Psychiatric Annals

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TRANSSEXUALISM AND TRANSVESTISM

Robert J Stoller, MD

Abstract

They both cross-dress but for different reasons. The transsexual, disliking his male body, expresses his real feminine nature. The transvestite, accepting his malesness, enjoys the feel of his body under women's clothes.

Abstract

They both cross-dress but for different reasons. The transsexual, disliking his male body, expresses his real feminine nature. The transvestite, accepting his malesness, enjoys the feel of his body under women's clothes.

Transsexualism and transvestism are two separate conditions in which there is an obvious similarity, cross-dressing. The purpose of this article is not only to distinguish the two disorders but also to argue the importance of separating them. This may encourage a proper search for etiology and thereby assist in the study of origins of gender identity, and also protect against misjudgments in treatment. If transsexualism and transvestism can be distinguished clinically and if etiological factors are found in one clinical state but not in the other, the physician will better serve not only his patients but also the larger issue of discovering origins of masculinity and femininity (gender identity). The fundamental requirement is careful clinical evaluation of patients.14, 16, 17, 20

We shall be discussing only people with no demonstrable biological abnormalities, either of chromosomes or of anatomy or physiology.

TRANSSEXUALISM

Male. This description is of male transsexualism in its most complete form. The condition usually shows itself at the very beginnings of behavior that can be judged as masculine or feminine; thus, it has already started by the time the boy is two or three. One soon sees the little boy developing a feminine gracefulness of movement and a fantasy life expressing only desires to be female. In games, he takes only female roles; in drawings, he portrays beautiful women; in watching television or movies, he openly identifies with feminine women; in play therapy, he plays only with the female dolls and constructs stories that express his choice of female dolls to represent himself. He chooses only girls for his friends, entering into their games with pleasure and imagination, andstrong evidence of the depth of his identification with females- the little girls accept him as a girl in their play. He never spontaneously chooses male clothes, but dresses in female clothes whenever possible; when these are not available, he improvises his own. He also enjoys trylhg on jewelry and makeup. All this behavior is summed up when he openly states he wishes he were a girl and expects to become a female when an adult. In order to do so, he says, he will have his male genitals removed.

At no time as he grows older does he retreat from this position. At most, because of the threatening attitudes of society toward such femininity, he will attempt- unsuccessfully- to imitate masculinity and will until adolescence struggle to keep his femininity from being too obvious. (Femininity is to be contrasted to effeminacy, the latter implying mimicry and therefore envy and hostility toward females. This is one way transsexualism can be distinguished from male homosexuality, for transsexuals do not have such hostility, as boys or as adults. There is no acting; they simply wish to be females.)

Because of this wish, his male genitals become the focus of his disgust and hatred; they signify the maleness from which he would escape. And so, In the clear-cut case, there is no period when maleness or masculinity are felt to be worthwhile.* He therefore is disgusted by erections and tries to suppress them, avoiding masturbation more or less successfully and also avoiding intercourse with females. He does not have a history of successful sexual relations with women, of marriage, or of having become a father. He does not develop perverse erotic practices, since the essence of such behavior is penile sexual gratification. Especially to be underlined here is that he never is fetishistic; he no more becomes sexually excited by women's clothes than do biologically normal women.

True transsexuals do not manifest the classic perversions: sexual excitement produced by inanimate objects, part objects, or animals, or aroused by exhibitionism, voyeurism, sadism, masochism, etc. The only comparable sexual aberration is homosexuality, but unlike the homosexual the transsexual does not feel that he desires intercourse with a person of the same sex; rather, he experiences his sexual relations as heterosexual (though both partners are anatomic males). In fact, if a transsexual feels a potential partner is a homosexual, he loses sexual interest in that person. He defines as homosexual a man who Is interested in another man's penis, and because he finds his own penis repulsive, the homosexual's interest in it makes sexual involvement with him abhorrent to the transsexual male.

His lifelong identification with femininity and feminine roles makes it possible for the transsexual male to pass as a woman with no trouble, except when too tall or muscular. His desire to become a female is intensified in adolescence (and especially so nowadays with the publicity given "sex-transformation" procedures), and so he begins to pass as a female. He usually does this well, managing in one way or another to pass the dangerous tests society sets up in its unthinking judgments of masculinity and femininity. "She" then searches out sex change. High motivation leads "her" to arrange, regardless of psychological or financial cost, administration of estrogens to develop breasts and otherwise create a softened figure; removal of facial and body hair by electrolysis; and amputation of penis and testes with vaginoplasty. As soon as possible, often before the anatomical changes, "she" has begun to live and work permanently as a female and begins a relationship with a man "she" can define as "straight," i.e. not homosexual. If possible, "she" will marry, though this is almost never legal.

