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The Border Area Between Transvestism and Gender Dysphoria: Transvestitic
Applicants for Sex Reassignment
Thomas N. Wise, M.D.1 and Jon K. Meyer, M.D.2
Clinical variants among the population of applicants for sex reassignment
have been previously categorized. These coherent entities were introduced in
an effort to sharpen the clinical presentation of syndromic diversity as well
as to enhance the specificity of prognosis and outcome. The description of
the so-called younger and aging transvestite has been further investigated.
Although the initial group of reported transvestitic patients was small, it
was suggested that these individuals constituted a coherent group definable in
terms of demographic variables, past history, current crises, psychodynamics,
clinical course, and special risks. This investigation presents a
supplementary series of aging and younger transvestites who have applied for
sexual reassignment. Since the original report, further elucidation of the
characteristics of both groups have emerged. The theoretical implications of
these categories have become clearer. The data support the original content
of the classification as an aid to evaluation, prognosis, and treatment.
KEY WORDS: transsexualism; gender dysphoria; transvestism; sexual identity.
1Sexual Behaviors Department Consultation Unit, The Johns Hopkins Medical
Institutions; Department of Psychiatry and Medicine, The Johns Hopkins School
of Medicine; Department of Psychiatry, The Fairfax Hospital, Falls Church,
Virginia 22046.
2Sexual Behaviors Consultation Unit, The Johns Hopkins Medical
Institutions, Department of Psychiatry, The Johns Hopkins School of Medicine,
Baltimore, Maryland.
INTRODUCTION
Confusion surrounds the assessment, diagnosis, prognosis, and management of
individuals requesting sex-reassignment surgery. The existing uncertainty is
related to the dramatic nature of the patient's request, the variability of
clinical presentation over time, and the difficulties inherent in controlled
studies where adequate control would require random assignment to surgical
ablation of genitalia (Meyer, 1979). Compounding the difficult is the fact
that there is little agreement on the fundamental issue of etiology.
Views on the categorization of applicants for sex reassignment widely
differ: Stoller and his associates have adopted a "bipolar" viewpoint,
partitioning male applicants for sex reassignment into "transsexuals" proper
and "nontranssexual men who seek sex reassignment" (Stoller, 1975; Newman and
Stoller, 1973).
Transsexuals, Stoller believes, are the most feminine males who have never
developed any sense of masculinity, even in rudimentary form. Stoller
suggests that such men never experience Oedipal conflicts, since there is no
scaffolding of masculinity on which to erect such a structure (Stoller, 1975).
He feels, however, that nontranssexual men demonstrate some masculine
identification and conflict.
Meyer has adopted a "continuum" perspective, viewing applicants for sex
reassignment as having in common fundamentally similar problems in gender
identity although of greater or lesser severity (Meyer, 1974, 1975, 1977,
1978). He emphasizes the common features of gender dysphoria among applicants
for sex reassignment but recognizes the clinical diversity by systematically
subtyping the stable variations in the common gender dysphoric theme (Meyer,
1974). Meyer and his associates feel that a continuum approach has more
clinical validity, since the applicants for sex reassignment present along a
continuum, the clinician ordinarily being confronted with shades of gray,
rather than a dichotomy. Clinical management is facilitated by a recognition
of those features which distinguish a given subgroup of applicants for sex
reassignment, without losing track of the fact that the given subgroup of
patients share features in common with other gender dysphorics which
distinguish them in certain ways from the paraphilias, those with other
character disorders, and the psychotics.
Among the clinical subtypes reported in 1974 were the "self-stigmatized"
homosexuals, the "schizoid" group, the "polymorphous perverse," and the
"sadomasochistic." Among the clinical variants reported in 1971, the "younger
transvestites" and the "aging transvestites" are of particular interest in
this report. This group is of importance theoretically since they illustrate
the bridge between gender dysphoria and transvestism. They are of importance
clinically because the dynamics of their request for sex reassignment, their
clinical course, and their management are particularly distinct.
"Aging transvestite" individuals are in middle age in contradistinction to
the young adults who constitute the majority of individuals with gender
dysphoria. There was a striking coexistence of extreme masculine behavior
along with their feminine wishes. They were generally married and usually had
sired children. These individuals were not ego-syntonic transvestites who
openly acknowledged and embraced their practices, but were largely guilt-
ridden crossdressers. At the periods of request for sex reassignment,
crossdressing had lost its capacity for sexual arousal; instead, the patients
spoke of being more comfortable while "dressed." They were often depressed to
suicidal levels and presented with anxiety to the point of depersonalization.
