E XT RE ME FE MININIT Y IN B O YS 58

Sex and Gender

VOLUME II
THE TRANSSEXUAL EXPERIMENT

Robert J. Stoller, M.D.

Professor of Psychiatry
DEPARTMENT OF PSYCHIATRY,
SCHOOL OF MEDICINE
UNIVERSITY OF CALIFORNIA AT LOS ANGELES

JASON ARONSON
New York
 CONTENTS

Acknowledgements page vii

Introduction
1
Part I
THE HYPOTHESIS

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
TESTS
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
PROBLEMS
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
TESTS
 11
THE TERM ‘TRANSVESTISM’

The term ‘transvestism’ appears in the literature rather frequently and, in

fact, the new nomenclature has now made it an official diagnosis. Yet there
is no common agreement what is meant by ‘transvestism’. Even the
Diagnostic and Statistical Manual of Mental Disorders fails to define the
term, though it makes a sharper attempt to perceive it as a diagnosis than
did the previous manual, by actually listing it as a sexual deviation. As one
reviews the literature, one does find one self-evident common
denominator: ‘transvestism’ is cross-dressing (putting on garments of the
opposite sex). But a piece of behavior or thought is not to be confused with
a diagnosis (e.g., hallucination is a symptom, not a diagnosis). The purpose
of this chapter is to review clinical data that would fall under the rubric of
‘transvestism’ as the term has been used in the literature and to suggest that
as a diagnosis it leaves so much to be desired that it fails.
I have noted that a diagnosis (in both physical and psychological
medicine) is a shorthand term for (1) a shared collection of signs and
symptoms (a syndrome), (2) underlying dynamics, either psychodynamic
or pathophysiological (these will not be discussed here because they are
difficult to demonstrate and descriptions of them often use too much
theory to convince most readers), and (3) etiology. While the last is rather
beyond our reach in most psychiatric conditions and the second criterion
often is, the first is always available to us when we observe precisely.
‘Transvestism’ as generally used in the literature does not satisfy the above
criteria for a diagnosis; I believe we can do better.
A Classification of Cross-Dressing in Males
While there are overlapping data (e.g., all subjects put on the clothes of the
opposite sex), seven groups can be distinguished.

142
 THE TERM ‘TRANSVESTISM’ 143

Fetishistic Cross-Dressing
Perhaps there can be a consensus that the term ‘transvestite’ be used only
with this group. I shall, however, refrain from calling people transvestites
in this chapter so as not to confuse the reader, though it would be easier to
say ‘transvestite’ each time, rather than ‘fetishistic cross-dresser’.
Phenomenology
This is perhaps the condition most often described in the literature as
transvestism. The following are typical of this deviation:
(1) What quite distinguishes this from others is that putting on clothes of
the opposite sex produces clearcut, unquestioned genital excitement,
generally leading to masturbation and orgasm. Within this category are two
different styles of behavior. People in the first are excited by a single
garment or a few garments, and the preference for these particular items
remains constant throughout life. The second group starts in the same
manner, but over the years there is a gradual spread to the use of more and
more garments, until finally the subject enjoys dressing from the skin out
in the clothes of the opposite sex. He wishes to be so successful in
appearing to be a member of the opposite sex that he goes out into the
world in this manner. In this latter group, then, it is not only the fetishistic
excitement that is important but, increasingly with the years, the sense of
feeling like a member of the opposite sex. In both cases, however, the
common denominator is the sexual excitement produced by the garments.
(2) Fetishistic cross-dressing is almost non-existent in women (at least I
have never seen such a person or met anyone who has; I know of only one
case reported [1]). While women cross-dress, they do not become sexually
excited by the garments they put on.
(3) Fetishistic cross-dressing is an activity indulged in primarily by
heterosexual men (2). Of course, one must say what he means by
‘heterosexual’, especially in a condition considered by most people to be a
form of homosexuality. What is meant here is the most superficial but also
the least controversial of measurements: a person’s avowed preference.
The great majority of fetishistic cross-dressers state that they prefer
144 THE TRANSSEXUAL EXPERIMENT

