and has been living as a woman since her orchiectomy
eight months ago.

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                             " I have always opposed the removal of my testes due fear of messing up the hormonal balance

                                        in my body, I desired that my testes be encapsulated in the folds of the labia" -me

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                                                                                 "I so much I had a vagina like her" - me

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​​​​The remaining sex conversion surgery will be scheduled when financially possible. She has a receding hairline, which she masks by wearing her hair forward. The beard is not visible but is still palpable; she must have electrolysis for another year. She feels comfortable as a woman in every social situation, except at the beach, where she is afraid her male genital will
show. She is not psychologically minded and in the interviews had difficulty remembering her early years. Nevertheless, she tried hard to cooperate, focused on trying to remember dreams and fantasies, and was very proud when she could. The relationship with the interviewer became very meaningful to her, and she has stayed in contact on a flexible basis since the termination of  her regular sessions.
Except for a two-year period between the ages of seven and nine, A. lived with his mother until they broke with each other over the orchiectomy and A.'s assumption of the female identity. The mother is now fifty-eight years old.
There is an older brother, thirty-two, who is married and the father of two sons.

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​In the two clinical examples that follow we have used the convention of referring to the patient as male
prior to assumption of the female role and as female after the assumption of the female role.

The parents were divorced when A. was two, and the father has had no contact with the boys thereafter. He died when A. was seven. A. has no memory of him.
A. was never close to her mother, though she feels she loves her. The mother is undemonstrative but will respond with affection if A. takes the initiative. She is described as strong-minded and stubborn but easily hurt and quick to tears. She worked as a saleswoman from the time she was divorced, leaving the boys with a neighbor until she came home. A. had pneumonia when he was two and was hospitalized for three weeks. As a child, he was very lonely and spent many hours by himself watching television. He was introverted and shy, not very assertive, and gave no trouble to anyone. In the early years, he relied on his brother, who was his "Lord Protector." A. has read Stoller's book (19683) and insists that her mother "in no way" resembles the mothers of Stoller's transsexual patients. (See discussion under Family History.)

 

 A.'s mother always had "beaus." Her longest romance was with D., who was something of a father-surrogate to A. The romance ended when A. was six. A few months later, the mother left the boys with relatives and went to live in another town. In her two-year absence, between A.'s seventh and ninth years, A. started dressing in women's clothes. The experience was always accompanied by a sense of warmth and well-being but was totally nonerotic.
When he was ten, his mother discovered his cross-dressing and severely be-rated him. He did not cross-dress again until several months prior to his surgery. However, he always wanted to be a girl and had fantasies of mothering a girl child. This is a common fantasy among transsexuals, first noted by Money (i968b). We interpret the fantasy as an attempt to mother oneself through identification with the child.

 

A. was not in the least effeminate as a child but was acutely aware of his difference from other boys and felt profoundly isolated. Until he was twelve he had frequent nightmares of being chased by a monster, and he wet his bed well into his teens.

He was always mildly anorexic until he began hormone therapy. At puberty and for many years thereafter, he made consistent attempts to "be a man," even though in personality he was nonassertive, overaccommodating,
and fearful of arguments, lest they become violent. He went out for football,lifted weights, and became a drag car racer. Manifestly, he was very successful in these endeavors, but inwardly they brought no relief. He used obsessive
preoccupation, first with playing football, later with mechanics, to hide his loneliness and depression, both from himself and from others. He had many friends with whom he shared activities, but he revealed himself to no one.
Nonetheless, many people used him as a confidant, respecting his judgment and discretion. He bound people to himself by endlessly doing favors—running errands, lending money, fixing appliances, and always being available.

After college, he worked for many years, productively, for an engineering firm. His sexual life consisted of infrequent masturbation, usually without any fantasy; occasionally, he fantasized about being a woman having intercourse
with an unidentified man. He never developed a romantic interest in either men or women. As his friends married, he became friends with the couples.
Often, he was the confidant of the wives and ultimately of the children, with whom he felt most at ease. He always saw the desired relationship between the sexes from a woman's point of view, but his attitudes were somewhat conventional; for example, men always had to open doors for women and light their cigarettes. He disapproved of a male friend's infidelity and identified with his wife.

A. has followed these rules of etiquette both as a man and as a woman. As for homosexuality, A. believes that one should not be judgmental, but she would find it personally abhorrent and unnatural.