The request for sexual reassignment was dramatic in view of the serious mood
disorder. They often viewed surgery as an alternative to suicide or self-
castration. Two patients in the original group had performed autocastration
prior to any medical contact. These individuals saw reassignment as a means
of relief from an internal struggle.
In addition to the "aging transvestites," a "younger transvestite" clinical
variant was also described. These individuals more frequently had homosexual
experiences than the "aging group," even though two of the initial cohort of
three were married. Surgery seemed to be a means of expressing passive
longings toward men, as well as escaping from the "perversity" of erotic
crossdressing. Because of the small size of the originally reported cohort,
it was particularly important that additional cases be examined to validate,
amplify, or amend those observations.
LITERATURE REVIEW
Reports of men whose eroticism is related to wearing women's clothing
and/or who request sex reassignment are found in both psychiatric and
psychoanalytic literature. Reports of the two conditions found in one
individual, however, are notably more scarce than of the two conditions as
separate phenomena. Buhrich (1977) has reviewed the role of transvestism in
history. Psychiatric phenomenologists have focused on transsexualism over the
past two decades since Caldwell coined this term and Benjamin popularized it
(Caldwell, 1949; Benjamin, 1953). Money has emphasized a longstanding sense
of neutral cross-sexualism as the essential characteristic of the transsexual
(Money and Primrose, 1968). Some investigators have viewed the wish for
sexual reassignment as a condition with strong biological determinants (Jones
and Saminy, 1973).
The psychoanalytic literature discusses erotic crossdressing in relation to
the theory of perversions. For the most part, attempts have been made to
account for the transvestitic symptom choice, with only secondary reference,
if any, to wishes for sexual reassignment (Bak, 1968). Greenacre (1968) feels
that transvestism, as well as fetishism, is developmentally related to early
disturbance in mother-infant relationships with subsequent faulty object
relations. She hypothesizes that identification with the phallic mother is,
in part, the genesis of this behavior. Socarides (1969) also considered the
wish to appear as a woman to be a disturbance of very early life.
In the literature linking transvestism and transsexualism together,
Lukianowicz (1959) feels transsexualism and transvestism are on a continuum
differing only in the degree of desire to alter one's sexual anatomy. Buhrich
and McConaghy (1977) have attempted to systematically factor out clinical
descriptors of applicants for sex reassignment in an attempt to partition them
from transvestites. They have found that transsexuals more frequently attempt
to crossdress in public, to pass as the opposite sex, to have a greater
conviction that they feel like the opposite sex, to have fewer heterosexual
experiences, and to more commonly have homosexual experiences. Additionally,
transvestites rarely reported sitting down to urinate whereas males who
considered themselves transsexual generally did. Furthermore, the
transvestite group showed significantly more penile erection to heterosexual
films than did the transsexual group.
Recently investigators have attempted to better categorize gender dysphoric
individuals who wish sex reassignment. Bentler (1976) empirically subgrouped
42 male-to-female transsexuals by behavioral characteristics. He found marked
differences in homosexual experiences, orientation, and heterosexual
interests. This concurs with other investigators who have described
categories of applicants as heterosexual crossdressers, effeminate
homosexuals, and asexual transsexuals.
From a more dynamic perspective, Stoller (1971) considers the relationship
among transvestism, transsexualism, and gender dysphoria. As previously
noted, he contrasts the clinical and dynamic characteristics of "fetishistic"
crossdressers with individuals whom he feels present with "true"
transsexualism. Meyer, however, has emphasized the close develop mental and
dynamic relationship between the paraphilias and the gender identity
disorders, seeing them as more similar than different (Meyer, in press: Meyer
and Dupkin, in press).
