Cross-gender identity in transvestites and male transsexuals

A self-theory of transvestism and secondary transsexuality in which gender identity is a major self subsystem has been advanced in previous research. Within this framework transsexuals and transvestites were compared on a number of developmental characteristics. While early-onset transsexuals (n =103) were dominantly female, both late-onset transsexuals (n =52) and transvestites (n =36) showed much more feminine behavior than expected. This was interpreted as a sign that they were already developing a feminine gender identity in their early years. Implications for this theory were discussed: (i) The assumption of two gender identity subsystems (a masculine and a feminine) in any human being, which can have any relative strength; (ii) the incorporation of the concept of expression of an identity subsystem, which can be unconditional or conditional (i.e., expression of aspects of the self only if certain conditions are fulfilled) and which has the function of self-seeking. Two continua are proposed. One ranges from a strong feminine gender identity subsystem that is unconditionally expressed to weak unexpressed femininity. The second ranges from a strong and unconditionally expressed masculinity to a weak masculinity. Male-to-female transsexuals (and normal females) are characterized by a strong unconditionally expressed feminine gender identity in combination with a weak unexpressed masculinity. Transvestism is a position in between in which both masculinity and femininity are conditionally expressed.     

The dyadic adjustment of female-to-male transsexuals

Dyadic adjustment, sexual activities, and marital stability in the relationships of female-to-male transsexuals and their spouses were examined. Participants were 22 female-to-male transsexuals who had undergone some form of surgery to alter their anatomical sex, their spouses, and a control group of married or cohabitating nontranssexual men and women. Participants were administered the Dyadic Adjustment Scale and additional items to assess quantitatively their marital relationships. The transsexuals and their spouses were also asked open-ended interview questions concerning marital and life adjustments. Generally, the transsexuals and their spouses reported good and mutually satisfying interpersonal relationships that are in many ways comparable to those of the matched control group. These findings lend support to the previous clinical interview studies that have reported that female-to-male transsexuals form stable and enduring intimate relationships.This study was made possible by National Institute of Mental Health Grant 1 R03 MH 32847-01 and a Boston University Seed Research Grant.     

Neuroendocrine response to estrogen and brain differentiation in heterosexuals,homosexuals, and transsexuals

Since 1964, we have found positive estrogen feedback to be a relatively sex-specific reaction of the hypothalamo-hypophyseal system in rats as well as in human beings. It is dependent on the estrogen-convertible androgen level during sexual brain differentiation and also on estrogen priming in adulthood. The lower the estrogen-convertible androgen or primary estrogen level during brain differentiation, the higher the evocability of a positive estrogen action on LH secretion in later life. In clinical studies, we induced a positive estrogen feedback luteinizing hormone secretion in most intact homosexual men, in clear-cut contrast to intact heterosexual or bisexual men. In addition, the evocability of a positive estrogen feedback was also demonstrable in most homosexual male-to-female transsexuals in significant contrast to hetero-or bisexual male-to-female transsexuals. The following relations have been found between sex hormone levels during brain differentiation and sex-specific responses in adulthood: (i) Estrogens, which are mostly converted from androgens, are responsible for the sex-specific organization of gonadotropin secretion and hence the evocability of a positive estrogen feedback in later life; (ii) both estrogens and androgens, occurring during brain differentiation, predetermine sexual orientation, and (iii) androgens, without conversion to estrogens, are responsible for the sex-specific organization of gender role behavior. Furthermore, the organization periods for sex-specific gonadotropin secretion, sexual orientation, and gender role behavior are not identical but overlapping. Thus, combinations as well as dissociations between deviation of the neuroendocrine organization of sex-specific gonadotropin secretion, sexual orientation, and gender role behavior may occur. A revised version of a paper presented at the annual meeting of the International Academy of Sex Research, Amsterdam, September 16–20, 1986.     