Transsexualism is not a psychosis, despite the accusations of some. It could only be considered such if one accepts the transsexual belief (that one is really a member of the opposite sex, regardless of contrary anatomic evidence) as a psychotic delusion. By the accepted criteria for judging psychosis, the transsexual is no more likely, in my experience, to be psychotic than is a random sample of the population.

What is the etiology of this condition? To create a male transsexual, one needs a particular sort of mother, a particular sort of father, a particular male infant, and a resultant particular form of rearing the infant. Not every element of the following description is always present in the family constellation, but they usually all are and in all cases most are. The more variance in the constellation, the less the individual resembles the full picture described above.

First, the mother. She is the daughter of a woman who did not adequately recognize, much less encourage, the girl's femaleness, but Instead treated the little girl as if she were neuter. While the girl got some sense of her feminine worth from her father, he "failed" her by death, by divorce, or by turning from her to another sibling. Somewhere between the age of seven and puberty she became masculine in her behavior and desires, so much so that she almost seemed like the girls who grow up to become female transsexuals. But unlike them, the feminization of puberty ended this girl's hope of being a boy, and she gradually covered over such desires with a feminine facade. Eventually she married.

She married a passive, though not usually effeminate, man, who distanced himself from his family. Unable to cope with his wife's strength and hatred of his maleness, he stays away from home, so that during the infancy and childhood of the son who becomes a transsexual, father is not present either to serve as a model for his son's masculine identification or prevent his son's developing femininity. Despite a marital relationship in which neither partner has satisfaction, and certainly not love, they persist together for years in order to serve neurotic needs in each. By staying together, a special homeostasis develops in the family, which depends upon the boy being feminized.

These are, very briefly, the parental antecedents for the process, but they are not the process itself. What actually impinges upon the infant to create the transsexual identity? It Is mother, unimpeded by the masculine protection father should give. The crucial final common pathway is excessive physical and emotional intimacy between mother and son. The relationship is almost always established by the above family constellation, though I have seen a few exceptions, such as a mother without the gross bisexuality or the father absent because of military service rather than passivity.

What is invariable Is the symbiosis, unbroken by father. From the moment of birth an Intense, blissful symbiosis is established between mother and infant, which nothing can unlock as the years pass, except in rare instances of successful treatment. At the moment of birth, the mother is filled with joy- the condition is not, as folklore would have it, the result of her disappointment because she did not have a daughter. She is thrilled to have given birth to a son, and the name she gives the boy confirms this: transsexuals always have phallicly masculine names of heroes, warriors, and kings. She senses that her empty life has suddenly been filled with perfection; she believes that the chronic depression and sense of worthlessness from which she has suffered since childhood has ended with the birth of this son. The trigger setting off this reaction in her is the contribution made by the Infant- his marked physical beauty. All the mothers report that at birth or shortly after they were astonished at how beautiful their sons were and mentioned innumerable examples of relatives, friends, and strangers spontaneously remarking on the child's beauty. (This explains what has been a puzzle for years: why one son In a family would be transsexual and the others not, despite the fact that parental personalities were the same during the rearing of all the children.)

She is not going to give up this beautiful gift, and so she holds him close to her for too many hours every day and night. This holding is not casual, but the vehicle of transmission for her most intimate and loving feelings. The rest of the world is excluded from this intimacy, especially father, whose personality prevents him from intruding on the symbiosis. Even as the years pass and the femininity becomes blatant, he does not interrupt the two; at most he stands, muttering, at the periphery of the family, unwilling to act decisively to interrupt mother and son.

Mother does not actively teach femininity in the beginning, nor do her occasional surrogates, a grandmother or one of the boy's sisters. Instead, the feminine qualities appear spontaneously during the first two years of life. Then the second stage of the process, the positive reinforcement of feminine behavior, takes over. When mother sees her son feminine, she expresses intense pleasure; she sees forceful, crude, messy, intrusive, and ungraceful behavior ("masculine") as unpleasant and so discourages it. Thus, excessive physical and emotional closeness to mother for too long creates feminine identifications, and then rewarding the resultant behavior increases the islands of feminine attitudes until they coalesce into a feminine identity. With father absent, the process is not interrupted and no appealing masculinity attracts the boy in that direction.