The ambiguity in the descriptive and dynamic literature may be partially
resolved by the recognition of the intragroup consistency of the transvestitic
clinical variants and their intergroup variations. Careful inspection of
transvestites who become gender dysphoric clarifies reports such as Newman and
Stoller's on nontranssexual men who seek sexual reassignment (Newman and
Stoller, 1973). Buhrich's (1976) recent discussion on whether fetishistic
behavior can occur in transsexuals is also coherently understood if one views
their subjects as aging transvestites who have previously been fetishistic
crossdressers. Other reports such as Barr et al.'s (1974) study of apparent
heterosexuality of two transsexuals is understood if this diagnostic framework
is adopted. Finally, the psychotic process, which Golosow and Weitzman (1968)
described in an individual who was labeled a transsexual, becomes explicable
if one recognizes that psychotic regression may occur in an aging
transvestite. These cases describe the regression of fetishistic
crossdressers, a transvestite who seeks sexual reassignment due to gender
dysphoria. They document regressive behavior, not the spontaneous occurrence
of "transsexualism."
METHOD
The methodology utilized in this study is that of retrospective case
review. Since the Sexual Behaviors Consultation Unit (SBCU) was organized in
1971, 403 individuals have applied for sex reassignment. Sixty percent of
these (241 individuals) were biological males. Each of these patients was
diagnosed as one of the reported clinical variants (Meyer, 1974). Whenever
present, psychiatric conditions were noted utilizing DSM II criteria. Since
the initial report in 1974, 17 additional individuals were diagnosed as aging
or younger transvestites. Three patients with transvestitic and gender
dysphoric elements, but who do not meet diagnostic criteria, are reviewed by
way of contrast. The criteria for diagnosing an individual as a transvestite
who becomes gender dysphoric include the following:
1. Application for surgical sex reassignment.
2. Evidence for longstanding crossdressing wishes and desires.
3. A longstanding history, which may or may not extend to the present, of
arousal when crossdressed.
4. Absence of psychosis or manic-depressive illness.
5. A longstanding history of active masculine pursuits vocationally,
sexually, and otherwise in the past which usually stands in stark contrast to
secret feminine longings.
6. Clear exclusion of other clinical variants.
CLINICAL MATERIAL
Among the 20 patients diagnosed as aging transvestites, three individuals
had clear psychotic illnesses which antedated their gender dysphoria. Thus
the request for sexual reassignment may have arisen from their psychotic
states. A brief vignette of one of these patients is outlined below:
The patient presented at the Sexual Behaviors Consultation Unit requesting
sexual reassignment. He had begun to wear his mother's undergarments, with
arousal, during his lonely adolescence. Beginning at 12 he frequently drank
his ejaculate while crossdressed and at 18 had one homosexual episode. In
young adulthood, he married, had regular heterosexual activity, and
episodically crossdressed with erotic arousal. One year prior to consultation
the patient was hospitalized with what was diagnosed as a manic depressive
psychosis. In the year since hospitalization, the patient was described as
slightly euphoric. When interviewed, he presented with a slightly elevated
mood and was dressed as a male. His request for reassignment procedures was
poorly organized. During consultation he requested breast augmentation only.
He gave a history of compulsive masturbation, hyperactivity, and crossdressing
only at home.
Table I. Transvestism and Major Mental Illness with Associated Requests
for Reassignment Procedures
Marital Number of Psychiatric
Patient Age status children Occupation diagnosis
Stresses
A 35 Married 5 Electronic Acute Not clear
technician psychotic
episode
B 45 Separated 3 Accountant Manic Extra-
depressive marital
affair
C 34 Married 2 Machinist Manic Not clear
depressive
The patients represented in Table I including the individual outlined in
the illustrative clinical vignette do not qualify for the diagnosis of either
aging" or "younger" transvestite. In each instance, their transvestism,
although longstanding, was bizarre or fragmentary. The request for sex
reassignment was similarly poorly organized, fragmentary, or bizarre and
seemed clearly a product of the psychotic interlude. The psychotic illness
appeared to be of insidious onset, and immediate life stresses were not always
readily identified. In such situations, prompt attention must be directed to
the underlying psychiatric illness, with consideration of rehospitalization,
if needed.
Seventeen patients were considered to have one of the two clinical
syndromes characteristic of transvestism associated with gender dysphoria.
They fell naturally into two groups on the basis of age, characteristic
prehistory, and clinical course. Ten of the individuals were classifiable as
"younger" transvestites, thereby materially expanding on the original cohort
of 3, and the remaining 7 were "aging" transvestites. In terms of age,
statistical analysis revealed a significant difference between the mean age of
35.9 for the younger group and 51.1 for their older subset (t = 4.825, df =
15, P < 0.001). There was no significant difference in terms of socioeconomic
status or number of children.
