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Sex and Gender


Robert J. Stoller, M.D.

Professor of Psychiatry

New York

Acknowledgements page vii

Part I

1. Bisexuality: The ‘Bedrock’ of Masculinity and Femininity 7

2. Extreme Femininity in boys: The Creation of Illusion 19
3. The Transsexual Boy: Mother’s Feminized Phallus 38
4. Parental Influences in Male Transsexualism: Data 56
5. The Bisexual Identity of Transsexuals 74
6. The Oedipal Situation in Male Transsexualism 94
7. The Psychopath Quality in Male Transsexuals 109

Part II
8. The Male Transsexual as ‘Experiment’ 117
9. * Tests 126
10.The Pre-Natal Hormone Theory of Transsexualism 134
11.The Term‘Transvestism’ 142
12.Transsexualism and Homosexuality 159
13.Transsexualism and Transvestism 170
14.Identical Twins 182
15.Two Male Transsexuals in One Family 187
16.The Thirteenth Case 193
17.Shaping 203
18.Etiological Factors in Female Transsexualism: A First Approximation 223

Part III
19 Male Transsexualism: Uneasiness 247
20 Follow-Up 257
21 Problems in Treatment 272
22 Conclusions: Masculinity in Males 281
References 298
Index 313
Part II


Are there any tests, in the scientific sense, for psychodynamic theories ?

It is possible to compare one person with another by reference to a

commonly defined and precisely measured factor, but with global
descriptive terms there is difficulty. For instance, one cannot measure
‘happiness’, ‘normality’, ‘masculinity’, or hardly even apparently precise
terms like ‘schizophrenia’. These are words that sum up a number of
different elements, and if some of the elements are unknown or
unrecognized, or are moral judgments, or require adherence to a specific
school, or are deeply influenced by personality factors of observers, then
the measurement will never be possible, even if the rest of the elements are
measurable. And so even more global concepts, which may be made up of
a number of these imponderables, may be beyond all scientific
methodology, including the proper use of statistics. While the family
dynamics theory of the etiology of extreme femininity in males comes into
this category, I have tried to ease the problem—increase the probability
that these factors contribute to extreme femininity—by comparisons that
may partially serve to test.*
Tests Within the Diagnosis
1. The literature. Case material published prior to the publication of my
theory, in which similar family dynamics are reported either to have
resulted in marked femininity or to have failed to, may test the theory
(depending on the quality of the clinical descriptions). For instance, in
Bieber’s book on homosexuality,


* I also have an easier job than I would in trying to confirm an etiology using
repression, intrapsychic conflict, and resolution of conflict by newly created character
structure. Transsexualism seems due to simpler, more easily measured factors, the
kinds of impingements on the infant that learning theorists have long been able to
measure because so visible.

published in 1960 (five years before I thought up this theory), many cases
of male homosexuality are presented, including effeminate males.
However, the most feminine case reported of over a hundred in the book is
one—and the only one—more or less conforming to my theory (see
Chapter 12). Also, a single case by M. Sperling of a ‘transvestite boy’, in
which the dynamic factors I postulated were present, was published prior
to my work. (See Sex and Gender for a review of this literature.) On the
other hand, neither before nor after this theory was published has anyone
presented data to refute it.
2. The theory began with material revealed in the psychoanalysis of the
mother of a very feminine boy. But a single case needs confirmation; the
first test was to see other feminine boys and their families. It was not quite
so simple, however, for although the mother in analysis had revealed these
factors, they had not impressed me as the etiological factors. In a
psychoanalysis one is overwhelmed with data, and one has to learn which
to consider especially significant. For instance, when told that the baby
was beautiful and graceful, I put that aside, recalling that I knew of
beautiful and graceful baby boys who did not become feminine. Or on
hearing the first descriptions of closeness between mother and infant, I did
not find them especially important, having long since been familiar with
the literature on homosexuality, which talks of ‘over-protective’ mothers.
And so I did not ask specifically about such features with the next few
families. Nonetheless these factors appeared; and after hearing them a few
times I recognized them as being either an odd coincidence or possibly
3. Now that a hypothesis had formed, based on small boys, the next test
was to see if it held with adults. There is little point in simply asking adults
how their mothers treated them in infancy; so I turned to the mothers. It is
in the nature of male transsexualism that the fathers, consistent in their
distant passiveness, will not be available for questioning, and that was
usually the case with the adult transsexuals. The handful of their fathers
seen were like the fathers of the boys.
4. Then families with adolescent feminine boys were evaluated (and in
time treated); the same family dynamics were present. With these
samplings from childhood, adolescence, and adulthood, one gains the
impression that these children grow

