Anda di halaman 1dari 27


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


No one has yet suggested that female transsexualism is not the same
condition, except that it occurs in a female, as male transsexualism. I shall
do so now, however. While both are the extreme of reversal of masculinity
and femininity, they seem otherwise different to me clinically,
dynamically, and etiologically. If they were the same, that should not be.
So again, we can make an experiment and see if contrast will serve to
control variables.
What is female transsexualism? (Let us restrict ourselves to those who
are biologically normal by present-day measures.) At birth, this female
infant is unequivocally assigned to the female sex: her parents have no
question that they have a girl and do not directly or subtly tell her she
really is somehow a male (as may be done with hermaphroditic children).
Then, nonetheless, this biologically normal and properly assigned infant
girl begins to show masculine behavior and interests as early as age 3 or 4
(and in a few cases earlier). The progress of the development of gender
identity (masculinity or femininity) then proceeds in a masculine direction,
so that by the time the child is 7 or 8, she has invented a boy’s name, plays
only with toys that boys usually prefer, walks and talks like a boy, has
developed unusual physical skills (as in athletics) and is stating openly to
family and friends that she is going to be a boy when she gets older and is
going to have the body changes (e.g. a penis) necessary to permit sex
reassignment and live from then on as a man. Unlike other types of
masculine females, there is


* I am indebted to my colleagues, Drs. Howard Baker, Justin Call, Richard Green,

Maria Lymberis, and Lawrence Newman who shared their patients and their findings
with me in this search for etiology.

no episode of clearly feminine development that has been thwarted and

overlaid with a secondary masculinity.
Growing older, she will be more and more insistent on being treated,
permitted to live, and dress as a boy, and will be on the way to
accomplishing the complex task of passing into membership of the
opposite sex. Powerful impetus toward that change occurs after puberty
and its hated development of menstruation and female secondary sex
characteristics. Sooner or later (nowadays usually in late teens or early
20’s) the transsexual will have passed, accepted as a male by a society that
does not know ‘him’ to be a female. Then ‘sex transformation’ procedures
will be negotiated (pan-hysterectomy, mastectomy, testosterone
administration and attempts to find a functional penis).
From childhood on the patient is attracted to feminine females. In
adolescence and adulthood these will further be defined as feminine,
heterosexual women with no homosexual drives visible or present in
history, women who desire pregnancy and motherhood, and who like male
bodies, not female bodies; only such women will be chosen for loving
and/or sexual relations.* Transsexuals deny they are homosexual and avoid
homosexual women, except occasionally as non-sexual acquaintances, for
two reasons. First, a homosexual woman, in desiring the transsexual,
defines the latter as being female, since the former, by being homosexual,
announces her preference for female bodies. Second, by wanting to touch
the transsexual’s body, the homosexual threatens the transsexual with a
most intense reminder that the latter’s body is female.
Intellectual and professional pursuits will be those defined by the society
as masculine (e.g. cowboy, machinist, engineer) without a feminine tinge
to them. Unlike what ‘butch’ homosexuals express, one does not sense
competitiveness with or anger (or studied denial of anger) at men for their
maleness. On the other hand, there will be no ‘give away’ of the secret by
feminine or effeminate behavior in even the most casual circumstances,
such as leg crossing, cigarette smoking, ball throwing, walking, and
vocabulary choice.
It is this group I shall call female transsexuals. There are,
* In fact, all the partners of transsexual females we have seen have looked like this.
I would add only that none of these women had a happy heterosexual life and none
gets pleasure from having a penis penetrate her.

in addition, very masculine women who are more or less similar to the
above description. However, I shall not be considering them but only
mention them now as points on a continuum of differential diagnosis:
‘butch’ homosexuals, mothers of transsexual males, and tomboys. (For
further discussion of the similarities and differences in these groups, see
Family Influences as Etiological Factors
Discussions about etiological factors are almost non-existent in the
literature (See Pauly’s review of the recent conjectures [6]); it is not yet
clear what forces cause female transsexualism. But the following
preliminary ideas on dynamics may be worth further investigation. At least
they can be given the form of testable hypotheses so that others seeing
patients who fit the above description* can check whether these factors
were present in their patients.
I doubt if female transsexualism is a biological abnormality present at
birth or shortly thereafter.† Rather, as a clue, let us recall the comparable
finding that male transsexualism may grow from a complex but clear-cut
family pathology to suggest that we search for a non-biological etiology in
extremely masculine females.
The search has been a long one. Since 1957, I have

* There is no point in discovering that these factors are not present in other
masculine females who do not however fit the description just given. That would
hardly test the hypothesis. A better test is when these factors are found in non-
transsexual females, for this would indicate that they are not exclusively etiological
for female transsexualism.
† If there are biological factors, there is no clear evidence yet. Arguing from
experiments performed on animals is neither convincing nor unconvincing; so far, it
is too close to arguing by analogy. More significant to me is the work of Money (5),
who has found in the unhappy ‘experiment’ when pregnant women are given
progesterone to prevent abortion, a number of the female infants are born with
masculinized external genitals; 8 or 9 years later, these girls, although heterosexual in
orientation, are unusually active and tomboyish. But even this is not proof that some
such force is at work in female transsexualism. At present, since one cannot
experiment on human fetuses, the biological hypothesis is not testable. On the other
hand, the hypothesis I am suggesting can be tested in the next few years, probably
even by rather simple interviewing of parents of transsexual females.