women to men for their sexual objects in reality and in sexual fantasies (2).
Most are married and have children. It is rare for men homosexual in
preference to be sexually excited by women’s clothes.*
(4) Fetishistic cross-dressers are not effeminate when in a man’s role, a
role that takes up by far the greater part of their life. They are found in all
the masculine professions and rarely in the professions preferred by
homosexuals. Their behavior, quality of vocal expression, choice of
language, style of clothes, and other behavioral manifestations of gender
when not crossdressing are unremarkably masculine.
(5) For these men, not only is their penis the source of the greatest erotic
pleasure but they also consider themselves men (not just males). Their
excitement is expressed through their penis; more important, its presence
sensed beneath the women’s garments is exciting. They never quite forget
the trick: the hidden penis. The thought that they are fooling the world is
surpassed in enjoyment only by the moment when they can reveal the
secret. This being dangerous, it can usually only be indulged with a
cooperative wife or girl friend.
Thus, maleness and masculinity are not just an unavoidable part of the
masquerade but an essential ingredient. It is not surprising then that even
the few who learn to pass as women retain a penetrating, aggressive
quality when cross-dressed.
CASE ONE
This patient, in his 30’s, married, father of three children, a precision
machine operator, remembers his first cross-dressing as a tremendously
exciting sexual experience when, as a punishment, an aunt forced him to
cross-dress at age 6. However, while he has no conscious memory of it, he
has learned that he was first cross-dressed by another aunt at age 4. From
puberty on, sexual excitement was invariably and intensely induced by
putting on women’s shoes, and as the years passed, this gradually
progressed so that he now dresses completely as a woman and, with proper
makeup to hide his beard, passes in society as a

* This conclusion is drawn from the absence of published reports of the behavior,
from our research team not having seen any though we have studied dozens of
homosexuals, and from Prince’s study (2). I have, however, heard rumors of two.
 THE TERM ‘TRANSVESTISM’ 145

woman for a few hours at a time. He has never had a homosexual

relationship and has no sexual interest in male bodies; he is interested in
female bodies, but though looking excites him, lying next to a woman is
more complicated: he can then only maintain full potency either by putting
on women’s garments or fantasizing that he has them on.
Etiology
While the etiology of fetishistic cross-dressing is still to be worked out,
there are suggestive factors.
(1) In the history of these men one finds a period, ranging from the first
two or three years of life to later years, during which the boy was allowed
to and did in fact develop masculinity. (Contrast this with transsexualism.)
(2) Only when this masculinity has developed and the masculinity itself
acts as the irritant that excites revenge desires in a female, is the boy
attacked precisely at the point of expression of masculinity. This attack
usually consists of a girl or woman putting female clothes on the boy
without his having seduced her into doing so.* This is his first cross-
dressing.† While I have not invariably gotten the history of a female who
puts the clothes on the boy, it seems to occur more frequently than
superficial evaluation or questionnaire would elicit. After not getting such
a history I (or one of my colleagues) have at times learned that a fetishistic
cross-dresser who denied any memory of having been cross-dressed in
childhood then discovers it either by seeing photographs in the family
album that go back before his memory begins or has had it reported to him
later by his mother, a sister, an aunt, etc. It is impossible to say this is a
universal etiological factor. But one can suggest as a testable proposition
that the cross-dressing typically follows an attack on the boy’s masculinity
by an envious woman, and that this attack, unlike that so frequently found
in effeminate homosexuality, consists especially of cross-dressing the boy.

* I cannot pretend to exact numbers. Those familiar with the case histories in the
literature, however, know this is constantly reported in fetishistic cross-dressing but
not in transsexualism or effeminate homosexuality.
† Men do not seem impelled as women are to do this to a boy. Instead, when it is
reported that a man has cross-dressed a boy, it is his father who has made the boy
cross-dress as ‘punishment’ after the boy has already been caught at it.
146 THE TRANSSEXUAL EXPERIMENT