Sexual activity and temperament in polish transsexuals

Two groups of 23 female-to-male and 14 male-to-female transsexuals were compared to a representative sample of Polish controls along following dimensions: (i) temperamental features including reactivity and mobility of nervous processes, as measured by Strelau's Temperament Inventory; and (ii) patterns of sexual activity, measured with Dulko's Questionnaire for Measurement of Transsexualism. Transsexuals were found to resemble respective controls on temperamental dimensions according to their sense of gender identity and not their somatic sex. Male-to-female transsexuals were more similar to control females than to control males and the reverse was true for female-to-male subjects. With respect to forms of sexual activity, transsexuals, particularly the female-to-male, were found to have a relatively versatile erotic life. Both groups experienced more dreams with erotic content than respective controls. However, they also manifested fewer successes at satisfying their erotic needs.     

Gender reorientation,psychological adjustment,and involvement with female partners in female-to-male transsexuals

The present research examined the relationship, in a sample of female-to-male transsexuals, between psychological and social adjustment, on the one hand, and gender reorientation (approximation of the status of the opposite biological sex) on the other. This work was conducted in two stages. The quantification of the gender reorientation construct was investigated in Study 1. A gender reorientation index (GRI) was developed and subjected to standard tests of psychometric adequacy. The GRI proved to be reliable and to have a satisfactory factorial composition, and it was considered an adequate measure of gender reorientation for use in the second study. Study 2 investigated the relationship between symptomatic depression and tension, involvement with a female partner, and gender reorientation. Four stepwise multiple regression analyses were carried out, one for each of four criterion variables (depression, tension, partner-involvement, and the MMPI Lie Scale). The predictor variables, gender reorientation and age, were the same in each analysis. There was a statistically significant negative correlation between depression and gender reorientation and between tension and gender reorientation, and a significant positive correlation between involvement with a female partner and gender reorientation. The GRI did not correlate with the MMPI Lie Scale, and age was not significantly related to any of the criterion variables. Thus, the present findings support the notion that gender reorientation is accompanied by improved psychological and social adjustment.     

Transhomosexuality,or the dissociation of sexual orientation and sex object choice

Subjects whose sexual orientation and identification is with homosexual persons of the opposite biological sex were studied. "Transhomosexual" has been coined to describe such persons. Forms of transhomosexual expression vary with different emphases found in regard to orientation to, idealization of, and wish to participate in activities of homosexuals of the opposite biological sex. Where identification is strong or overriding, such persons become "transsexual." However, there are important differences between these and conventionally diagnosed transsexuals. Sexual orientation then is not defined entirely or always by the sex of the sexual object choice, but sometimes additionally by references to preferred heterosexual or homosexual styles of relationship.     

Sella turcica in male-to-female transsexuals

Roentgenological examination of the skull in 11 male-to-female transsexuals revealed considerable asymmetry (2.5–3 mm) of the sellar floor in three cases. There was no asymmetry exceeding 1.5 mm in 103 male controls. Asymmetry of the sella turcica suggests the presence of an intrasellar pituitary tumor. This finding in three patients with transsexualism is of interest in view of reports of endocrine disorders or hormonal secretion abnormalities in patients with atypical sexuality or gender identity problems.     

The discrete syndromes of transvestism and transsexualism

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.This project was supported by a National Health and Medical Research Council grant.     

Endocrine evaluation of forty female-to-male transsexuals: Increased frequency of polycystic ovarian disease in female transsexualism

A retrospective study of 40 female-to-male transsexuals was performed to investigate the frequency of endocrine dysfunction prior to hormonal treatment with testosterone. Two patients had laparoscopic evidence of polycystic ovarian disease (PCOD) prior to androgen treatment. Nine additional subjects had clinical evidence of PCOD, including ultrasonographic evidence of multicystic and enlarged ovaries in three patients and/or evidence of hirsutism and oligomenorrhea associated with increased androgen levels and/or an increased plasma luteinizing hormone (LH)/follicle-stimulating hormone (FSH) ratio. Two subjects had evidence of gonadal dysgenesis. Plasma levels of testosterone, prolactin, LH/FSH ratio, and dehydroepiandrosterone sulfate were significantly increased in 30 female transsexuals prior to testosterone treatment when compared to normal adult female controls studied in the early follicular phase of the menstrual cycle. These data indicate that female transsexuals have an increased incidence of endocrine dysfunction (32.5%) which should be investigated prior to hormonal treatment.     