seen in psychotherapy* (which has been of no use whatsoever, if one’s goal

is to make the adult patient more feminine; there are optimistic hints in
treating children), five patients of colleagues in research conferences, and
one for evaluation only. Only recently does it seem that some of the pieces
are falling into place (one of the advantages—if the findings turn out
correct—of long-term studies done in the trusting ambiance that treatment
can provide). These pieces are:
(1) An infant who does not strike the parents at birth or later as beautiful,
graceful, or ‘feminine’ (whatever that would be to the parents of a
( 2 ) An infant who is not cuddly when held but who habitually pushes
away, even if a good feeder.†
(3) A feminine mother who at the birth of this daughter and at times later
in childhood is removed in affect from her child, most often by overt,
severe emotional illness, usually depression.
(4) A masculine father, who is nonetheless not present psychologically in
at least two crucial areas:
(a) He does not support his wife in her depression.
(b) He does not encourage this daughter’s femininity in the ways
fathers of feminine daughters do.
( 5 ) Given these factors, the little girl is shot into the breach that her
father abandoned, the role of succoring husband; the motive that propels
the drive toward masculinity seems to be the family’s manufacturing out of
this daughter a substitute male (a husband) to assuage (‘treat’) mother’s
depression.‡ This is done by constant encouragement of masculinity by
both parents. Simultaneously, the child on her own is inventing a role—the
masculine father-substitute—to mitigate her own

* One for 3 years and then a 7 year follow-up until death; one for 3 years, and then a 9
year follow-up to the present; one for 4 years to the present; one for 2 years with no follow-
up; one for 1 year with a 4 year follow-up by mail only to the present; one for one year with
a 3 year follow-up to the present; and one for 6 months with no follow-up.
† There are no feeding problems consistently reported in these infants.
‡ Different families, of different make-up, will manufacture other creatures out of their
children in order to fill vacuums, appease guilt, improve social position, provide a sacrifice
(as in families of some future suicides). It has often been noted that families, like other
social institutions, are organisms with homeostatic mechanisms of their own that may be as
much at odds with the individual element (person) as those of the body differ from
individual cells sacrificed for the whole.

terrible loneliness produced by having a mother whom she cannot reach

and who does not reach out to her. Soon the process becomes self-
perpetuating, when what at first was the development of isolated areas of
high performance that are not inherently masculine or feminine (e.g.
throwing a ball well, not crying when hurt, facility with a tool) coalesce
into an identity, a sense of masculinity. This occurs both by the family’s
invariably encouraging masculine behavior* and by this masculine-
oriented father enjoying sharing masculine interests with his daughter
I am sure, however, that these mechanisms are not always present in the
most masculine of females and shall briefly review a case (Case Ten)
where they were not all present. This need not disprove the hypothesis, but
it suggests that we must be cautious about everything regarding female
transsexualism from diagnosis to etiology.
Case Material
I have drawn more from colleagues’ cases than from my own for the
case material reported here in order to minimize the possibility that my
theorizing might influence the findings unduly.
His colleagues have no suspicion this transsexual female is not a male.
He is a social worker, responsible, skilled, an empathic administrator and
therapist. Two years ago, before passing from a woman’s to a man’s role,
the patient was a borderline psychotic, sharply depressed, very masculine
woman on her way to suicide.‡ She then passed as a male, and for the past
year has been a socially useful person, contented, no longer borderline, no
longer depressed. The following is excerpted from a conference with our
research team after the change.

* At least until, too late, they awake to the child’s rather total masculinity.
† This patient was treated by Dr. Newman.
‡ When forced to be a woman, she had believed that she was not a human but a
‘hollow giant’ who simulated a live person. She owned some puppets whom she
believed to be alive and who gave orders that propelled her activities. While
appearing to relate to others (and thus not considered odd by colleagues at work—the
only people with whom she associated), she did not believe that this was reality, since
she did not exist.

Dr. S: Tell us what your mother was like and what your father was like?
Pt: Well, my mother doesn’t much think much for herself; usually she mimics
or says whatever my father says, like he makes a rule and she goes along with
it. She takes care of the house, and she pays the bills and she makes sure my
father does the things he is supposed to do. My father’s very handy; he built
our house and he built an electronic elevator for the office and he drew the
plans on the architecture for the building. He is a bee keeper and he does
mechanics; he is a gardener, a photographer. He was a real groovy dad. My
brother and I both dig my father, except it is very difficult to talk to him. They
neither one of them knew my brother or myself as far as how we felt or what
we thought about. Because they were so busy doing things because it is a sin
not to always be constructively using your time to the best advantage so if
you were not always doing something you better get with it kid. So I learned
lots and lots from my father because he would let me do things with him, and
I learned a little bit about everything he does.
Dr. S: How old were you when that started ?
Pt: Ever since I can remember. When I was 3 he was helping me make
woodwork and letting me use the jig saw and leather craft and doing crafts
and pot holders and stuff and. . . .
Dr. S: Were you masculine at that time ?
Pt: Yes.
Dr. S: And he was encouraging ?
Pt: Well, he wanted me to be a girl, but I guess he didn’t see anything wrong
with it; he could see it made me very happy to make stuff with my hands, and
I was good with it.
Dr. S: If you put on boys’ clothes, what would he say?
Pt: They let me because I used to cry so bad or I used to withdraw or something
if they would not let me wear jeans and my mother dressed me in pants
because it was cold in the winter.
Dr. S: I would like to hear more still about her and her personality.
Pt: Well, she was, is always sort of sickly. If anything goes wrong, she goes to
bed and sleeps it off and has to go to the doctor to get a vitamin B-12 shot,
and that gives her nervous energy and immediately takes effect, and like at
Christmas if we all came home and something would upset her she would run
to the bedroom and say, ‘I am just too tired’ and then we would have to