 

In essence, then, with the exception of his asexuality, A. made a good behavioral adaptation as a man. He was even able to maintain platonic dating relationships and was much sought after by women. At the same time, in his inner life, he felt estranged, lonely, anxious, and depressed. Were there no such thing as sex-conversion therapy, A. believes that he would have been able to maintain such a life indefinitely, but it would have remained joyless and empty.

 

As time went on, his depression deepened. His friends became progressively more involved in their family lives, and A. felt more and more excluded. Amid mounting social pressure to get married, he was totally unable to desire or initiate sex with a woman. With the years, it became more of a burden to sustain his masculinity, and his interest in mechanics and racing cars waned. He began to surfer an increasing sense of oddness, and life seemed less and less worth living. He had heard of Christine Jorgensen some time during college and thought that her experience might apply to him. He began to read
all the literature on transsexualism, and his preoccupation with sex reassignment gradually took on obsessive proportions. He started saving his money and began treatment as previously described. Shortly thereafter, he resigned from the engineering firm, resumed cross-dressing, and began to live and work full time as a woman. Currently, A. is employed as a file clerk, a step down vocationally, but a price A. is willing to pay.

 

After adopting the woman's role, A. has experienced some remarkable changes, both in feeling and in behavior. The mild anorexia has disappeared, and A., previously a heavy smoker, has totally given up cigarettes. She reports a greater ease and sense of well-being. She particularly stresses her increased ability to be assertive. She is now able to make demands on others instead of constantly doing favors for them. She no longer lets people take advantage of her but has learned to protect herself. Her propensity for obsessive preoccupation remains, but the content has shifted to the practical realities of being a woman—accumulating money for the operation, shopping for clothes, making new girlfriends, learning how to use make-up, and so forth. A. has been asked out by men, but she is too embarrassed about her beard and penis to risk it.

She feels once these last signs of maleness are gone, she will have no difficulty finding men.

 

Case 2.

B., now twenty-nine years old, has been followed for two years. When first seen, she had been receiving hormone therapy for a year and was undergoing epilation, but she still lived, worked, and dressed as a man. One year ago she underwent sex reassignment surgery and subsequently has lived full time as a woman.
 B. comes from an unstable family background. Her mother was a "good" woman who provided essential care, but in a distant way. She and B. were never close. She knew nothing of B.'s inner life, nor did she ever show any interest in it. The father, a traveling salesman, was away a great deal. His visits home, however, were not happy occasions. He paid little attention to B. and there were frequent angry confrontations with the mother. He had a "nervous breakdown" when B. was six and has been in a mental hospital ever since.

There is a younger brother, now twenty-five, who is married and has children.​
As an infant, B. suffered from severe bouts of asthma. He was hospitalized for three weeks at nine months of age and again for four weeks at fourteen months. The condition then stabilized, and he required hospitalization only one more time, when he was four years old. According to his mother, there was a real question of his very survival during the first year and a half of his life. He was obese ever since he could remember and remained markedly overweight until the first year of hormone treatment between the ages of twenty-six and twenty-seven during which he lost 100 pounds. He was a lonely child and had no playmates except for his brother and his brother's friends. He engaged in boys' activities with them, but with a private sense of distaste. He was not considered effeminate but was perceived as "fat and nervous." He spent most
of his time alone, watching television and thinking his own thoughts.

He began to cross-dress at the age of four. He first tried one of his mother's dresses, which he would have preferred, but it was so large that he got lost in it. Snugness was important to him, so for a few years, until he grew bigger, he settled for her underpants. The feeling accompanying the cross-dressing was always one of "warmth," never erotic. He often stayed home from church on Sundays so that he could wear his mother's clothes. He remembers by the age of twelve lying in bed longing to be a girl. He prayed to be discovered by his mother or grandfather so that they would share his secret and help him with his burden. Eventually, of course, they did discover him. He told them the truth, that he preferred to be a girl, but they refused to listen and brushed him  off with the comment, "It will pass. Just don't do it any more." A misfit among
boys, he prided himself solely on his "breasts," which were unusually large because he was so fat. He had no sexual outlet other than very occasional masturbation unaccompanied by fantasies.