It seems unlikely, however, that a single act of a female putting her

clothes on a boy would produce a life-long perversion; the conditioning
hypothesis—that perversions are caused by a single traumatic or exciting
event—is a heavy burden to lay on our credulity.
More likely, early childhood experiences prepare the ground (3-6) but
what these are exactly, is unclear. As one tries to fill in blank spaces in the
puzzle, the first pieces seem to be that a boy who has been able to develop
in a masculine manner and who would be traumatized if treated in an
unmanly way is humiliated by a female in his most visible vulnerable spot,
his masculine appearance (clothes). Another proposition to be tested (there
is suggestive evidence but not enough for a sense of conviction) is that the
fetishistic cross-dresser who comes to dress and pass in society as a
woman has a specific disruption in the relationship with his father. This
father is a distant, passive man. Sometimes he is simply that—an unseen
potential in the household. But there is also another version of the distant
father. His son sees him as a cold, rigid, powerful, masculine man, usually
unreachable but with moments of all-too-close rage, but our examination
of these men, since we are not at the same disadvantage in age and size as
are their sons, is that this second type of father is frightened and passive
with a not very successful facade of punishing pseudomasculinity.
While frightening and distant, these men introduce another quality into
the relationship: they have rare moments of capricious tenderness with
their son. And so the boys hunger for their fathers, loving them
despairingly and with an almost sexual tinge. By this I mean that the
yearning is so intense, the hope that he might be won so close, that an
eroticized state of tension and frustration builds up. This tantalizing
element is similar (perhaps identical) to that seen in some fathers of male
homosexuals and may be the major homosexual mechanism at work in
these fetishistic cross-dressers.
Transsexualism
Phenomenology
What first catches the observer’s eye in transsexualism is cross-dressing,
and so it too is called transvestism (e.g. 7-10).
 THE TERM ‘TRANSVESTISM’ 147

Its differences from fetishistic cross-dressing should, however, be apparent

in the following description.
Transsexuals (as the term has been used herein) are never found to be
fetishistic. There simply are no reports of sexual excitement induced by
garments.
Transsexuals do not alternate between periods of masculinity and
femininity or effeminacy.
They are feminine, not effeminate.
There is no period in early childhood in which they develop masculine
behavior, a conviction that masculinity is valuable and to be preserved, or
acceptance of one’s maleness. Starting in earliest childhood, transsexuals
behave, talk, and fantasy as if they were girls. They have no capacity for
episodes of unremarkably masculine appearance. They do not grow out of
the femininity. They do not work in masculine professions.
In object choice, they are incapable of sexual relations with the opposite
sex. The true transsexual invariably prefers masculine, ‘straight’ men.*
They very early develop an almost uncanny capacity for sensing which
men are obviously homosexual; the key to that test is whether the man
shows an interest in the transsexual’s penis. Only those who do not are
accepted as sexual partners.
The transsexual has no interest in his own penis, either as an insignia of
maleness or as an organ for expressing eroticism. Some transsexuals have
rare or no orgasms (9), and even those who do, fantasize that the erotic
sensations are being felt in a vagina. They are not concerned with
preserving their penis as are fetishistic cross-dressers and homosexuals but
rather make every effort to be ‘sexually transformed’ into anatomically
normal females.
This desire for sex change starts in the first few years of life and never
mitigates.
What can be emphasized, then, is that the true transsexual does not have
a sense of maleness and a feeling of the value of masculinity to be
protected (which is accomplished by the fetishistic perversion), but instead
shows femininity from the earliest days that he can show gender behavior.
He is not first cross-dressed by a woman but rather is reported to

* Many of whom, however, as noted elsewhere, have their own transsexual

tendencies.
148 THE TRANSSEXUAL EXPERIMENT

start it spontaneously himself, within the first or second year of life. The
condition does not operate as a technique of preserving genital potency
and sexual pleasure but is a more fundamental procedure, an attempt to
establish and maintain an unswerving sense of gender identity.
CASE TWO
This patient, in her 20’s, appears to be a beautiful woman. This is not a
folie à deux with the research team, for she is a fashion model who no one
in the fashion world knows to be a biologically normal male. She has
never had nor even fantasied sexual relations with a woman, getting no
excitement from women’s bodies but rather feeling the same casualness in
regard to them that most heterosexual women do. Sexual interests are felt
only toward men. As far back as memory goes, she recalls being feminine
and wishing she were biologically female. Her mother confirms this and
says that she never saw masculine behavior in her son. She says they were
extremely close and loving but that his father was never present. She never
dressed the boy in girls’ clothes but was surprised and pleased that her son
at age 2 was already dressing up in girls’ clothes and putting on makeup.
The patient hates her male body, wants it changed to female, but does not
deny it is male. She does not consider herself a homosexual but rather a
biologically normal male with completely feminine desires. She has
worked as a woman for many years, unrecognized by anyone in society
not to be a normal woman. She has never been sexually excited by any
garments, masculine or feminine.