take over and do stuff. When I was younger I used to have to bring a cover
and cover her up in the living room on the couch and bring her her supper
sometimes, and I had to do the washing and the dishes and clean the house
and stuff like that.
Dr. S: How did you feel about that ?
Pt: I didn’t like it. I used to fight quite a bit.
Dr. Z: Is there any story you know in terms of your mother being disturbed
when your brother was born or when you were born ?
Pt: Well, I guess she had some kind of a depression after she had my brother.
She didn’t go to a hospital, but she stayed in somebody’s home. I don’t know
what it was but she wasn’t—like with me, she did not take care of me for the
first 6 months or so; I guess she had to lie in bed all the time.
Dr. S: Who did take care of you ?
Pt: She did not during the day; she didn’t go out of the house; she just kind of
laid in the house all the time, and she wouldn’t go to the bedroom upstairs;
she just slept in the studio room downstairs for a long time because she had
just had a baby, and she couldn’t walk upstairs.
Dr. Z: Who filled in then ?
Pt: We had a housekeeper. When I was a year or so, she [housekeeper] went
back to school, and I had baby sitters and housekeepers from the age of 10
months. They came and went.
Dr. S: Did your father participate to a great extent in taking care of you at that
time ?
Pt: I can only remember my father putting me to bed or tucking me in, which
wasn’t very often. I usually put myself to bed. He would read me stories and
put me to bed sometimes.
Dr. B: Did he fill in a great deal?
Pt: I would say that when he came home from work he probably did quite a bit
take care of my brother and me. That’s what I think and what my mother said
too; that she was unable to do much for a while and so my father did, like
because he sews and stuff too. My mother can’t mend so my father mends
our clothes. He also cooks when my mother doesn’t feel well, and he dug us
kids. He likes kids. So I am sure he took over the care of us, bathed us and
stuff like that because he liked us and probably enjoyed doing that. I really
liked my father. I was daddy’s girl. I didn’t like my mother, and anything that
went wrong or anything I wanted I always went to my father, and I would be

good if I sat on my father’s lap in church, and I always begged to go with

him; I didn’t like to stay home with my mother.
Dr. S: Were you daddy’s girl, like we are familiar with that term ? Daddy’s girl
usually has ribbons, clothes and cute dresses, and she is always hugging
daddy and kissing him and snuggling.
Pt: I was very independent of him, but I would go to him for ‘Let me help you. I
want to do that too.’ I was a carpenter one day and an electrician the next day,
and a leather craft man the next day. No, I never—affection is not one of the
things in our family; there wasn’t much touching or kissing or anything like

This 8-year-old girl’s mother was acutely and dangerously suicidal early
in the girl’s life, having been chronically depressed for years before. The
child’s father impressed us as a masculine man, not passive, but interested
in and a real part of his family. Unfortunately, as he notes, this could not
always be so. The parents tell us of their daughter:
Father: She’s always been a very active child, in the last two and a half years,
three years, we have been concerned and have talked to the pediatrician about
her insistence on playing with boys, and boy games, and later on it became a
fact that when she grew up she was going to grow up to become a boy and in
other words she had definitely the idea that ‘when I grow up I will turn into a
boy.’ And then when the movie, the Christine Jorgenson thing, came out
again she began spouting about she could get an operation when she grew up
to become a boy. Television, the news—the TV news and she was watching
the six o’clock news with me and from then on she was going to grow up and
she could have an operation. Everything boys did was more fun and more
active, and she’s always been a very active child—but the complete
insistence on it! Boys get to do more things than girls do.
Mother: Our youngest child [girl] is much more of an indoor child, will sit and
play indoors, will play in her room and entertain herself for much longer than
X [patient] ever did. X is not an indoor child even now.

* This family was first seen in evaluation by Dr. Green and then interviewed (the
present material) by our research team. The mother subsequently refused treatment
with me, perhaps correctly, fearing she might again become suicidal.