The result is the transsexual, a biologically normal male who truly believes his feminine identity is trapped in a body of the wrong sex, No wonder he will do anything to correct that body.

Female. The female transsexual is a biologically normal woman who nonetheless believes herself inwardly a male, and so wishes to become and live permanently as a man. The condition is rarer than male transsexualism, perhaps one-half to one-eighth as frequent.1,11

The development of cross-gender behavior and attitudes in the paradigmatic female transsexual parallels in many ways that of the male. In the first few years of her life, she is already walking, talking, and fantasying herself as a male, accepted by male peers in all games, and acquiring a masculine nickname. The development of female secondary sex characteristics in adolescence appalls her, and she begins the actions necessary to pass as a man. Sooner or later, these result in "his" dressing all the time as a male, working as a male, and eventually living entirely and undetected as a man. Transformation procedures are sought: androgens to lower the voice and produce body and facial hair, mastectomy, panhysterectomy, and occasionally closure of the vagina. Although the patient would like a functional penis, "he" must suffice without, for surgical skills cannot yet complete the transformation.

The female transsexual considers "himself" to be exclusively heterosexual and avoids homosexual women. "His" ideal partner is a woman whose past history seems unfailingly heterosexual, with visible proof in the form of prior marriage and child-bearing.11, 14, 21

Only recently has a testable hypothesis about etiology surfaced. It was delayed by three factors: first, fewer female transsexuals are seen; second, it is hard to distinguish the syndrome from that of the masculine homosexual woman; and third, calling the condition in females "transsexualism" presumed that comparable familial factors would appear as in males, but they did not. Our research team found ourselves often disagreeing about whether a given masculine female were a transsexual or a homosexual, a kind of disagreement we do not have with male transsexuals, and the life histories and personalities of the patients were just not similar from one family to the next.

However, it now seems possible that there are common factors at work in the childhoods of these most masculine of women. In female transsexualism there is originally a disruption of the mother-infant relationship, rather than the blissful symbiosis of male transsexualism. In each of the 10 cases adequately studied so far, the mother was clinically depressed or (more rarely) otherwise psychologically distant from her infant daughter. The father, instead of succoring his wife, slides this child In as his substitute for providing care and loving attention to help assuage the mother's emotional illness.

And so, for several years, starting in infancy, this little girl finds herself powerfully and continuously encouraged to get close to and comfort her unreachable mother, taking over this crucial aspect of her father's role. This is done not only by having the little girl act as caretaker but by encouraging all behavior which the family looks upon as "masculine." (Given différent family attitudes, a daughter chosen as caretaker can be feminine, with an end result that is not transsexualism.) The girl identifies powerfully with her father's masculine interests; she hunts and fishes with him, plays in sports with him, and learns carpentry or farming or whatever activities already reflect father's masculine role. The separate masculine ego functions in the female transsexual are thus positively reinforced to coalesce eventually into a masculine identity. However, unlike those of male transsexuals, the female transsexual's parents do not typically show disturbances of gender identity. The mothers are feminine women, with no history of severe bisexual conflicts or identifications in earlier life, and the fathers are masculine men. While a few fathers have been distant and passive, the majority have not, and in no case was there any suggestion of a father being effeminate.21

Because female transsexualism originates in a painful and dangerous situation, the circumstances seem related to the childhood origins of some female homosexuals. Perhaps this accounts for the difficulties our research team has had in separating the two conditions, transsexualism and homosexuality; for they may not be so different in the female as they are in the male.

Treatment. There is no known treatment, biological or psychological, for the adult transsexual so that he or she finally develops a gender Identity consonant with the biological sex.*· ,4, " Unless and until such a procedure is found, the adult transsexual's only hope to assuage the anguish of feeling trapped in the wrong body lies in the so-called sex-transformation procedure. Repeated observations show that this has made transsexuals happier and more settled in their lives.'' '*· "· "· M It would appear that a physician, regardless of his theoretical or ethical questions, cannot refuse the patients these treatments on the grounds that they are not helpful. Also, it is an unpleasant dilemma to withhold treatment and offer nothing in its place.

There are further complications. First, while adequate follow-up studies are in progress, they are not complete, and we do not yet know the long-term results of sex transformation. Second, these procedures are performed throughout the world on persons who by no stretch of the imagination, except their own, can be considered transsexuals. Some physicians accede to the patient's request without careful psychiatric workup, and we have seen overt homosexuals, fetishistic cross-dressers, and paranoid schizophrenics whose bodies were "transformed" only because the patients asked and had the money. The risks are too great for such inadequate medical practice. Depression, suicide, psychosis, or permanent despair on losing what one now (too late) sees as one's proper genitals may be the result of failure to attend properly to establishing the correct diagnosis.