Effeminate Homosexuality
Phenomenology
(1) Effeminate homosexuals on occasion may put on women’s clothes;
these acts are intermittent, last only a few minutes or hours, and are not
accompanied by sexual excitement induced by the clothes. A small number
of homosexuals will learn to do this so successfully that they can appear
briefly as lovely looking women.
 THE TERM ‘TRANSVESTISM’ 149

(2) The very word ‘effeminate’ is a clue to what observation reveals—

that the homosexual is not being feminine but rather effeminate. The
effeminate homosexual, while identifying with women is also angry at
them; the mimicry and hatred cannot be removed from what is a
performance. (There is no performance quality to the transsexual’s
feminine behavior, though there may be, to a lesser extent, in the fetishistic
cross-dresser’s.)
(3) A homosexual generally is an avowed homosexual (either to the
world or to himself). He knows that he prefers men for sexual objects,
enjoys having a penis, would not wish to lose it, uses it whenever possible
in all sorts of sexual situations, and enjoys sexual relations with men who
in return focus on his penis. (This latter is anathema to transsexuals.)
CASE THREE
This man, in his 30’s, is an actor. Although he had sexual experiences
with women as an adolescent, these were perfunctory, his feelings ranging
from lack of interest to disgust with women’s bodies. On the other hand,
he was easily seduced by a man at age 9 and instantly recognized this as
his real sexual pleasure. He had homosexual relations with increasing
frequency after this, and since his early 20’s has been exclusively
homosexual. He feels he is a homosexual, prefers to be socially only with
homosexuals, and is accepted in his profession in part because he is
homosexual. He has never been excited by masculine or feminine
garments. Since age 6 or 7, however, he has been effeminate. On occasion
in his teens, he would throw on a few female clothes in order to prance
around, mimicking women. At present he can dress skillfully as a woman
and can act appropriately if it is for no more than an hour or so. This
makes his friends laugh, for he is recognized at these times to be a man
successfully imitating a woman. He has had occasional fantasies of being
transformed into a woman (these fantasies are ‘experimental’, in that he
tried them to see what it feels like). In addition, he has several times
imagined during anal intercourse that he was using a vagina. However, he
has never sought ‘sex-transformation’ operations; the idea is repugnant to
him because he does not wish to lose his penis and its pleasure and
because he likes being a male.
150 THE TRANSSEXUAL EXPERIMENT

Etiology
Homosexuality is not a homogeneous condition in which, as in a clear-
cut diagnostic category, all members share the same syndrome and
etiology. Among effeminate homosexuals, however, many have suffered
more or less the same childhood family pathology as exemplified in
Bieber’s et. al. ‘close-binding, intimate mothers’ (11) (see Chapter 12).
These are women who are stimulated to damage their son’s already
developed masculinity and to accept only passive and unmanly behavior;
the anger in their son’s effeminate mimicry may then be the only
expression of rebellion open to the boy. Masculinity is driven
underground, damaged and hidden, distorted but not destroyed.
(Remember the difference in the transsexual, where no masculinity
develops, though femininity is greatly encouraged.) These mothers mix
over-protective bribery with subtle and severe, though usually not
physically punitive, forbidingness: as long as the little boy represses his
masculinity, such a mother is comfortable, and when he openly shows that
it is damaged, she gratifies him in the most sensual ways. He has, however,
developed some masculinity; its presence is what provokes her to suppress
it.
The fathers of effeminate homosexuals are apparently a rather mixed
bag. (I draw here far more from the literature than from clinical
experience.) Some of them are as distant and uninvolved as are the fathers
of transsexuals and some fetishistic cross-dressers, while others are angry,
punitive, frightening men to their sons, in the way that has been seen with
other fetishists. In fact, the fathers in all three groups do not seem
described clearly enough in their character structures for one to be able to
discuss them in any more detail than this.
Overt, Borderline and Latent Psychotics
Phenomenology
Nothing fancy is implied in the semi-diagnostic terms. The concerns as
to who is borderline or how latent is psychosis before it is overt are not
under consideration here. What is meant now is that, using the usual
standards one otherwise applies (e.g. hallucinations, delusions, gross
thought disorder) mental status examination reveals psychosis or near
psychosis. There
 THE TERM ‘TRANSVESTISM’ 151