Father: Because even as a small baby, even under a year old, she would be held
when you fed her but as soon as she was through eating she would kick and
push and she was never what I’d call a cuddly baby. She was always very
active, where the other one was always, as long as you held her, she was
happy. Just two extremes. And she always, even 1, 2, 3 years old would rather
roll a ball or anything like that and her interest span was for active things, not
for any type of thing that took any kind of patience or time; she was always
very, very active. She insists a lot of times that she’s not a girl, that she’s a
tomboy. ‘No, I’m not a girl; I’m a tomboy.’
Dr. M: Do you remember whether either of you had any preference before she
was born as to whether you were going to have a boy or a girl ?
Mother: I wanted a boy.
Dr. M: You wanted a boy. And you?
Father: I wanted, for my first child, I wanted a boy, but I didn’t feel at the time
disappointed that it was a girl. . . . My honest feeling with her was that she
was the ugliest thing in the world. She had no forehead and. . . .
Dr. K: How long do you feel your depression went on and how did that affect
your relationship with both children ?
Mother: It went on for two years [including several hospitalizations for a total
of one year] and it affected my relationship with my children—to the point
where Y spent—until I started going into hospitals—the first 9 months of her
life in a crib. I picked her up to change her maybe once during the day, but
she got all her bottles in her crib or her playpen and X would just play outside
or I would lay on the couch and she would watch cartoons. And then she was
uprooted out of kindergarten and taken to stay with her aunt and uncle.
Dr. M: Your statement about X being an ugly baby, did that affect your own
desires and feelings about holding her and cuddling her; did you feel less
inclined to cuddle her?
Father: Well, that was my initial reaction—when they held her up in there—she
had still the little wrinkles—no forehead whatsoever; she went straight up,
and she had two gigantic forceps marks on each side of her head and her
forehead was still all wrinkly like a hand that had been in water. And a friend
of mine who was with me reassured me that these things go away, but my
initial look at her was: boy, what has she got. And I was disappointed more
that she was so ugly more than I was disappointed that she

was not a boy. And then after a couple of days naturally, these things went
Dr. M: After that initial period, did she become a fairly attractive little baby?
Father: Yes.
Dr. G: What are the really feminine things that she likes to do ?
Father: How about being the bat-boy for the City College baseball team?
Mother: She cooks pretty well. . . .
Father: We got her an oven for Christmas, and we were delighted — two
Christmases ago she wanted an oven so she could cook; she made one cake
and the oven hasn’t been used since, even though we’ve tried to encourage
using it.
Mother: I got her hair cut right before school, and it’s short and I was getting
her ready to come up and see Dr. Green, and she had on a pink pants suit and
her tennis shoes, and I said—because she was after me to get her hair cut
short, because I was letting it grow—and I said, ‘How do you like your hair’,
and she said, ‘I don’t; it makes me look too much like a girl and I want to be
a boy.’
She [X] has a unique image of herself; she thinks she can relate better to
boys than she can to girls. And in the primary grades at school, the girls and
boys have recess together; when they reach the fourth grade they’re
separated. The boys have P.E. and the girls have—they don’t play together.
And the teacher was saying, she shouldn’t play with the boys at every recess.
And then she went to City College and became the bat girl for the College
team and left her own friends her own age and did nothing but go down there,
and she claimed that they were her friends, and I didn’t feel that 19 and 20-
year-old boys were her level. And then I walked up one day and met the
coach and in front of her he said, ‘She certainly is a good little baseball
player; we could use her on our team because we’re losing.’
Father: I think too, one of the reasons the boys still accept her is that she is
good; she is a good basketball player for her age and as good, if not better
than most of the boys and she is a good, if not better, baseball player than
most of the boys.
Mother: She went to school one day and came home just beaming because she
had played handball with an upper grader who was a fifth grader, and she
beat him. I said, ‘Oh, that’s nice.’
Dr. K: I’d like to know more about your depression. Were you

away from your home? How long and how old was she at the time?
Mother: She was between 4 and 5,* and I was in and out of the hospital for a
year—a year’s period at different times.
Dr. K: Were you aware of what kind of reactions she had to those many changes
and separations from you ?
Mother: I didn’t care; I didn’t care.
Father: She was concerned about her mother in the hospital and was withdrawn.
I knew at the time I should be spending more time, but I couldn’t with her—
with the two children, but it was almost impossible, and I talked to her doctor
at the time and the decision was made that it would be better for the children
to be in a family environment together with my brother and sister than it
would be to keep them home. And any problems that they might develop as a
result of this illness could be worked out later in life, but the main concern at
that time was returning my wife to the home in good condition which would
be the better thing for the children in the long run. X was very ecstatic when I
would visit there, very unhappy when I would leave.
In the above material one can see these mothers’ depressions and the
fathers who are masculine enough but do not succeed in comforting their
wives. One also learns that the infant, while properly assigned as a
female,† because of her activity and independence, is from the start not
treated as a feminine creature. Then, attributes develop that the parents
consider masculine and encourage. Finally, father, reacting to his
daughter’s oncoming masculinity, offers himself as an object for
identification by spending time teaching her masculine tasks and roles,
rather as mothers usually teach their daughters about feminine roles.
How often is this found ? Of the thirteen females I have known who may
have been transsexuals, seven were in the early days when I did not know
enough to search for an etiology in the family. Of these seven, three
families (Cases Five, Six, Eight) nonetheless fortuitously gave such a
history, while in one these