The ten younger transvestites had all been married, although two were
separated. Five had children. Their occupations were generally of the type
considered masculine; although one was a nurse, he functioned as an
administrator. Concurrent psychiatric illnesses were primarily affective
disorders. Although information about erotic crossdressing was not
sufficiently accurate or confirmable to submit to statistical analysis, the
patients reported longstanding and well-organized, primarily covert "dressing"
going back to early adolescence or latency. The uniform request was for
sexual reassignment because of unhappiness with their maleness and a wish to
be female. Although great dependence on wives and other important people
seemed evident, the relationships were characterized by isolation,
intellectualization, and hollowness. As a group they often displayed
histrionic, dramatic characteristics. They were also quite narcissistic. An
illustrative clinical vignette is presented below:
The patient was initially seen in the SBCU requesting sexual reassignment.
The patient had been married for 9 years and had a son 5 years old. He was
the middle of two children. His father was a hard-working, often absent
individual. His mother, who was perceived as depressed during his early life,
occasionally dressed him in curls and allowed him to wear lipstick. She was
remembered as proud of him for being such a "cute young man." Crossdressing
began at age 6 following the birth of a sister who received much attention.
Thereafter, crossdressing was pursued episodically throughout life.
Heterosexual activity began at 14 and there was no evidence of any homosexual
behavior or fantasy. He served in the Army 2 years without difficulty and had
a successful business career in a "masculine" field. Crossdressing became
increasingly frequent following the birth of his son. As his son became more
active and Oedipally competitive, the patient concurrently found crossdressing
of increasing pleasure although without overt erotic excitement. It was
during this time that he began to feel "truly" himself when crossdressed. A
year prior to the consultation, when his son was 4, he noted markedly
increased libido and increased masturbation frequency. He also initiated an
extramarital affair and separated from his wife for a few weeks. During the
separation he occasionally crossdressed. After a trial reconciliation with
his wife he felt that he would no longer remain married because of his wish to
undergo sex conversion and be female himself. He then divorced his wife,
noting increased wishes to become a woman on the heels of the separation. He
entered psychotherapy but crossdressed even more frequently. He ultimately
came to living and working as a female, being quite successful in his own
business. He changed his name and underwent breast augmentation. There were
no relationships with men, however. The patient's wife subsequently remarried
and moved with the child to a distant city. Following this, his ardor for
sexual reassignment abated. He returned to the male role, and abandoned plans
for further surgery. During the clinic visits, the patient spoke words
indicating an attachment to wife and son, but they seemed devoid of feeling.
He was narcissistically quite preoccupied with himself, including his
appearance, the impression he was making, etc. It is worth noting that there
was no evidence of grief, sadness, or lowered mood!
Table II. "Younger" Transvestites:
A Clinical Variant of Gender Dysphoria
Marital Number of Psychiatric
Patient Age status children Occupation diagnosis
Stresses
D 38 Separated 4 Taxicab Neurotic 65-Wife
driver depression leaving;
argument
with
father
E 37 Married 1 Mechanic Neurotic 29-Work
depression stress,
increased
responsi-
bility
with pro-
motion
F 30 Separated 2 Insurance None 44 -
agent Oedipal
-aged
son;
intimacy
with wife
G 38 Married 2 Systems Neurotic 44 -
analyst depression Oedipal-
aged son
H 49 Married 0 Nurse Schizoid 50 -
character Mar-
disorder riage;
pressure
to have a
child
I 35 Married 2 Computer None 44 -
programmer Oedipal-
age son;
intimacy
of mar-
riage
J 33 Married 0 Policeman Neurotic 100 -
depression First wife
died 3
yr ago;
present
marital
problem
K 32 Married 0 Computer Neurotic 40 - Wife
programmer depression preg-
nant;
hernia
surgery
L 33 Married 0 Salesman Neurotic 35 -
depression Marital
pressure
for
intimacy
M 34 Married 0 Program Neurotic 35 -
analyst Marital
stress;
depress-
ion
wife's
recovery
The patient recalled his mother, a depressed, lonely, and angry woman, as
having cultivated his curls and being proud of his cuteness. Unfortunately,
there was no access to material which would allow us to verify these reported
memories. Verification is important in such instances because of the tendency
to project fantasies retrospectively to form screen memories rather than
actual recollections. It seemed clear, nonetheless, that crossdressing did
begin with the birth of the sib at a time when the patient might have been
expected to be going through the very difficult competitive and rivalous
(Oedipal) phase that characterizes transvestitic patients.