 

B. did well academically. In the second year of college, he read a newspaper of a famous transsexual, a female impersonator. Slowly, he began to believe that this syndrome described his plight. He dropped out of school and
confronted his mother, who again denied the problem. He became very depressed, made a serious suicide attempt, and was hospitalized. The psychiatrist was unsympathetic, thought he was psychotic, and treated him with electric shock.
Released, he tried once more to be a man. He gave up cross-dressing, got a good job as a computer operator, and spent all his spare time as a drag car racer. The effort was unsuccessful. No matter how busy he made himself, he could not suppress the wish to be a woman. One day, when racing, he became aware again of his suicidal impulses, this time the wish to drive the car off the road. Fearful that he would kill himself, he began to save money and secretly made plans for hormone therapy and sex reassignment.
One month before surgery, well epilated and big-breasted, B. began to dress full time as a woman. Almost immediately he attracted a bisexual male with whom he had a sexual affair. This was his first sexual encounter with another person. The two had intrafemoral intercourse with B. in the female position. He imagined himself to be a woman and thus did not consider the act to be truly homosexual. The ease with which he attracted a man proved to be a harbinger of the future. The change in personality since reassignment has been quite startling. The withdrawn, shy, unattractive, dowdy, acneiform young man has metamorphosized into a forceful, lively, humorous, attractive young woman.
Within two months after the operation, B. had two proposals of marriage, the first from an elderly transvestite, which she refused, the second from a six-foot, seven-inch construction worker, which she accepted. We were fortunate
in being able to interview both men. The successful suitor was a bisexual who had previously been married and was a father. He stated that he had always been behaviorally heterosexual except for a single brief homosexual relationship. He maintained that he looked upon B. as a real woman, no different in his eyes from any other. At the time of this writing, he and B. are living together and plan to marry as soon as his divorce becomes final. B. describes sex as pleasurable and claims that she is orgastic.  (Some years later, it turned out that the successful suitor was a closet transvestite, who become more
interested in B.'s night gowns than in B., and B. ultimately left him. (Footnote added, 1998.)

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Family History.

From observations of male transsexuals, Stoller (i968b) delineated a characteristic mother-son interaction within a disturbed marital setting. The crucial factor is an "excessive, blissful physical and emotional closeness between mother and infant, extended for years and uninterrupted by other siblings" (p. 169). Thus, according to Stoller: The mothers "have given
their infant sons a blissful closeness in which all wishes are granted, especially, unhappily, the wish to remain a part of mother's body" (p. 167). The mothers were generally unhappy people with underlying depression and a deep sense
of emptiness, who lived in loveless, essentially sexless marriages. The fathers were emotionally detached, passive and/or feminine, and often physically absent, particularly during the transsexual's early years.
Our series often primary transsexuals do not bear out the crucial factor, the characteristic mother-son interaction. However, we relied solely on reports from the subjects, without any primary data from the mothers. Even so, the historical accounts we obtained were so uniform that it is difficult for us to reconcile them with Stoller's findings. In no instance did we elicit a history consonant with a state of "blissful closeness" between mother and child. When several patients were pressed to comment on the infantile experience as described by Stoller, each insisted that it would have been impossible, because
nothing in the mother's personality indicated any potential for close-binding behavior, physical or emotional.

 

page 119
 

​ In all ten of our subjects, when they described their mothers, there was one key feature that never varied: the mothers dutifully provided routine care, often in the face of harsh realities, but were insensitive to the child's emotional
needs. This was stated in a variety of ways by different patients, but the meaning was always the same: "She was oblivious to my depression and loneliness."
"She was too preoccupied with her own troubles to know what was happeningwith me." "She was strong-willed and stubborn; she never listened." "She would always try to help, but so many things got left unsaid." Essentially, the
mother was responsive to the child's needs as she saw them, not as he experienced them. In our sample, therefore, mother and son were not excessively close but rather excessively distant. The fathers, however, as viewed by our subjects, were very much like those reported by Stoller.
We have already postulated that early separation anxiety is a necessary precondition in the development of transsexualism. In this connection, it is of interest to note that half of our primary transsexuals, five out of ten, gave a history of physical separation from the mother within the first four years of life. In each instance, the separation was necessitated by the child's hospitalization for illness. Separation anxiety, of course, can be produced by a variety of causes. In our series of primary transsexuals, it seemed to arise from a deficit  in the quality of empathic mothering, often in association with a real separa-
tion precipitated by the child's illness.

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Developmental History and Clinical Course. Several workers (Stoller, 19683; Money, i968b]; Green, 19683) have reported that transsexual patients showed an early displeasure in boyish pursuits, concomitantly with a preference for girls' activities and for girls as playmates. Many were mothers' helpers and derived pleasure from housekeeping. According to these workers, effeminate behavior was common, and the patients were often called sissies by their peers. Our findings for primary transsexuals are at some variance with these reports, particularly in regard to effeminacy.