The bisexual identity of transsexuals: Two case examples

Clinical data from two cases of male transsexualism, a child and an adult, illustrate the nature of the bisexuality typical of such patients. The first, an 8-year-old boy whose desire to be a girl is seen in his constant dressing and acting like a girl, confirms in play therapy, story telling, and drawings his fantasies of being a female. However, these fantasies are never free of the knowledge that he has a penis and a male identity as well. That this bisexuality persists into the transsexual's adulthood is exemplified in the fantasy life of the second case, a 30-year-old operated male transsexual. The memory, I was once a boy never quite fades away; no matter how successfully the passing as a woman is managed, she cannot rid herself of the secret maleness. The belief in such patients that they are fundamentally female though possessed of an anatomically normal male body will persist through adulthood, unaltered by sex change, by hormonal or surgical procedures, or by living successfully for years as a woman. This bisexuality is conscious, painful, and not assuaged by symptom formation, forgetting, or other defenses that would remove the conscious sense of having two sexes. In the child the unwanted sense of belonging to the male sex, which causes a disquieting undercurrent, can be used as the base upon which a more solid sense of masculinity can be built. Unfortunately, for the adult transsexual the balance of the two-sexed awareness cannot be tipped to a willingness to live as a man; despite treatment aimed at making them more manly, adult transsexuals retain their wish to be female—and their secret knowledge that, after all the operations and female hormones, a male part remains untouched within.Read at the Fall Meeting of the American Psychoanalytic Association, New York, December 1969.     

Sexual Orientation of Female-to-Male Transsexuals: A Comparison of Homosexual and Nonhomosexual Types

Homosexual and nonhomosexual (relative to genetic sex) female-to-male transsexuals (FTMs) were compared on a number of theoretically or empirically derived variables. Compared to nonhomosexual FTMs, homosexual FTMs reported greater childhood gender nonconformity, preferred more feminine partners, experienced greater sexual rather than emotional jealousy, were more sexually assertive, had more sexual partners, had a greater desire for phalloplasty, and had more interest in visual sexual stimuli. Homosexual and nonhomosexual FTMs did not differ in their overall desire for masculinizing body modifications, adult gender identity, or importance of partner social status, attractiveness, or youth. These findings indicate that FTMs are not a homogeneous group and vary in ways that may be useful in understanding the relation between sexual orientation and gender identity.     

Can fetishism occur in transsexuals?

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.This project was supported by a grant from the National Health and Medical Research Council of Australia. This research was carried out while N. B. was a Research Fellow of the New South Wales Institute of Psychiatry.     

Gender identity disorder and eating disorders

We report three cases of transsexual patients who are suffering from an eating disorder: a biological male patient diagnosed with anorexia nervosa (AN), a biological male patient with bulimia nervosa (BN), and a biological female patient with AN as well as a severe alcohol dependence. The relationship between eating behavior, gender identity, sexual orientation, and body dissatisfaction is discussed.     

Postoperative psychological functioning of adolescent transsexuals: a Rorschach study

The Rorschach Comprehensive System was used to assess postoperative psychological functioning in transsexuals who applied for sex reassignment in adolescence. We investigated a group of 22 consecutive adolescent transsexuals, who were otherwise psychologically well adapted. Nineteen subjects provided valid Rorschach protocols before and after sex reassignment. The most notable change found was an increase in X+%, reflecting a decrease in both distorted perception and idiosyncratic perception. Little support was found for the idea of major psychological deterioration for the patients as a group. Rather, the results suggest stability in psychological functioning over time. The Rorschach findings are consistent with questionnaire data from earlier studies, with the exception that the Rorschach data may point to some improvement in reality testing.     