* At other times we learn that mother was constantly depressed from before the
patient was born, throughout infancy, and childhood.
† A provocative puzzle: In the nine patients in which the first name on the birth
certificate is known, five of the girls were given a clearly bisexual name, that is, a
name appropriate for either a boy or a girl.

mechanisms were absent (Case Ten); in three families there is not enough
Then, after working three years (it would now take a few minutes) with a
patient in her 20’s (Case Four), the above dynamics appeared, and I began
to wonder if they held for other cases. So this patient alerted me to look for
the possibility in the five other cases seen in the past year. In all these
others, the girl was in fact moved in as mother’s caretaker during the
latter’s depression, while father and others (family and friends) encouraged
the developing masculinity.
Let me report much more briefly on these other cases. Only a glance can
be given to each lest the chapter be inordinately long.
The patient was 8 at the start of treatment. The following paragraph is
taken from a summary placed in the patient’s hospital chart by her
therapist* before I developed the present hypotheses. I quote only a sample
that demonstrates how this mother was depressed and unsupported in her
pain by her husband.
The patient’s interest in boy’s clothes and her wish to be a boy date back to
the years of 2-3 years old. At that time her parents separated and her father
disappeared for the next two years. Her father has been in contact with his
children on a regular basis since the parents were divorced which was when the
patient was 5½ to 6 years old. The patient’s mother became very depressed,
unhappy, and extremely hurt over the separation and divorce. In fact, she had
even contemplated suicide on various occasions during those years. She saw a
psychiatrist for a few sessions but declined treatment. She herself stated that she
was totally preoccupied with her own problems and just went through the
motions of physically taking care of T, in her infancy and early childhood.
However, she was not able emotionally to relate to T, and she was unavailable
to her on an emotional level. In fact, she was unable to relate emotionally to
anyone else for several years and even at present she is not quite over this.

* Maria Lymberis, M.D., treated this child for two years. The mother was also
treated at UCLA.

This patient is a 24-year-old identical twin, a physically normal female
whose twin is not masculine. (This case is the one reported in Chapter 14.)
The patient’s father is a passive, distant man, who, while masculine
enough at work is a silent participant in the family. His wife, who was
quietly depressed for many years, gradually became more and more
sensitive until six years ago, when she began to require psychiatric
treatment for a paranoid condition, which gradually developed into a
chronic paranoid psychosis. This twin, the more active and more
physically healthy from birth on, was always encouraged to display
masculine behavior while her twin sister, who was not, did not become
This case can serve to represent the typical rescue fantasies that are the
product of, and demonstrate the action of, the family dynamics
hypothesized here as etiological for female transsexualism. If these girls
become masculine because they substitute for father in trying to rescue
mother from her depression then we should expect to find daydreams that
mark this dynamic as well as behavior that acts out the rescue fantasy in
the real world.
The patient, living away from home, was told that a tumor had just been
found in her mother, who would be operated on the next day. She
responded, ‘I must go there immediately; there is no one else who can help
her.’ She said this despite her father being with her mother, as were her
twin sister and brother.
Here is a typical daydream:
Pt: I have often imagined that I was a police officer riding on a motorcycle. I
think of myself riding along on the freeway and I see someone parked on the
inside [most dangerous] lane, and they can’t get to a phone. So I stop and
help them. But I couldn’t want to give speeding tickets or things like that;
that’s not interesting.
Dr. S: ‘Someone’?
Pt: Well, of course, not just someone. A woman.
The patient then adds that there are endless fantasies, sexual or not, in
which ‘he’ rescues a beautiful, feminine woman in severe distress. ‘He’
may be a gunfighter, medic in the army,

astronaut, or any other heroic, manly figure, but the essence of the story is
that a woman in distress is rescued.
The second half of the fantasy tells us more of the underlying dynamics.
Having undergone the great danger and having been exhausted or
wounded beyond the capacity to help himself, but having successfully
performed the heroism, the hero is now cared for and loved by the
beautiful woman he saved.
This is a 9-year-old child brought to treatment* because she believes she
is about to grow a penis. Although for years she has acted as if she were a
boy, her parents were not concerned. She was born about 9 months after
they married. Her mother, widowed the previous year, was devastated by
her first husband’s death, and still sorely depressed, met the man who was
to be her second husband, the patient’s father. He insisted they should
marry; although she was emotionally unfit to do so, she did not have the
strength to stall him. An older man, with rescue fantasies of his own
(expressed in his profession), he would not wait to begin having children
but insisted the couple should start immediately. So, when the patient was
born, her mother was so depressed that she was simply incapable of taking
care of the child. Her husband substituted as much as possible, considering
that he was not home all day, but the child’s first years were spent in the
presence of a helpless, dazed mother.
The child was mobilized to care for her mother, and this care, interpreted
by her parents as strength, was encouraged; while others see masculinity,
these families recognize only charming independence, pride, and
This now 22-year-old graduate student, accepted by everyone in his
university as a male, first passed successfully as a male in mid-teens, but
he says he has wanted to be a male all his life.
To summarize only the point I wish to make now: Since his earliest
childhood, his mother has never been able to go to a store to shop. In
addition, she never learned to drive. She barely runs her household;
overwhelmed when it consisted only