 

In our series of ten primary transsexuals, nine showed no evidence of effeminacy in childhood. They were identified by their peers as boys and were never referred to as sissies. At school, they participated in rough-and-tumble behavior when required, but with an inner sense of abhorrence. As far as we can make out, they did not engage in girls' activities or play with girls any more than normal boys did. Some helped out with housework, but as a necessary chore, not because it was especially pleasurable. Only one of the ten was effeminate and dubbed a sissy in his boyhood. He avoided boyish pursuits,
preferred girls' activities, and had girls as playmates. This one transsexual, effeminate in mannerisms, was also emotionally withdrawn and asexual, both characteristic findings in primary transsexualism. We have therefore classified him as such, though actually he would fall on a continuum between primary and secondary (homosexual) transsexualism.

All ten of our primary transsexuals were socially withdrawn and spent most of their time after school by themselves at home. They read, watched television, occupied themselves with hobbies, or just sat, stewing in anxiety and depression. In effect, they were childhood loners with few age-mate companions of either sex, an observation also made by Pomeroy (1968). As children, our patients were envious of girls and fantasized being girls, but none actually believed that he was a girl. To summarize, then, in his childhood, the primary transsexual is not effeminate, but he feels either abhorrence or dis-
comfort in boyish activities. This creates a feeling of difference and estrangement from other children, both boys and girls. The result is a chronic sense of isolation, the inner experience of every primary transsexual in our series.
Stoller (19683) has described three boys, first seen between the ages of four and five, who in their characteristics resembled adult male transsexuals he had previously studied. They were extremely effeminate, cross-dressed in their mothers' clothes, wished to be girls, and insisted that when they grew up they would become women. On this basis, Stoller diagnosed them as cases of childhood transsexualism and suggested that they could become adult transsexuals. All three boys had very emotionally expressive, theatrical personalities, described by Stoller as follows: "It is interesting to note that all three of
these boys are considered to be extremely creative by their families, teachers and other observers. All have a remarkable precocity with regard to painting, dancing, costumes, designing of clothes, acting, hair-dressing, story-telling, and love of music" (i968a, p. 94).

 

Here again, Stoller's findings are at variance with ours. The differences between these three boys and our primary transsexuals are startling. Our patients were neither effeminate nor theatrical; if anything, they were at the opposite end of the personality spectrum. How are we to account for these discrepancies in findings? Why are our observations of mother-son interaction, childhood masculinity, and personality structure exactly the opposite of those reported by Stoller and other workers in this field? We believe the answer lies in their failure to distinguish sufficiently between primary and secondary
transsexuals, who have different childhood histories and hence different personalities as adults. To us, Stoller's histories sound very much like those Biebe and his associates (1962) obtained from adolescent homosexuals, including the cross-dressing. If, in fact, Stoller's three boys grow up to be transsexuals, we predict that they will first pass through a homosexual period; that is, they will be secondary (homosexual) transsexuals.

 

In our sample, as he advances through childhood, the primary transsexual becomes increasingly aware of the difference between himself and other boys.
This difference is sharply defined in adolescence, when most boys become sexually aware of girls and homosexual boys become sexually aware of other boys. The primary transsexual, however, does neither; instead, he is essentially asexual and shows little sexual interest in either sex. Most often, he has no sexual experience other than masturbation, and even the masturbation is infrequent. Seven of our ten subjects masturbated less frequently than once a month. Masturbation was usually performed in a mechanistic, dissociated way, either with no fantasy at all or with a vague heterosexual fantasy in which the patient saw himself as a woman. The fantasies were impersonal, and the partner was usually a stylized man rather than a real person. The pleasure yield was minimal, at times almost to the point of anhedonia (inability to feel please).