are those who say that by definition a transsexual is psychotic because he

suffers from a ‘delusion’ (e.g. 12-15): ‘I think I am a woman in a male
body.’ Obviously, the transsexual has a false belief, but not all false beliefs
are delusions (thus it would be the poorest psychiatric practice to diagnose
all members of an exotic religion as psychotic because one is convinced
their beliefs are not based on reality).
On the other hand, psychotics often have gross disturbances in
masculinity and femininity, and some hallucinate body changes as if their
anatomy were becoming that of the opposite sex. However, transsexual
desires, which are found frequently in many people (not only the
psychotic) are not to be equated with the diagnosis: transsexualism.
Obviously, such hallucinations, which are very painful, nonetheless spring
from (repugnant, forbidden, repressed) wishes of a transsexual nature,
while the transsexual’s desired body changes are as egosyntonic as is
normal gender identity. And so the psychotic and near psychotic are easily
distinguished from transsexuals. First, the former use widespread
psychotic mechanisms. Second, psychotics are not comfortably feminine.
Third, their defenses against the wishes to change sex are ubiquitous (the
very use of egodystonic hallucination to express the wish is evidence of a
defense against it). The picture in such patients is chaotic, while the
transsexual is possessed of a coherent identity, although it is built around
an unreal hope.
Schreber (16) would be a good example of this category and the quickest
reading of Schreber’s description of his body changes compared with that
of transsexuals immediately demonstrates that the two have more
differences than similarities.*

* For instance, Schreber writes: ‘For a long time I had to recite certain strange-
sounding incantations, such as “I am the first leper corpse and I lead a leper
corpse”—incantations, which, as far as I could understand, were connected with the
fact that lepers had to consider themselves doomed to certain death. ... I do not know
whether it was in any way related to the occasional cases of bubonic plague of the
present time. Nevertheless, even the plague did not develop to its full extent but
remained confined to more or less marked indications. The reason for this was the
fact that the manifestations of the disease were always subsequently removed by pure
rays . . . Other things that happened on my body were still more closely connected
with supernatural matters. ... It was thought that this could
152 THE TRANSSEXUAL EXPERIMENT

CASE FOUR
This is a man in his 30’s, married, hospitalized with a schizophrenic
reaction. He hallucinates a voice telling him he is a woman and that rays
are being sent through his testes, causing body chemistry poisoning so that
polluting female substances are changing the sensations of his body and
the function of his brain. He feels therefore that his body is gradually
becoming more and more female. He has episodes of raging despair that
unknown enemies are inflicting these horrors on him, contrary to his wish
to be a normal man. The present episode was set off by his reading a
description of a homosexual seduction in a book. He has never had
homosexual relations, except for one episode of mutual masturbation in
early adolescence. He has never been excited by clothes. Neither before
becoming psychotic nor during the illness was he feminine or effeminate
in appearance or behavior nor did he beg for sex transformation.

Etiology
This is no place for a discussion of the complicated subject of etiology in
the psychoses, but let it suffice that no one has reported in any of the
psychoses or borderline states the kind of symbiosis that is present in the
transsexual’s childhood or the uncomplicated, natural-appearing femininity
of the transsexuals. Likewise, the dressing up in the clothes of the opposite
sex so often found in the fetishistic cross-dresser is either rare or absent.

The Mixed Group

Phenomenology
A patient in the mixed group (which will be considered further in the
‘Discussion’ in regard to a continuum of crossdressing) will have attributes
of more than one of the above

be achieved by unmanning me and allowing my body to be prostituted like that of a

female harlot, sometimes also by killing me and later by destroying my reason
(making me demented). But with regard to the efforts to unman me it was soon found
that the gradual filling of my body with nerves of voluptuousness (female nerves) had
exactly the reverse effect, because the resulting so-called “soul-voluptuousness” in
my body rather increased the power of attraction. Therefore “scorpions” were
repeatedly put into my head, tiny crab- or spider-like structures which were to carry
out some work of destruction in my head’ (pp. 98-99).
 THE TERM ‘TRANSVESTISM’ 153