* With Justin Call, M.D.


of herself, her husband, and the patient, she can still do little better now
that the patient is gone and there are only two to the household.
The patient’s father is a chronically angry man; suspicious of his
neighbors, he never talks with them. He has no friends. He works in an
engineering profession that permits him to deal only with machines. He
considers his wife inept and does what he can to help her remain so.
During the patient’s first three years, he was away in Military Service.
This child, now 14 and in treatment,* was a year and a half when her
mother became bedridden due to bleeding during pregnancy. This occurred
also with the two subsequent pregnancies, ‘and she remembers that the
period during which she was bedridden seemed to increase in duration
with the succeeding pregnancies. During these periods, she would not get
out of bed at all, not even for meals or to go to the bathroom. . . . She
stated that, “This was a trying time because I had no one to rely upon.” ’
Her husband was not available except in the evenings.
On one occasion, ‘She was losing bright, red blood and apparently cried
out in a rather panicked fashion, “I am bleeding”. She doesn’t know what
her daughter saw, but she is sure that the child was very upset.’
Because these cases add no special new information to that above, they
can be summarized simply by stating that in both cases the patient
spontaneously (that is, without specific questioning) related the family
story that mother had been depressed and withdrawn during the first few
years of the now adult transsexual’s life. In both cases father was described
as an ineffectual though not effeminate man, off to the periphery of the
family, while mother, although considered weak and in need of special
handling, was the focus around which the family concentrated.
To summarize these ‘statistics’: Of thirteen cases, enough information
was present in ten to test the hypothesis that extreme

* With Dr. Baker, whose quotes follow.


masculinity in females results when the child is encouraged to be

masculine in order to serve the family as the depressed mother’s caretaker,
father failing to do so. In nine of the ten families, this is reported to have
Here is a summary of the tenth (reported elsewhere [8]) in which the
constellation described does not hold but wherein the child was so
unquestionably masculine that she passed successfully as a male in her
teens.* As far as I can tell, at no time has this mother been depressed and at
no time was mother psychologically abandoned by father. The parents
admire each other and enjoy being with each other. Father is a masculine-
looking man, with masculine interests, a successful and forceful business
man. The nature of his work during the first four years of his daughter’s
life permitted him to be home, and so father and daughter were together
hours a day. He always enjoyed her physical ability, and so the child was
forever encouraged to do things boys do. By 4 or 5, she would not dress in
girl’s clothes and instead was dressing always as a cowboy. This was
encouraged since it matched her remarkable skill in riding horses, at which
he has become a master.
By 8 or 9, the child now very masculine — and still with no protest from
her parents — began turning from her father. She felt he was not good
enough for her mother, who had to be protected from his alleged
boorishness. This became so intense that a good part of my treatment with
him (masculine pronouns now, to indicate successful passing) dealt with
his rage against his father. He could not stand the idea that his mother
loved his father, much less that they could be intimate. He was convinced
his father was an alcoholic because father had a drink or two before dinner.
During rages, he would accuse his father of being brutish and insist (for
instance by smashing a liquor bottle) on shielding his mother while she
protested she did not need such protection. These violent reactions stopped
only when the patient finally moved away from home.

* He was in psychotherapy three years, with nine years’ follow-up to the present;
the parents were also seen many times.

Among the factors that may assist a little girl in becoming feminine and
heterosexual* are a feminine and heterosexual mother. As we know, there
are various aspects of her mother with which she should identify if a little
girl is to grow up to be (what our society has defined as) feminine:
mother’s femaleness (a sense of comfort with one’s sexual anatomy);
mother’s femininity (a sense of comfort in behaving and fantasying in
whatever styles are defined as feminine in the society); mother’s
motherliness (desire to bear and raise children); mother’s heterosexuality
(desire to be with and penetrated by a male); mother’s wifeliness (desire to
be married and to appreciate her husband in his role as her husband).
Likewise, a girl’s femininity can be promoted by her father; if he sees her
clearly as a female, encourages her feminine behaviour, likes being close
psychologically and physically to her (even with an occasional minimal
erotic quality to this)—if he openly enjoys her femaleness and femininity,
the little girl will be reinforced in admiring these attributes in herself and,
while frustrated in her hopes to possess her father, will anticipate a future
in which she will share in the pleasures of heterosexuality, including
marriage and having her own children. To what extent are these factors not
at work in the childhood of the female transsexual? The preceding case
material gives the answer: both parents encourage their daughter to be
boyish. Whatever dynamics lead to masculinity in these girls, a final
common pathway is parents’ pleasure when they see it.
To test the hypothesis, we should now ask parents of transsexual girls if
at birth the infant was unbeautiful, boyish-looking, unlovely, ungraceful,
unusually active, or uncuddly.'†

* The two words overlap in their meanings but are not synonymous, e.g. there are
feminine homosexual women and masculine heterosexual women.
† Those girls we have seen up to puberty have, despite masculine interests and
dress, not been physically masculine; their physiognomy and build have been fine-
featured and girlish. The active, uncuddly, unpretty quality of the first months does
not grow into a masculine look in bone structure or muscle distribution. So, in
addition to there being no evidence on physical examination or special laboratory
tests of a biological abnormality, there is no evidence of a masculine diathesis. The
only biological contribution the child may make is that she does not strike her mother
as soft, cuddly, or graceful in infancy.