 

A major component of this asexuality in all of our primary transsexuals was a specific self-loathing of male physical characteristics. The loathing typically began in late adolescence and was a progressive phenomenon. It encompassed not only the genitalia but all other aspects of maleness as well, such as fat distribution, musculature, hair distribution, absence of breasts, and so forth. The penis, of course, is the most significant of all the male insignia. The willingness, or rather eagerness, to part with the penis is the "sine qua non" (an essential condition; a thing that is absolutely necessary) of primary transsexualism. Secondary transsexuals are also willing, but not quite so eager

"For myself, to have a vagina and not a penis is sine qua non" - me

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The male insignia, particularly the penis, block the credibility of womanhood; that is, they give the lie to the psychic fusion with the mother. They also represent a demand for masculine performance, a demand that cannot be met.
The self-loathing is focused on the male insignia, thereby preserving a modicum of self-esteem for the fantasized other self—that is, the "female" self. For the same reasons, the primary transsexual indignantly rejects homosexuality; were he to accept it, he would perforce acknowledge he was male.
There is a uniform history of childhood cross-dressing in our sample often primary transsexuals. All ten began to cross-dress sometime between the ages of three and ten, usually in the mother's clothes. All preferred outer garments, most often a dress, occasionally a slip, sometimes both. A few tried on undergarments but did not sustain much interest. Undergarments, of course, are more intimate apparel and, as such, more sexual in their connotation. The cross-dressing in all ten was surreptitious/secretly. Typically, in early adolescence, the practice evoked shame and was voluntarily abandoned as unmasculine, then resumed openly on a full-time basis after the transsexual resolution. In contrast, cessation of cross-dressing is infrequent in secondary transsexuals, both homosexual and transvestitic.

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In the primary transsexual, the memory attached to the first experience of cross-dressing is invariably the same: "I felt very warm, very comfortable." ..."I had company." . . . "I felt relieved." . . . "I felt wanted." This experience is very different from the transvestite's initial experience, which is often erotic and, if not, later becomes so. The primary transsexual never relates to the clothing fetishistically, nor does texture have the same intrinsic interest for him that it has for the transvestite. In our opinion, the primary transsexual's response to women's clothing reflects solely the alleviation of separation anxiety. We interpret his cross-dressing, therefore, as symbolic fulfillment of the unconscious wish for symbiotic fusion with the mother.
Primary transsexuals when first seen may be dressed as either men or women. In our sample, those who presented as men showed none of the characteristics of exaggerated femininity associated with effeminate homosexuality. They were conservative in dress and subdued in manner, the very antithesis of flamboyance or even style. They claimed to have no interest in male attire and were reluctant to call attention to themselves as men. Those who presented as women gave a much different impression. Not only did they pay more attention to dress, but mannerisms, voice, and posture were more animated. The overall effect, however, was still on the conservative side, especially in comparison with effeminate homosexual cross-dressers.

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In postadolescence, the primary transsexual often makes "one last effort" to be a man in order to resolve the confusion he feels and to overcome his sense of isolation. This effort usually involves an all-out immersion in some activity commonly regarded as distinctly masculine. For example, the patient may join the army or go out for football. Two of our patients devoted years to drag car racing. Often the patient enters into the selected activity with mono-maniacal zeal in order to crowd out all doubts about his masculinity, along with associated thoughts and feelings. When this "last effort" fails, as it inevitably does, the patient becomes even more isolated, anxious, and depressed.
Ashamed, confused, with no outlet for intimate conversation or even confession, he begins a quest for some explanation of his distress. He avidly reads the psychologic and sexual literature, searching for clues to define his real nature to himself. Eventually, he stumbles on an account of transsexualism, usually about Christine Jorgensen (1967). Finding there are others similar to him becomes a great relief and for many Christine Jorgensen's autobiography has become their "Bible." Not only do they find relief, they find a new scenario for possible resolution.

 Although there is a history of gender discomfort, the fantasies of childhood and adolescence are cast in the form of a wish, not a conviction; for example, "I would like to be a girl," not "I am a girl." The conviction, "I am a female soul," usually crystallizes out rather abruptly in late adolescence or early adulthood when the patient learns of the existence of transsexualism.
Patients commonly speak of being greatly confused as to what they are heterosexual, homosexual, transvestite—until they learn of transsexualism. This revelation, with its attendant explanation, offers relief, first of all, by giving the patient an identity. Thus, one patient, referred by the Erickson Educational Foundation, stated his reason for contacting us: "I want to be a transsexual."
Secondly, the literature on transsexualism offers a medical vehicle for a fantasy—the wish to be a woman—to be converted into a reality.  It is at this point that the wish hardens into the conviction that the patient is indeed a woman trapped in a man's body. Many physicians, upon hearing that the patient believes he is a woman, automatically assume that the patient is psychotic. However, since the patient is presented with medical evidence that the condition does exist, his subsequent belief that he is a woman does not fulfill the criteria for classification as a delusion. In point of fact, the vast majority of
transsexuals are not psychotic.