groups. Since this is just a ‘miscellaneous’ group and not a diagnostic

category, a few examples may suffice. Some subjects are strongly
fetishistic but have more intense wishes for ‘sex transformation’ than does
the typical fetishistic cross-dresser. Others are homosexual prostitutes who
can pass as pretty women as well as transsexuals can but who enjoy their
penises and do not wish to be females. Others are a complex mix of
fetishistic, homosexual, heterosexual, and transsexual tendencies, all of
which may be present at one time while at another only one style will
predominate. There are men who report episodes of fetishistic cross-
dressing only rarely, say four or five, in their life. This desire is then
replaced by that of wanting to appear like a woman and to live as a
woman, but they insist on retaining their genitals. Others progress further
to requesting ‘sex transformation’ operations. In many regards, by the time
we see the latter they look (in physical appearance and deportment) rather
like transsexuals. We distinguish them from transsexuals in that their life
history is different, early childhood especially: these men* have valued
their penis in the past. It has given pleasure and they have lived
comfortably at times in a man’s role. They come upon their transsexual
desires later in life than do the true transsexuals and then work hard to
learn the transsexual role rather than inventing it spontaneously in early
childhood. On being refused treatment, they often later return, reporting
they have reverted to fetishistic crossdressing or pleasurable sexual
relations with women but especially that they no longer want a ‘sex
transformation’ operation.
CASE FIVE
This man, in his 30’s, is married with two children. He is a completely
masculine looking man and has never made any attempt to pass as a
woman, though he regrets not being one. The wish to be female developed
only in the last ten years. He has had no homosexual experiences. In his
capacity as a pharmacist, he has been able to take estrogens. When he does
so he feels very calm and is especially pleased that his sexual desire drops
away, though he feels guilty that he is now being ‘unfair’

*And they clinically usually have the ‘feel’ of men; because of a masculine aura,
we are uneasy using female pronouns with them.
154 THE TRANSSEXUAL EXPERIMENT

to his wife. After taking estrogens for a few months, his breasts begin to
swell; this also makes him feel guilty (though pleased he is more
feminine), and so he stops taking the estrogens. He then becomes
depressed. He has had three episodes in his life of sexual excitement when
putting on his wife’s underclothes; but these were not so exciting that he
was compelled to repeat them regularly. In fact, between each of these
episodes was several years’ freedom from such desire. He wishes now to
have his genitals removed but does not care if an artificial vagina is
constructed. If he could get such an operation, he does not wish to have his
facial or body hair removed nor to dress or pass as a woman.
Etiology
The etiologies seem as mixed as the phenomenology in such patients.
One fact has emerged so far: none has the early childhood family history
(etiological factors) the transsexuals have.

Biologically-Induced Cross-Dressing
This is a heterogeneous group (discussed in Chapter 10) in whom
biological forces, mediated through the CNS, are felt to cause cross-
dressing, regardless of childhood experience and environmentally
produced character structure. These, reported so far only in males, are:
1. Congenital hypogonadism (see [17] for a review of the literature).
2. Temporal lobe disease (see [18] for a review of the literature).
In a small but suggestive number of cases of the above disorders, cross-
dressing appears. It is not known why, nor why the greatest number of men
who also suffer these biological states do not cross-dress. The cross-
dressing is not accompanied by sexual excitement.
(It is odd that these few cases have convinced some workers that cross-
dressing is biologically induced, a logic that makes anxiety an adrenal
disease because tension is high with pheochromocytomas.)
CASE SIX
This person was born a normal-appearing male; there was
 THE TERM ‘TRANSVESTISM’ 155

never any suspicion in childhood that he was not a normal boy, for there
was no visible anatomic defect. He has now, in his 20’s, been discovered to
be intersexed—an XXY Klinefelter’s Syndrome. From earliest childhood,
he was like a transsexual in that he would cross-dress whenever possible,
acted like a girl, and wanted to be so transformed. Neither of his parents,
however, were at all like those found with transsexuals; also, the feminine
behavior was invariably forbidden. After his male genitals (which had
never responded with an erection) were surgically removed, an artificial
vagina produced, and estrogens given, the patient developed intense sexual
sensations in the artificial genitals and for the first time in her life has
orgasms. She is now trying to get her birth certificate changed to female so
she can marry her fiancé.
Casual Cross-Dressing
Children occasionally try on the clothes of the opposite sex without
sexual excitement, without persistence, and without thoughts of changing
sex. While this behavior may draw psychodynamically from identification
with the opposite sex, the process is far weaker than in the conditions
discussed above. It is transient and casual, not leading to later pathology.
Some adults may act similarly under carnival conditions such as costume
parties and Mardi Gras.