Then we can ask how mother (and later father as he begins to impinge
upon the infant’s perceptions) responded to these ‘masculine’ qualities.
The mother who would discourage them and who would be sensitive to
any gentler qualities that she could feel were feminine would begin a
pattern of positive and negative reinforcement that would quickly shape
the infant’s style of behavior. (This same shaping goes on continuously in
the rearing of all infants and is an essential part of the non-conflictual
contribution of learning to be masculine or feminine.)
If femininity is enchanced by one’s being raised by a mother who is
female, then a girl has an added burden in becoming feminine if either her
mother is not so or if her mother, while feminine, is not intimately
available to the girl in the first year or two of life.
Then, once the process of developing masculinity is well under way and
the child unmistakably boyish, does this behavior, so incongruous to the
child’s anatomy, produce a viable protest in the parents ? Or do they either
encourage it by buying toys and clothes appropriate to the boyish urges or
at least ignore it to the extent that the child, picking her own ways of
manifesting her boyishness, is silently permitted to proceed in the
masculine style? For instance, do the parents give the child a bisexual
name at birth or boyish nickname at a few years of age (showing their
pleasure and acquiescence in the masculinity) or at least accept the boyish
nickname the child gives herself? Do they encourage the dressing up in
boys’ clothes (for instance, as manifested by the parents taking
photographs and preserving the moment in the family album) ? That the
parents report in later years they tried to stop the process after letting it
develop for so long need not be taken seriously if in their description they
say that they complained to the child but did not otherwise act to stop the
Here we are again considering shaping of personality qualities: the girl is
encouraged to become masculine because of distortions emanating from
her parents. But is that all? The analyst cannot help but think also of
defensive maneuvers, the result of cumulative trauma (4), set into action
within the girl to master the resultant chronic states of painful affect. What
is it like to be the infant of a sorely depressed mother* who, being

* That is stated too vaguely—‘sorely depressed mother’ — to permit much


so depressed, cannot make mothering a happy experience for her infant?

One cannot imagine that the growing masculinity is the result only of
passively received forces of ‘shaping’ — positive and negative
reinforcement. It is logical to presume that the child will try to find ways
to reach such a mother, to make her happier so that better feelings will be
transmitted back upon the suffering child. That is quite a different process
of ‘shaping’—more ‘dynamic’—from the blander one usually described.
From time to time the question is raised whether transsexualism is a
clinical entity or an invention of biased reporters. Long-standing issues
that have bothered psychiatrists regarding underlying questions in
diagnosis (for instance, whether a psychiatric diagnosis is in any way
comparable to a medical diagnosis) show up when one thinks about
transsexualism. It is easy enough to collect odds and ends of behavior
together and say that they form a syndrome, though even here there are
problems, such as deciding which signs or symptoms should be included in
and which are fortuitious. Even more difficulty arises when we build a
diagnosis around family and psychodynamics, for we then run the risk of
losing balance; that is, in weighting the significance of a psychodynamic:
is it present but not pressing for expression or is it a principal source of
overt behavior ? (What is even more difficult is the interpretation of
behavior to tease out the underlying psychodynamics: Are they really there
? Is there a consensus that they are there ?).
Finally, one would expect of a usable diagnosis that the etiology of the
condition was known (for therein, in the rest of medicine lies the true
source of diagnostic system). Etiology in psychiatry is not yet a discipline.
And if one’s classification changes its rules in midstream, it must be
tentative indeed: a neurosis may be diagnosed by the outstanding affect
(e.g. anxiety) or behavior (e.g. conversion); psychosis by a mixture of
history, behavior, and psychodynamics; and character

of an answer, but we can expect that the child will be made vulnerable and that her
solutions will be shaped by the specifics of that particular mother, that mother’s
particular way of being depressed, that particular father—and all these details, I
believe, if known to the observer, would tell much why one girl turns out like a boy
and another, for instance, a chronic feminine masochist.

disorders, especially those that are egosyntonic, by how ego-dystonic they

are for society.
An instance: if those called transsexual are really homosexuals* then it
should be questioned whether the so-called transsexuals should receive
different treatment than do homosexuals (as if they were all dealt with in
the same manner). These sticky issues have been discussed elsewhere (3,
8), though primarily in terms of male transsexualism. I believe there are
adequate reasons for separating out male transsexualism from other
conditions in which males in one way or another feel or act like women,
but I would like to worry this question further regarding females.
To start with a conclusion, I believe female transsexualism looks more
‘homosexual’ than does male transsexualism. Let me amplify this. Having
found the constellation of forces already described for males, I expected
something of the same in females, so long as the precaution was observed
of choosing from among masculine females only those who were the most
masculine, could successfully pass as men in society, and who had been
that way since early childhood. In the seven years since finding the
etiological cluster in male transsexuals, our research team had been able to
confirm it, but, although now alert, I was not able to find a comparable
situation in females, that is, mothers with a particular personality and
fathers with a particular personality. One family would raise our hopes; the
next would not show the new-found features—and I was once again
uncertain. Especially troublesome was that our team was not agreeing
from one case to the next as to who was a female transsexual and who was
not but rather a homosexual. We had not had those problems with male
transsexuals,† In