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Personality Inventory. The description that follows applies to patients prior to conversion therapy. We found very little variation in the personalities of our primary transsexuals; to know one was almost literally to know all. We have already commented extensively on their ambiguous core gender identity and their relative asexuality. Another feature was their uniformly low aptitude for psychologic insight. We found it difficult to elicit dreams, and in those few that were reported associations were meager and accompanied by considerable denial. Fantasies were more available, mostly stereotypic female fantasies lacking in both imagination and color. Except in masturbation, they were usually asexual and focused mainly on the romantic aspects of male-female relationships.

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 Depression, most often experienced as loneliness, was another characteristic feature. The depression was not guilty, self-accusatory, or angry, but was essentially an empty depression. The patients described their lives as men historically and in the present as sad, lonely, empty, and colorless. Suicidal ideation and suicide attempts were frequent. Six of the ten men admitted suicidal preoccupation, and two had made actual suicide attempts. The depression could perhaps be attributed mainly to failure in the masculine role with subsequent anxiety and loss of self-esteem. Our clinical impression, however,
is that these patients were describing an ongoing depressive core, intensified by current stress but not caused by it. In their histories, there are frequent occurrences of thumbsucking, enuresis, and eating disorders, either anorexia or overweight. We believe these childhood symptoms, as well as the depression, are related to early separation anxiety.

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There is a schizoid quality to the primary transsexual's personality. As previously described, his childhood is characterized by isolate behavior. Nonetheless, by adolescence or adulthood, some of these patients had acquired the knack for friendly but not intimate asexual relationships with both men and women. A great deal of time is spent with others, but feelings are not ordinarily alluded to. The patient is ingratiating and makes himself indispensable in a variety of ways; however, his friends are totally unaware of the transsexual problem or of his mental agony. These friendships, as experienced by the
patient, have a symbiotic coloring, but typically he withholds a full commitment, as though anticipating rejection.

As a group, we found the primary transsexuals extremely gentle and self-effacing. Assertiveness was seriously crippled, though it survived enough in the work area to allow adequate and, on occasion, even outstanding performance. Energy and creativity, if present, were expressed in solitary pursuits and hobbies, often with obsessive thoroughness. These patients were always pliant and agreeable in their relationships with others unless thwarted in their demands for sex reassignment. In these circumstances, they became stub-born, strong-willed, and intractable. Otherwise, they were generally incapable
of manifest anger.

 

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Mental life, before and after surgery, is characterized by obsessive preoccupation with gender-related items. The obsessive form remains throughout; only the content changes. Thus, in childhood, the primary transsexual is obsessed with being a girl. In adolescence, he is obsessed with "one last effort" to be a man. In adulthood, before surgery, he is obsessed with sex conversion.
His waking hours are filled with plans to get enough money for the operation and with learning how to be a woman. After surgery, he is first obsessed with the anatomical results, then centers on how to be more feminine both in appearance and in behavior.

"This I can't relate to" - me

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The endless striving for perfection in the feminine role may lead to further surgery, usually facial plastic procedures or breast augmentation. In fact, one might say that the preoccupation with making "one last effort" as a man gives way to a preoccupation with fitting into the feminine norm. It is our impression that gender ease is never fully established. However, we have not seen subjects five or ten years postconversion, so that it remains theoretically possible that obsessive preoccupation with gender eventually recedes.
In sum, then, primary transsexuals are schizoid-obsessive, socially with-drawn, asexual, unassertive, and out of touch with anger. Underlying this personality, they have a typical borderline syndrome characterized by separation anxiety, empty depression, a sense of void, oral dependency, defective self-identity, and impaired object relations with absence of trust and fear of intimacy (Kernberg, 1967; Grinker, Werble, and Drye, 1968; Masterson, 1972). In our opinion, they most closely resemble a subgroup of the borderline syndrome that Grinker calls "the adaptive, affectless, defended, 'as if persons"
(Grinker, Werble, and Drye, 1968, p. 87). Unlike other borderline patients, however, primary transsexuals are distinguished by severe impairment of both core gender identity and of gender role identity from earliest childhood.