It was clear later that crossdressing increased in frequency with its
driven quality during the pregnancy of his wife and following the birth of his
son. This is a common enough finding, generally, in the paraphilias (Meyer,
1979), but in this case the progression is typical for the younger
transvestites who are vulnerable to decompensation into gender dysphoria.
There was a flurry of erotic crossdressing, driven hypermasculine behavior (an
affair, elevated masturbation rates), and finally separation and the request
for sex reassignment.
In our experience the birth of the child and the child's passage through
critical developmental stages reactivate the patient's own childhood,
generative struggles. In those transvestites vulnerable to gender dysphoric
decompensation, the collapse usually comes as the child enters the Oedipal
phase. In the patient's recapitulation of his earlier conflicts he abandons
his aggressive masculinity, separates from his mother-surrogate (his wife),
and repairs his loss by becoming a woman himself. In the clinical vignette,
once the sources of conflict were removed, sex reassignment was no longer
necessary. Among the "aging transvestites," all individuals had been married
previously but at the time of request only three of the seven were married.
They all had "masculine" to "hypermasculine" occupations. Their concurrent
psychiatric illnesses were primarily affective disorders. The following is a
clinical vignette which illustrates the clinical course of such patients:
The patient was initially seen in the SBCU requesting sex reassignment.
His career had been in one of the military services. He had recently begun to
wear feminine apparel in public and remarked on the constant daydreams of
himself as a woman, but denied any fantasies of intercourse with men. The
patient was married and having intercourse (without crossdressing) at the time
of the request for reassignment. His three children, ages 14 to 21, had no
history of sexual deviance. The patient was the fifth of twelve children but
described a lonely childhood. He began trying on his sister's underwear at 8
and episodically masturbated while dressed. He pursued a successful career in
the military but retired after a myocardial infarction. Following his illness
and retirement, he noted an increase in wishes to crossdress. His wife
tolerated his crossdressing at home as long as his three children or the
neighbors were kept unaware of his secret. When examined, the patient was
dressed as a male but was wearing panties. He had no suicidal or
autocastration ideation. There was no evidence of a depressed mood, but he
was preoccupied with the notion of sexual reassignment.
This patient's wish for sex-reassignment surgery began after two major
losses, his retirement and serious illness. His premorbid history shows clear
masculine identifications with episodic eroticized crossdressing.
Furthermore, his wife appeared comfortable with his perversion as long as it
was controlled. She is similar to the "succorer" style of women who accept
transvestitic behavior in their partners because of their anger toward
competent mates (Stoller, 1967).
Although the patient had several children, there was no history of the
degree of crisis around conceptions, pregnancy, childbirth, and early
childhood development that characterizes the younger transvestites.
Similarly, there is no history suggesting the onset of crossdressing in
relation to sibling birth or more dramatic conflicts. It seemed to have had a
rather quiet, autogenous onset in midlatency.
Table III. "Aging" Transvestites:
A Clinical Variant of Gender Dysphoria
Marital Number of Psychiatric
Patient Age status children Occupation diagnosis
Stresses
N 52 Married 3 Accountant Neurotic Illness
Business depression (carci-
college noma)
0 49 Divorced 2 Steel worker Alcoholism Job
loss;
High 47 -
school illness;
ankle
injury
P 48 Separated 6 Machinist Neurotic 38
-
depression Mone-
tary
prob-
lems;
father's
Illness
Q 66 Separated 2 Clerk Neurotic 52 -
depression Illness
(carci-
noma)
R 45 Married 3 Retired None 53 -
Army Career
officer retire-
Store ment;
manager illness
(myo-
cardial
infarc-
tion)
S 52 Married 2 Business Neurotic S3 -
executive depression Illness
(myo-
cardial
infarc-
tion);
son's
death
T 46 Separated 0 Naval Neurotic Separ-
officer depression ation
from
wife;
retire-
ment
pending
DISCUSSION
The nature and quantity of life stresses which are effective in producing
gender dysphoric decompensation in vulnerable transvestites represent one
factor which appears important. Quantitative estimation of the major
stressors in the 2 years prior to request for sexual reassignment was done by
computing the number of life change units utilizing the Social Readjustment
Rating Scale (Holmes and Rahe, 1967). No significant difference in
quantitative life stressors between the two subsets appeared. On the other
hand, the two groups, "younger" and "aging," differed markedly in the kind of
stresses identified as contemporaneous with the request for sex reassignment.