Comment
Behind this concern about diagnosis lies a point of view: different precise
constellations of behavior have different precise causes, and, until the
discovery by pharmacologists of the ‘universal antidote’ for unpopular
behavior, different treatments are indicated. So, if, as is the thesis here,
different disorders are mistakenly considered to be the same, how can one
ever find their separate etiologies ? If, for instance, one believes that
transsexualism and fetishistic cross-dressing are the same, then the
discovery that only some of these ‘transvestites’ have a particular set of
family dynamics may lead to the confused belief that, since this etiology is
not found in all ‘transvestites’ it is not etiological in ‘transvestism’. But if
one can see in the signs and symptoms that there are two different groups
and that the particular family dynamics rather precisely fit the one group
156 THE TRANSSEXUAL EXPERIMENT

only, then one is on the way to clarifying diagnostic and etiological

puzzles.
In addition, mistakes in diagnosis can lead to disastrous consequences
with treatment. To perform ‘sex-transformation’ operations on the
psychotic or near psychotic is to risk subsequent wildly aberrant behavior;
or, in the effeminate homosexual, his sense of loss and the impossibility of
undoing the castration at times may lead to suicide. This is no theoretical
point. There are surgeons, perhaps with the cooperation of psychiatrists,
who will operate on any of the patients in the first six categories listed
above, so long as the patient is sufficiently demanding in his request for
‘sex transformation’. Naturally, this is terrible medical practice (see
Chapter 20).
Since the classification of cross-dressing suggested here is an unfamiliar
one, it may be of value to summarize the important differences between
the three main categories.
It is especially around the meaning and the uses of the penis that
fetishistic, transsexual, and homosexual cross-dressing can be
distinguished. (1) Fetishism: As we have seen, fetishistic cross-dressing
does not exist in transsexuals and is very rare in homosexuals. (2) Erotic
pleasure in the penis: is not acceptable to the transsexual but certainly is in
the other two most powerfully. (3) Object choice: The fetishistic cross-
dresser, when another person is present for sexual purposes, prefers a
female (and senses himself to be heterosexual); the homosexual prefers a
male (and senses himself to be homosexual); the transsexual prefers a male
(and considers himself to be psychologically heterosexual but anatomically
‘homosexual’). (4) Sense of maleness: The fetishistic cross-dresser
believes his penis, his maleness, and his masculinity valuable, endangered
and preservable only by means of his perversion (more or less); the same
is true of the homosexual; the transsexual cannot stand his maleness or his
genitals and makes tremendous efforts to get rid of them.
A second major area useful for distinguishing these conditions is the
expression of feminine behavior. The transsexual would do so all the time
if permitted and is unaffectedly feminine in these expressions. The fetishist
does so only intermittently and adds an essential piquancy to his
perversion by alternating masculinity with (incomplete) feminine role
playing. The
 THE TERM ‘TRANSVESTISM’ 157

effeminate homosexual labels his performance as imitative; he mimics

feminine behavior.
Third, the histories of the conditions are different in that transsexualism
starts in the first year or two of life and persists unchanged (without
treatment); it is not preceded by an earlier stage of masculinity. Fetishistic
cross-dressing begins only after some years (sometimes starting as early as
4, 5, or 6 but often not until adolescence or later), before which there is a
clear-cut masculine development, with associated pleasure in masculinity,
a sense of masculine identity, and desire to remain a male. The same is true
for the effeminate homosexual. Both of the latter seem to be attempts to
preserve the sense of maleness.
Last, in etiology, the transsexual is the product of the symbiosis, a
process that starts from birth and continues uninterrupted for several years.
In the fetishistic cross-dresser this excessively close symbiosis is not
found, but rather there is progressive separation from mother and
development of masculinity; this process is then put under attack by a
female, especially by clothing him in female garments, to embarrass his
sense of masculinity. In the effeminate homosexual, there is often an
intermixing of excessive gratification and punishment; this blackmail is
exerted by the mothers whenever the already developed masculinity is
expressed by the boy.
The difficulty conceptually, if not practically, comes with the patients
who do not fit (i.e. the mixed group). May not this ordering into categories
be an artificial clarification produced by extracting out of a continuum
these patients with mixed features? We are now in the familiar dilemma of
psychiatric classification when etiology is not organic and when a myriad
of different forces can produce the most subtle shadings of character
structure and disorder.
The problem comes partly from the concept of a continuum, which can
sometimes express reality and sometimes hide it. Thus, saying there is a
continuum of cross-dressing (19) may obscure further understanding.
(There is a continuum for bellyache, but the condition is sometimes due to
tuberculosis, sometimes to a fifth of whisky, and sometimes to anger.) The
fact is, as we know, there are continua that make up larger continua.
Regarding cross-dressing, here are a few: how often;
158 THE TRANSSEXUAL EXPERIMENT