 

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The Transsexual Syndrome in Males:
              Secondary Transsexualism

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S E C O N D A R Y - T R A N S S E X U A L I S M;  is defined as transsexualism that develops in homosexuals and transvestites regressively, under conditions of stress. Homosexual and transvestitic secondary transsexuals are distinguished from each other and both from primary transsexuals. Primary transsexuals, as we have seen, are essentially asexual and progress toward a transsexual resolution without significant deviation, whether heterosexual or homosexual. In them, the transsexual
impulse is insistent and progressive, and usually they cannot rest until they reach their objective. Secondary transsexuals are effeminate homosexuals and transvestites who gravitate toward transsexualism only after sustained periods of active
homosexuality or transvestism. In them, the transsexual impulse may be a transient symptom or may harden into a full-blown transsexual syndrome.

Although our study is based on ten applicants for sex reassignment, five homosexual transsexuals and five transvestitic transsexuals, our discussion draws on our much wider clinical experience with effeminate homosexuals and transvestites, many of whom have transsexual impulses but do not seek sex reassignment.

 

Homosexual Transsexualism

The vast majority of male homosexuals lack the propensity for a transsexual regression. The propensity exists almost entirely in cross-dressing effeminate homosexuals who comprise a very small segment of the homosexual population.

As we noted in Chapter 5, they fall into two subgroups: passive effeminate homosexuals-me and the more aggressive, though equally effeminate, drag queens. These two subgroups have similarities as well as differences in personality and psychodynamics. In the two clinical examples that follow, we will describe a typical patient in each subgroup.

Case C. is a fat, effeminate 32-year-old man who lives with his parents. He is compliant, nonassertive, and unable to mobilize much anger. Despite these inhibitions, he is engaging, affectively responsive, and easy to talk to. His adaptive competence is of a very low order. Although extremely bright and articulate, he failed to complete high school, dropping out in his senior year.
He has worked only a total of two years in his entire life. His mother has always slipped him money, while both pretend to the father that he is working. There is one sister, now twenty-five who is married. C. has been an exclusive homosexual as far back as he can remember. He now wants sex reassignment so that he can marry his current lover and live with him as his wife.

C. and his mother are bound together in a mutually interdependent relationship, each unable to let go of the other. As we would expect, he is markedly ambivalent about her. A sampling of his comments, culled from the interviews, follows: "I once loved my mother passionately, but I went through a period of hating her. She destroyed my life. . .. She was always very physical and smothered me with kisses. We used to see each other naked all the time.... She's either totally giving or totally selfish. She never ate until my sister and
I had enough, I have never been able to move away for fear of hurting her."
The mother and father have never gotten along. The father makes good money but gambles it away, so money has -always been a problem. According to C., the father was ungiving and a tyrant at home, but generous to everyone else. The mother has always manipulated the father by lying to him and, C. suspects, by withholding sex. He doubts that they have had any sex life for many years. After C. was born, the father began gradually to absent himself from the family, and by the time C. reached adolescence, the father was seldom present. C. does not know for certain whether this was volitional withdrawal or
whether he was pushed out by the mother, but the arrangement seemed perfectly acceptable to both.
We interviewed C.'s mother, who confirmed the familial history. She rationalized her lifelong intrusiveness into her son's life by predicating it on his physical frailty, a total fiction. She had always known of C.'s homosexuality and fully accepted it, but she refused to acknowledge his wish for a sex change.

We found her psychologic aptitude nonexistent. She was almost impossible to interview because of her incessant hysterical pleas that we help her boy and save him from the surgeons. As she saw it, his sole problem was his inability to work. It was clear to us that her underlying motivation was to keep C. at home with her.

 

C. was an effeminate child. He played with girls and pursued girlish interests. He cross-dressed regularly with parental approval from early childhood until the age of fifteen. The cross-dressing was theatrical and used to enhance C.'s fantasies of being a girl. It was never erotic, as in the transvestite, nor did it provide a feeling of comfort, as in the primary transsexual. His  parents thought it so amusing that they often asked him to entertain. Once, when he was seven, they took him to relatives for Easter dinner dressed as a girl.

C. began a very active and pleasurable sex life when he was twelve. He engaged in various homosexual activities with peers, older boys, and adults.
His sexual preference is passive anal intercourse, although he will reluctantly engage in other sexual transactions in order to please a partner. In such circumstances, he is capable of assuming the active role, but he does not enjoy it.
His sexual relationships have been mostly transient contacts with partners picked up while cruising. Prior to his present involvement, he had only one long-term affair. This occurred ten years ago and lasted for one year. C. was so upset when the affair ended that he became suicidal and had to be hospitalized.