up to be these adults (though that can only really be proven by watching

the same person grow up).
5. The next test was provided by treatment, i.e. by time and trust.
Historical data collected during a psychoanalysis can be accurate, for in
the years the treatment requires, there are innumerable opportunities for
cross-checking: overt and subliminal cues in behavior observed during the
treatment hour, internal consistency, dream material, etc. In addition, an
analysis that goes properly promotes an atmosphere of increasing trust;
one can lean on data so collected (with caution; such data are not as hard
as in the sciences). Also corroboration may be found in histories given by
other families in psychotherapy, and then in the less carefully collected
histories given by families seen in the non-therapeutic, non-trusting
atmosphere of the psychiatric evaluation.
6. Family snapshot albums and home movies may give additional
information. One might suspect, for instance, that the stories of femininity
from early childhood given by adult transsexuals or their families are
fabrications. Having the photographs of the child so dressed can then help.
One can even infer that, if they took such photographs, the parents were
not discouraging the cross-gender behavior.
7. Data can be skewed by the way subjects are brought into the research
and thus falsely corroborate or disprove a hypothesis. For instance, were I
to gather up those feminine males who already had a history with hints of
the hypothesis confirmed, this would be an incomplete test. It would be
better to ask only that feminine and effeminate males be referred to one
and then see in which cases, if any, the family dynamics are present. And
so I have seen fetishistic cross-dressers, effeminate homosexuals, the
intersexed, paranoid psychotics with gender disorders, and people with
mixed clinical features—adults and children. So far, in no case have the
family dynamics described been found in a male who was not of the
extremely feminine sort. Of great value has been a different test of the
theory: in a few cases of extremely feminine males, the complete family
dynamics were not present, and this has led me to believe that these
dynamics are a main, but not the only, route by which (other sorts of?)
extreme femininity can be created in a little boy (see Chapters 16 and 17).

8. It is common knowledge now that those wishing ‘sex change’ give

authorities the history necessary to prove their transsexualism; the patients
have read the literature well. A history from them is therefore suspect. To
what extent this also holds for their parents is unknown. My check on this
issue is that the theory was developed on people who had not read the
theory, since it was not then published. Because of this complication—
publication—in the last few years I have not even tried to corroborate it
further with adult transsexuals and their families. However, talking with
the families of little boys is a different matter: they are not motivated to
tell a story that will lead to the child getting a ‘sex change’ operation.
9. Observation of the children in play therapy (along with simultaneous
treatment of parents) gives further check on statements about the child’s
gender identity and his relationships with his parents. In addition, his
version of the family dynamics can be observed when he expresses his
fantasy life in drawings, in stories he tells, and in play. When his version is
like theirs — as it has always been with these families of our experience—
the hypothesis is confirmed a bit more. Watching his mother and father
when they are with him also helps, for they act then as they say they acted
in his infancy.
10. All interviews—evaluation or therapy—except for psychoanalyses,
are recorded in toto (unless someone requests otherwise). It is technically
possible (though at times there will be problems in protecting
confidentiality), therefore, for an outside observer to judge for himself
conclusions drawn from the raw data.
11. Colleagues have also done consultations on and treated adult and
child transsexuals and their families. While these workers may be
contaminated by friendship with me and familiarity with the theory, it is
possible, with their different personalities and styles of interviewing plus a
lingering objectivity, that they too can serve to help keep the research
Tests Across Diagnoses
There is a whole other system of cross-checking, alluded to indirectly
above. It consists in measuring one type of patient against another, where
each shares a certain variable. Studying cross-dressing, which in the past
has indiscriminately been given

the diagnosis of ‘transvestism’, I have found a number of different states

with this symptom. How many grow from the family dynamics described
for transsexualism ? Answering this question has been a long task, still
incomplete. So far, those dynamics have not shown up in any patients I
have treated or evaluated who did not fit into the class of the most
feminine of males.
In later chapters we shall test the hypothesis by contrasting the following
to transsexuals: fetishistic cross-dressers (transvestites), effeminate
homosexuals, heterosexuals, paranoid psychotics, the intersexed, and a
mixed group. On doing this, one can then establish a number of checks for
the major family dynamic factors (such as mother’s and father’s
personalities, the symbiosis, or the boy’s beauty); these can be measured
clinically by an objective observer. Although I have at times indicated
these checks when reporting clinical material earlier herein, in the
following chapters the above conditions will be taken up and again
amplified, to strengthen the argument that the elements making up the
family dynamics are found only in the transsexual ‘experiment’:
(1) Fetishistic cross-dressers get excited by women’s clothes. That is no
more likely to happen—namely, never—in those I consider transsexuals
than in women. Fetishism indicates powerful personality factors at work.
That should mean different parents, different infancy, different
psychodynamics (Chapter 13).
(2) Effeminate homosexuals love penises, their own and their partners’;
transsexuals feel their own penises are misplaced as would a woman who
found one tacked on. Again: different clinical syndromes should arise from
different circumstances (Chapter 12).
(3) If the condition is genetic, it is likely to appear in both identical twins
if one is transsexual. No cases of identical twin transsexuals have been
reported; however, two sets of identical twins discordant for marked
gender disorder, one male and one female, have been studied (Chapter 14).
(4) The hypothesis accounts for the fact that the condition does not show
up in brothers of the markedly feminine boy with the explanation that only
the beautiful and graceful child is feminized. The hypothesis would be
further tested if two beautiful, graceful, and cuddly sons were born into
such a