how completely; for how long; how natural-appearing; with how much
hostility. Yet even this ‘precision’ can fail. There is no continuum for
fetishistic cross-dressing in transsexuals; they simply are never excited by
clothes any more than are most humans. There is no continuum for the
blissful, excessive symbiosis found in the transsexuals; the mother-son
relationship is not infiltrated with the double bind and blackmail one sees,
for instance, in the effeminate homosexuals.
Among the men seeking ‘sex transformation’ procedures, however, we
occasionally see a man who did not start in earliest childhood with his
feminine behavior, who has had a few episodes of fetishistic excitement in
his life but not in recent years, and whose natural-appearing femininity at
the present time is indistinguishable from that seen in transsexuals. He
falls between the transsexual and the fetishistic cross-dresser. In this
regard, then, there is a continuum (made up of many different continua) of
patients who less completely but partially fit criteria of both
transsexualism and transvestism. When one has seen the clear-cut
examples of each group, however, one once again feels clear-cut
diagnostic categories are useful. This may be so till the day one will know
so much about every person’s past—both what was done to him from
infancy on and what he makes of what was done—that these psychological
contributions to etiology will convince us that everyone is more different
than diagnoses imply.
These issues will only be worked out if many workers study many
patients. Then, one can better judge the value of this diagnostic attempt.
The simplest test of the hypothesis is to take a person with a similar—but
not the same—condition and see if he grew out of the same family
dynamics. If he did, the hypothesis is inadequate; if he did not, belief in
the hypothesis is strengthened (though it is not proven). Let us do this now
with the two conditions most similar to transsexualism, homosexuality (in
the next chapter) and transvestism (in the following) ; although some of
the defining features have already been noted, it should help if we lay each
of these subjects out more extensively.
First, let me establish that transsexualism and homosexuality are similar
but not the same.
 THE TERM ‘TRANSVESTISM’ 159

Chapter 11
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Aberrations, Vol. II., by W. Stekel. New York: Grove Press.
2. Prince, C. V. (1965). Survey of 390 Cases of Transvestism. Read at
Western Divisional Meeting APA, Honolulu, Hawaii.
3. Bak, R. C. (1953). ‘Fetishism’. J. Amer. Psa. Assn. 1.
4. Fenichel, O. (1930): ‘The Psychology of Transvestitism’. Collected
Papers, I. New York; W. W. Norton, 1953.
5. Freud, S. (1940 [1938]). ‘Splitting of the Ego in the Process of Defence’.
S.E. 22.
6. Greenacre, P. (1953). ‘Certain Relationships Between Fetishism and the
Faulty Development of the Body Image’. Psychoanal. Study Child 8.
7. Allen, C. (1969). A Textbook of Psychosexual Disorders, 2nd ed., London:
Oxford University Press.
8. Bakwin, H. (1960). ‘Transvestism in Children’. J. Ped. 56.
9. Benjamin, H. (1966). The Transsexual Phenomenon. New York: Julian
Press.
10. Lukianowicz, N. (1959). ‘Survey of Various Aspects of Transvestism in
the Light of our Present Knowledge’. JNMD 128.
11. Bieber, I. et al. (1962). Homosexuality. New York: Basic Books.
12. Meerloo, J. (1967). Letter to the Editor: ‘Change of Sex and Collaboration
with the Psychosis’. Am.J. Psychiat. 124.
13. Ostow, M. (1953). Letter to the Editor: JAMA 152.
14. Socarides, C. W. (1970). ‘A Psychoanalytic Study of the Desire for
Sexual Transformation (“Transsexualism”): The Plaster-of-Paris Man’.
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15. Stafford-Clark, D. (1964). ‘Essentials of the Clinical Approach’. In
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16. MacAlpine, I. and Hunter, R. A. (1955). Schreber: Memories of My Mental
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Lobe Disorder’. In Transsexualism and Sex Reassignment, eds. R. Green
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In Sexual Inversion, ed. J. Marmor. New York: Basic Books.