After his release, he hung around with a drag crowd for about six months. Once again he cross-dressed, but only in public to be seen, never in private.
Initially, he felt secure in the group, liked the feeling of fooling people, and dreamed of "high drag." This was obviously an adaptive maneuver to compensate for the loss of his lover, but it failed because he had neither the physical attributes nor the money to be a successful drag queen. He received no narcissistic reinforcement as a woman since he lacked beauty, and the masculine homosexuals whom he was really after paid little attention to him since most of them wanted another man, not a drag queen. Thoroughly discouraged, C. gave up drag and returned to his previous existence, with its characteristic
cruising.
For a time, in search of a new lover, he was extremely promiscuous. Gradually, as the years passed, he became disenchanted with gay life. He was not meeting the right people, he was getting the wrong responses, and he was picking up repeats. He began to gain weight, and although he is only five feet, eight inches tall, he now weighs over 200 pounds. His sex life diminished markedly, and his infrequent attempts were marred by erectile failures. In the interviews, he lamented his plight: "I feel inadequate as a homosexual.

I can't do the bathroom thing any more. If someone is hypermasculine, I tremble with fear; if swish I don't like it. I have gotten too fat and I'm losing my hair."
Whenever pressure mounted, he wheedled money from his mother and traveled. Last year he went to Spain and met a presumed heterosexual with whom he lived. He engaged in face-to-face intrafemoral intercourse with this
lover and fantasized himself as a woman. For the first time in his life he began to think seriously of sex reassignment: "I've known about transsexualism since Jorgensen. I could relate to this guy in Spain better if I were female. He wants me to stay in the house and play the whole thing, be subservient." He believes he is willing to forego sexual pleasure in order to live as a woman with this man. He is still hesitant, however, because he is skeptical that the lover will, in fact, marry him. At the same time, he is loath to give up life with his mother, since she so completely caters both to his dependency needs and to his
passivity.

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Case 2. D.  is a very attractive twenty-two-year-old drag queen. He is a fashion designer on New York's Seventh Avenue, where he works dressed as a man, but he frequently hustles as a woman, presumably to make money to support his art school tuition. He belongs to the gay liberation movement and devotes considerable time to homosexual causes. Away from work, he is a member of a network of drag queens, all of whom, like D., are active hustlers. He has been taking hormones for two years in order to enhance his impersonation of a woman, but he has never before sought sex reassignment. Now, however, in the wake of an abortive love affair, he is pursuing a transsexual resolution.
D. lives with his parents, a brother one year younger, and a sister three years younger, in a lower-middle-class ethnic neighborhood. The father is a foreman in a factory. He has a reputation as a street fighter and, according to D., has always been "extraordinary violent" both in and out of the home. D. and his brother were frequently beaten, though the brother, who was more defiant, bore the brunt of it. The sister for the most part was spared. The father has not hit D. in a while and is described as mellowed, but D. is still terrified of him. He openly states that he hates his father and would like to see him dead, though he concedes that his father "adores" him.

In early childhood, before the age of four, D. had repeated bouts of broncho-pneumonia. On several occasions he required hospitalization. His mother has told him that more than once she believed it was "curtains" for him. D. describes his mother as very devoted but not overtly affectionate. She did not shower the children with kisses, but neither was she cold. D. likes his mother but is not especially close to her. The mother and both siblings know of D.'s homosexuality and seemingly accept it. They do not know, however, that he is a drag queen and a hustler. The father is totally ignorant of D.'s private life.

 

As a child, D. was fat, and he remained so until he started taking hormones two years ago. Since then he has lost forty pounds. He was always effeminate and preferred playing with girls. Although outwardly lively and gregarious, inwardly he felt lonely and spent hours by himself reading avidly. He became consciously aware of his homosexuality at the age of thirteen, when he read Krafrt-Ebing. In adolescence, he switched his major interest from books to movies and became a "movie freak." His fantasy life is extremely rich and draws on books and the screen for heroines, with whom he identifies.

He began cross-dressing secretly at home in his own room when he was a child. He was never discovered, and to this day no one in the family knows about it. As in the case of C., the cross-dressing was not erotic and was not used directly to relieve anxiety; rather, it was the stimulus for fantasies of D. himself in theatrical female roles. He became progressively involved in full drag and the queen circuit beginning when he was eighteen. He gave up dressing in private at that time and now dresses only to go into public to be seen as a woman.