The younger transvestites were more often involved in overtly conflictual
marriages. Their wife's insistence on intimacy appeared to be a factor in
three of the cases. In one case, the patient was being pressured by his
wife's insistence that he father a child. Three patients had Oedipal-age sons
who were troublesome to them. Losses were present in only one patient who was
recently separated from his wife.
In the "aging" group, illness and physical loss, as well as separation,
were common to each member of the sample. Illnesses varied from myocardial
infarction (two patients) to neoplastic disease (two patients). The illness
of a parent or retirement was also a stressor. Although all of the aging
transvestites except one had children, there was no history obtained of the
same kind of cataclysmic reaction to their children that was true of the
younger group. Whether more careful histories will reveal such episodes is a
question for future clinical inquiry. It is also not clear whether the
younger transvestites, as they age, will show vulnerability to the stresses
characteristic of the aging group.
This is an important issue. While it is clear that parentage and children
on the one hand and illness and retirement on the other are age-dependent
stressors, the absence (so far) of a history of reaction to pregnancy, birth,
and development among the aging group suggests that the two groups are
differentially vulnerable to certain stresses. This, in turn, suggests that
the two groups are dynamically and etiologically somewhat different. This is
by way of contrast to the notion that they may be the same group merely at
different stages of the life cycle and, therefore, vulnerable to the different
stresses that characterize their different ages.
Along the lines of the two-population hypothesis is the suggestion that
overt symptomatology in the "younger" group may start at an earlier age be
related to sibling birth, and be more flamboyant. It is certainly true that
for both groups their sexual histories included use of feminine garments for
sexual excitement.
The family constellations varied. What emerged, however, was a picture of
a father who was distant or absent and a hovering mother who was basically
lonely. Maternal attitudes toward the fathers were often hostile or
indifferent. The patients were utilized to make up for the maternal
loneliness. The mothers clearly formed symbiotic relationships with the
patients.
The histories of aging and younger groups revealed no early unhappiness
with their assigned sex or the classical stigmata of the reconstructed
childhood "transsexual" history. They did not play "girlish" games or give
histories of wishing or asserting that they were girls. Rather, evidence of
feminine identification was found in their early, and continuing, attachment
to women's garments (Meyer, 1979). Similar evidence of feminine
identification is, of course, found in other transvestites, including the bulk
of such men who, while they almost universally have episodes of yearning to be
female, do not endorse the wish with action even under situations of
extraordinary stress. The vulnerability or the need of those transvestites
who are basically gender dysphoric to make concrete their feminine
identification theoretically bespeaks earlier and more continuous trauma in
their relationships with early figures, more primitive defenses, harsher self-
criticism, and more poorly sublimated urges. (See Meyer, 1979, and Meyer and
Dupkin, 1979, for more detailed theoretical treatment of such issues.)
None of the seven aging transvestites had homosexual experiences, although
seven of ten in the younger group had such relationships. However, none of
the 17 individuals had homosexual fantasies during any form of sexual
activity. The fact that the "younger" transvestites had homosexual
experiences whereas the "aging" did not may be related to the propensity of
the former to decompensate in relation to their sons. The younger group seems
more able to form narcissistic identifications with other males (as in
homosexuality), living vicariously through them. We propose that they
similarly identify with their sons. When the sons, quite naturally, become
aggressive and competitive, their own conflicts are vividly reexperienced.
The "aging" transvestites are more self-involved and do not form similar
identifications with other men or their sons. Their world collapses when they
are no longer able to maintain the hypermasculine side of their personality
(because of illness, infirmity, retirement, or loss of prestige) as a
counterbalance to their feminine side.
It is our impression that it is most useful to regard the "younger" and
aging" transvestites as having a borderline personality organization
(Kinderberg, 1967, 1970, 1975). Their masculine and feminine identifications
and self-images are kept split, as are, respectively, their aggressive and
loving urges. They are not psychotic even in the gender-decompensated state
since there is no falsification of physical or external reality. It is not an
example of multiple personalities since there are always both the masculine
and feminine sides, even when one is dominant. This pathological result is
compatible with the type of long-range consequence of profoundly disturbed
early relationships described by Kernberg (1966). We believe from our
clinical experience that the transvestism has served a function of
symbolically expressing maternal identification in order to ward off very
early anxieties (Mahler, 1963). Under sufficient stress the symbolic
expression is insufficient and collapses into a demand for real expression of
the maternal identification through sex reassignment (Meyer, in press).