family. They both should be feminized, if the dynamics between mother

and father are relatively unchanged as described. Such a family finally
came to us (Chapter 15).
(5) If transsexualism is the result of cross-sexed prenatal hormones, then
it is not easy to understand why subjects exposed to massive amounts of
circulating prenatal cross-sexed hormones (such as females with
hyperadrenalism or females masculinized with progesterone taken by their
mothers) while tomboyish are not markedly masculine in behavior
(Chapter 10).
(6) Even female transsexualism is a check on the hypothesis regarding
etiology in male transsexualism. We must be cautious. Although the same
word—transsexualism—serves as the diagnosis of extreme femininity in
males and extreme masculinity in females, consistency requires that I look
for the comparable clinical picture, underlying dynamics, and etiological
factors in both males and females. If male and female transsexualism are
the same condition except that they occur in two sexes, like, say,
schizophrenia or senile brain disease, we will expect to find comparable
etiologies. If they are clinically two different conditions, like, say
transsexualism and transvestism, then the etiologies should differ. This will
be considered in Chapter 18.
(7) Then there are the very feminine boys who seem the same as these
transsexuals but the family dynamics are not present. Are there other
routes to extreme femininity ? (Chapters 16, 17.)
A critical category is missing: cross-cultural studies. Therein lie great
pools of data, ‘natural experiments’ en masse. My subjects are mostly
white, middle-class, American with only a few black and chicano or other
‘Spanish-American’ families. So far most or all of the predicted factors
have shown up, but the hypothesis requires a systematic study of child-
rearing in other cultures and sub-cultures.
There are other controls one can find to test one or more of the
elements in the hypothesis. The main points are that it can be tested and
that, so far, testing has not disproved it. Fortunately the elements can be
checked without the use of special, esoteric techniques (like
psychoanalysis) or a pre-determined commitment to a school or theory. In
part that is because the

marked femininity is the result of simple learning effects rather than the
more complicated processes with which analysts usually work.
Yet when lost or when I want to force myself to the most rigorous testing
—where there can be no hiding from one’s conscience by means of
scientific method — I return to psychoanalysis. Unlike most other
identified full-time researchers in sex and gender, I believe that analysis is
the most powerful tool so far for discovering non-biological aspects of
gender development. The other techniques—questionnaires, standardized
interviews, observation of great numbers of subjects seen briefly,
psychological tests—were invented mainly to save labor in the crucial job
of confirming hypotheses. Most researchers cannot afford to take the time
for more searching examinations, for getting under the skin; one would not
then have seen enough subjects to achieve statistical significance.
Psychoanalysis is a hopeless means of confirming a finding or a theory.
Analysts never present their data, and no one other than the treating
analyst can ever even observe his data. Yet analysts and related depth
psychologists are the only ones who dare take on the realities of human
psychology: the sense of flow and dynamics in human psychic function,
the feeling for growth and development—for change, for meaning and
motivation, for sense of self, for threat and danger and pain and conflict
and defense and resolution, for the immense intricacy found when chaos is
organized into identity, for awareness of depth and magic, of precise logic
and of imaginative sweeps, for attention paid to the great issues of the
human state. To contemplate these and to place them in a coherent model,
there is no place yet in the world of psychology to turn except to Freud and
his descendants (not all of whom are analysts). Leaving these conditions
out of one’s research makes it more scientific and lets one play it safe; and
those who do so will have less anxiety about what they do not know and
the immensity of the questions they research. Their answers are often puny
because their questions lack courage. But they are less likely to be wrong
in the magnificent, ludicrous, dare-devil, naive way of the first—the great
—psychoanalytic thinkers.
A last word on these problems in confirming the complicated hypothesis
of this book. I do not propose to list how many sub-

jects were seen, with what diagnoses, or how often an element was found.
With my sorts of observations such listing is useful more to suggest that
one is experienced and thus possibly dependable than to establish a, fact.
Unhappily, for many of my tests I have only one patient or one family to
serve as ‘control’, as for instance where transsexualism appeared in two
siblings. And how, to take another example, should I weight information
gathered on patients seen in a conference of our research team as
compared with one treated for three years — and in what ways are the
patients comparable at all?
Perhaps time will help.