Sexuality Before and After Male-to-Female Sex Reassignment Surgery

The sexual behaviors and attitudes of male-to-female (MtF) transsexuals have not been investigated systematically. This study presents information about sexuality before and after sex reassignment surgery (SRS), as reported by 232 MtF patients of one surgeon. Data were collected using self-administered questionnaires. The mean age of participants at time of SRS was 44 years (range, 18–70 years). Before SRS, 54% of participants had been predominantly attracted to women and 9% had been predominantly attracted to men. After SRS, these figures were 25% and 34%, respectively.Participants median numbers of sexual partners before SRS and in the last 12 months after SRS were 6 and 1, respectively. Participants reported number of sexual partners before SRS was similar to the number of partners reported by male participants in the National Health and Social Life Survey (NHSLS). After SRS, 32% of participants reported no sexual partners in the last 12 months, higher than reported by male or female participants in the NHSLS. Bisexual participants reported more partners before and after SRS than did other participants. 49% of participants reported hundreds of episodes or more of sexual arousal to cross-dressing or cross-gender fantasy (autogynephilia) before SRS; after SRS, only 3% so reported. More frequent autogynephilic arousal after SRS was correlated with more frequent masturbation, a larger number of sexual partners, and more frequent partnered sexual activity. 85% of participants experienced orgasm at least occasionally after SRS and 55% ejaculated with orgasm.     

Psychosocial differences between dutch male and female transsexuals

One-hundred sixty-eight male and 55 female transsexuals, in hormonal treatment at the Gender Foundation in Amsterdam, were compared with respect to psychosocial characteristics. Results indicated that females more frequently had displayed cross-gender behavior during childhood than males, that they cross-dressed more often, and that, contrary to males, none had married in her anatomical sex. Females also applied for surgical gender reassignment at an earlier age than did males. More of the females lived in a stable relationship with a partner of their own biological sex. Relations with the parental home were better for females than for males, and the former were more often employed or enrolled in a study. No significant differences existed with respect to psychiatric treatment, substance abuse, or attempted suicides. It is concluded that unambiguous cross-gender behavior is more common in female than in male transsexuals and that the social conditions of the female are more satisfactory. However, a relatively high incidence of psychiatric treatment and attempted suicides indicates severe psychological problems in both the male and female groups.     

Development of male gender identity/role and a sexual orientation towards women in a 46,XY subject with an incomplete form of the androgen insensitivity syndrome

Transsexualism and homosexuality have been theorized to originate in the male from insufficient androgenization of the brain. For verification of this hypothesis clinical science must rely on subjects with an abnormal prenatal/perinatal endocrine history. A case of a 33-year-old 46,XY subject with an incomplete form of androgen insensitivity syndrome (AIS) is presented. In adulthood the only genital sign of masculinization is a clitoris of 4 cm; the vagina is normal size. The diagnosis AIS was verified by androgen receptor studies. At birth there was confusion as to the sex of the newborn. Originally, the subject was assigned to the male sex, but this decision was reversed 5 days after birth and the subject was reared as a girl. At age 30 the subject applied for gender reassignment treatment to the male sex. Upon psychological evaluation the gender identity was unambiguously male and the sexual orientation was exclusively towards women. The estrogen feedback effect on LH, regarded by some as a marker of the sexual differentiation of the neuroendocrinium was negative before orchiectomy but positive after orchiectomy. Our observation demonstrates that in 46,XY subjects a male gender identity and a sexual orientation towards women can develop with a strikingly lower-than-normal level of biological action of androgens.     

Developmental profile of 200 male and 100 female transsexuals in Singapore

Two hundred male and 100 female transsexuals compared with 100 male and 80 female heterosexuals were studied in Singapore. Transsexuals started their psychosexual development earlier than controls. Transsexual feelings started in childhood. Male transsexuals went through a homosexual phase followed by a transvestite phase, before they became transsexual. Female transsexuals did not go through distinct phases. Cross-dressing was one of the early signs of transsexualism and started earlier in females. None of the transsexuals were married, in contrast to reports showing that up to 50% of Caucasian transsexuals had been married. Cultural differences may explain the contrasts between Singapore transsexuals and patients from Western countries.     

Female-to-male transsexualism,heterosexual type: Two cases

Two cases of gender-dysphoric genetic females who describe a sexual attraction to phenotypic males are reported. After outlining their individual histories, the authors note common clinical features of this subtype of transsexualism. Similar characteristics have also been found in the few cases of heterosexual transsexualism in genetic females reported by others. Familiarity with the distinguishing features of this subgroup could assist clinicians in diagnosing and treating such patients.