COURSE AND MANAGEMENT
These disorders are episodic, recurring at times of dynamically resonant
stress whether the stress be from the intimacy of a marriage, the Oedipal
flowering of a son, or losses in vigor or status. Proper diagnosis is the
essential in management. The history of masculine identification and
eroticized crossdressing, with the characteristic precipitant, is critical.
The disorder of the aging transvestite is clearly episodic, and close
support will see the urge for sexual reassignment abate. It seems probable
that the "younger" transvestite's request for sex reassignment is also time
limited. As the patient's desire for surgical sexual reassignment declines,
the idea of sex change will become increasingly ego dystonic. It must be
remembered, however, that this disorder is recurrent and the therapist should
always be available for exacerbations of this condition.
Psychotherapy, much as has been outlined for the borderline individual
(Kernberg, 1975), is the treatment of choice. It is rarely helpful to include
the patient's wife in his treatment. The symptomatic request for sex
reassignment is in part a hostile gesture toward her. Sensing this hatred, as
the wives usually do, nonetheless may make her own treatment useful for her.
Another reason for individual treatment for the patient is that it is more
difficult to establish a successful therapeutic alliance if the wife is
present. The therapist will be seen as trying to convince the patient of the
undesirability of undergoing sex change. Often the wife's hostility will
create disruption in the therapeutic situation. It is essential to maintain a
nonjudgmental attitude. The therapist must sympathize with the patient's
emotional pain but also must convey the need to explore the reasons for such a
drastic change. Strict enforcement of gender identity clinic criteria can
also give a valuable "breathing period." The Johns Hopkins Gender Identity
Committee requires 2 years of crossdressing, working in the opposite gender
role, and receiving hormonal medication and psychotherapy prior to
consideration of surgery. Once these prerequisites are stated, it is up to
the patient to carry them through while he and the therapist can work on the
various issues that present themselves. This allays the urgency of the
request for both patient and therapist. Often enough the patient's relief at
the criteria is palpable. Because of some integration of his personality, he
cannot fully endorse conversion since the masculine "side" of his personality
still fosters the ambivalence.
The initial phases of the therapy should include identification of stresses
which provoked the regression. The therapist should be well aware of the
potential of suicide and autocastration in such patients. Medications should
be utilized if concurrent psychiatric illnesses are present. Patients also
must be hospitalized if they become acutely suicidal, nonfunctioning, or
psychotic. This condition is episodic and often will remit in time.
After an initial phase of therapy where there is a clear agreement of a
didactic relationship, the aging transvestite will often experience a
depression. This occurs as a individual begins to react to the various
stresses which had created his wish for sexual reassignment. Whether this is
a specific loss, an aging process, or the Oedipal rivalry of a child, the
individual will often initially experience the mood disorder and then
cognitively deal with the content of his mood changes. Initially this
depression is rationalized as being due to the realization that immediate
surgery is not forthcoming. Furthermore, the initial euphoria from the
fantasy of changing sex roles becomes a more realistic problem. The
tremendous difficulties in actually crossdressing in public, consideration of
new employment, and reaction of family and friends modify this euphoriant is
during this period that suicide and autocastration can occur. Ongoing
supportive therapy, potential use of antidepressants, and possible family
support or hospitalization may be needed. Exploration of the realistic
difficulties that the patient has at present plus past difficulties in develop
mental and interpersonal relationships not directly related to gender
dysphoria are areas which can allow useful working through of this stage of
treatment.
CONCLUSION
This report supports and expands Meyer's earlier classification of the
"younger" and "aging" transvestites as clinical variants of gender dysphoria.
These categories make comprehensible certain discrepant findings in the
literature regarding transvestism, gender dysphoria, application for sex
reassignment, and the nature of the relationships among these phenomena.
These findings also enlist the vast literature on the borderline syndromes in
the effort to comprehend the psychology of these patients. On the clinical
level, the need for an accurate diagnosis is essential if one is to adequately
map the course of any individual requesting sexual reassignment and prescribe
appropriate treatment. Recognition of the episodic course of the gender
dysphoric transvestites allows rational management and prevents needless,
irreversible surgery, which would provoke further suffering in these troubled
individuals.
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