* One’s heart sinks realizing that the term ‘homosexual’ is not used more accurately
diagnostically than is ‘transsexual’.
† I now believe that this is because two very different etiological processes are at
work. In male transsexualism it is a non-conflictual learning process on the order of
imprinting, conditioning, shaping, and identification; this does not cause
homosexuality, a group of conditions I believe are produced as the end-products of
processes of defense against trauma (1, 2, 7). In female transsexualism, defense
against trauma—a depressed mother unable to love and care for her infant—requires
the defense the family helps the girl manufacture. The child is really loved and
admired as she develops boyish traits, and in doing so, one can see the family heal.
Once the gender

female transsexualism we seem to have a syndrome with less sharply

defined clinical boundaries and more variable etiology as is the case in
homosexuality, both male and female.
Whatever the differences, perhaps in these very masculine females we
have a common mechanism at work on the child despite the mothers not
all having similar personalities (except in that they have withdrawn) nor
the fathers (except that they will let this daughter take over some of their
tasks as husband).
The common mechanism appears to be that each of the female
transsexuals reports that as far back as she can remember she has felt very
protective toward her mother and has conscious thoughts of taking care of
her as a husband would (but not with accompanying conscious sexual
fantasies about her), and her mother has reciprocated, openly encouraging
the transsexual-to-be to serve in this protective way. These mothers have
been tired, long suffering, sad, or angry women, left too much alone by
their husbands (except Case Ten). In these families just noted, the little girl
moved into the vacuum created by her mother’s sadness and unfilled by
the husband. Perhaps this child is the one chosen of all the children
because in infancy she strikes her parents as unfeminine in appearance or
One can guess that the mother of the transsexual girl makes clear very
early the task before the girl, which is to protect mother, and that the
mother’s greatest sweetness, drawn from all too limited reserves, is saved
for those moments when her daughter functions properly in this regard.
The first fortuitous acts of the little girl may then be so positively rewarded
that she will increase such behavior, and since, to be a proper protector,
she will have to take on masculine attributes, these, as the months pass,
will begin accumulating. The daughter’s own depression, the result of a
mother who cannot mother, is then

aberration has begun to appear in male and female transsexualism, then the same
process—positive reinforcement of the behavior—causes it to flower. It is the process
of defense against trauma and the erection of identity structures to prevent identity
destruction by recurrence of trauma, that especially allies female transsexualism to
the homosexualities.

‘cured’ only when she does something to which mother will respond
warmly: when the girl acts like a protecting husband.
Whether this is the actual mechanism or not, we do know that the
masculine behavior is not discouraged once it appears. Unlike the mothers
of feminine girls, these mothers permit their daughters to wear masculine
clothes, play masculine games, associate with boys as if a boy, and, with
the increasingly masculine appearance and behavior, the mother is not at
all discomfited. Not only that, but the child, now growing older, is able to
act even more in the role of a husband. (I guess, without data, that behind
using this daughter to fulfill the role of husband, mother is seeking for
herself a good and protective father. When such mothers are treated, it will
be important to find whether their mothers were distant or absent, creating
a void in the little girl who is to become the transsexual girl’s mother.)
As if there is not enough reason for caution in these tentative findings,
the reader may also be warned that all these families are white, middle-
class American. We have seen no black or chicano* transsexual females,
though we have seen such male transsexuals. I simply do not know yet if
this is a sampling error or the result of sociological factors that yield
psychodynamic differences in these families.
Another significant test of these postulates will come in discovering if
other girls, who do not become so masculine, also are used in the same
way (not just similar) to care for their disturbed mothers. So far, I know of
no such reports.
We have many data still to collect; perhaps this is a start.

* Pauly reports two (6).


Chapter 18
(1) Bieber, I., et al. (1962). Homosexuality. New York: Basic Books.
(2) Freud, S. (1910): Leonardo da Vinci and a Memory of His Childhood.
S.E. 11.
(3) Green, R. (1970). ‘Persons Seeking Sex Change: Psychiatric
Management of Special Problems’. Amer. J. Psychiat. 126.
(4) Khan, M. M. R. (1963). ‘The Concept of Cumulative Trauma’.
Psychoanal. Study Child 18.
(5) Money, J. (1969). ‘Sex Reassignment as Related to Hermaphroditism
and Transsexualism’. In Transsexualism and Sex Reassignment, eds.
R. Green and J. Money. Baltimore: Johns Hopkins Press.
(6) Pauly, I. B. (1969). ‘Adult Manifestations of Female Transsexualism’.
In R. Green and J. Money, op. cit.
(7) Socarides, C. W. (1968). The Overt Homosexual. New York: Grune
and Stratton.
(8) Stoller, R. J. (1968). Sex and Gender. New York: Science House;
London: Hogarth Press.