Only those rare patients who fulfill the criteria described above- the most feminine of males and the most masculine of females- should undergo sex transformation.

On the other hand, intensive psychotherapy on transsexual children may possibly stop or reverse the process.5- 6· " Our research team has been involved in this attempt for some years, and in the treatment of both boys and girls (especially when treatment starts as early as age four or five) there have been gender identity changes. However, not enough time has passed to determine if these changes last into adult life.

TRANSVESTISM

Male. As with transsexualism, we have insuperable problems if we cannot adequately define the condition clinically. Transvestism is "cross-dressing," and unfortunately, whenever in the past one found evidence of cross-dressing, he shifted from symptom to diagnosis simply by using the Latin word. No wonder attempts to find etiologies have failed in the gender disorders.

When one takes a general term like "transvestism" and tries to give it a new or restricted meaning, he must push against the habits of tradition. In this discussion "transvestism" will refer only to fetishistic cross-dressing; by "fetishistic" I mean specifically that women's clothes produce an erection. This sharply differentiates the condition from transsexualism, where fetishistic sexual excitement is never found. Transvestism is a perversion in the sense that an inanimate substitute, instead of a full human relationship, is required for maximum sexual gratification. The sexual act of cross-dressing focuses on the genitals as the most prized and necessary producer of pleasure; it follows that if a man gets his greatest pleasure from his penis and spends much of his time preoccupied with methods of gratifying his sexual needs, then- whatever appearances to the contrary- he prizes his maleness. This is the case with the transvestite, as paradoxical as it seems, since he enjoys dressing as a woman. He does not consider himself a female trapped in a male body; he considers himself a male, and wishes to remain so. Even when dressed in woman's clothes, his greatest pleasure is sensing his penis hidden beneath. These are almost always masculine-appearing and masculine-behaving men, except when seized by their sexual impulse, who are in masculine professions, married, attracted to women's bodies, and heterosexual in their overt behavior."· 14, "· " Their cross-dressing is intermittent, not permanent.

The overt manifestations of transvestism usually begin at puberty or soon after, when the young man is for the first time sexually excited by putting on women's clothes. (Infrequently, the initial episode occurs in childhood or well into adult life.) Usually a single type of garment, such as shoes or underwear, is used at first for excitement. In one group of transvestites, the single garment remains the technique of choice in promoting the masturbation which follows; in others, the cross-dressing desire gradually spreads, so that eventually the greatest excitement is produced by dressing completely as a woman. This latter group of men may also enjoy passing for hours as women in open society. However, unlike the transsexual, the transvestite's excitement comes from knowing that he is a male successfully running the risks of passing. Those transvestites who enjoy transient passing usually have accompanying transsexual fantasies, occasional thoughts of what it would be like to have a female body. But the duration, depth, and extent of these fantasies are not comparable to those of transsexuals, nor is there the demand to become a female no matter what the risks.

The clues to etiology in transvestism are less clear than those in male transsexualism. Perhaps this is because no adequate studies have yet been done of the parents of transvestites. A psychiatrist sometimes encounters transsexuals when still children, and can study their infancy through the eyes of their parents, but these opportunities are not available with transvestites, who are only seen In late adolescence or adulthood. So we have only an impressionistic picture of etiology.

Transvestites do not give a history of the close, symbiotic mother-son relationship, nor do the few mothers of transvestites so far studied. They do not give a history of very early femininity, but on the contrary tell of (and photographs in family albums illustrate) a period of several years of masculine development. Then, typically, comes the story that a female dresses this masculine little boy in women's clothes. This experience, forced on an already masculine boy who can sense the humiliation aimed at him, is not sexually exciting. But in time- and here I am theorizing without data- the original traumatic experience seems to be converted into a triumph, so that what was originally humiliating becomes sexually exciting, a success. This theory could account for the fact that transvestites are masculine and wish to preserve their penis, not destroy it and be converted into females.

Father's role Is less clear than in transsexualism, and the descriptions of fathers and those fathers whom we have seen do not add up to a class of men with similar features. While some are distant and passive, others are noisy, angry, cruel disciplinarians. So far I have not heard of a loving, respected father.

Female. Contrary to general opinion, there are no female fetishistic crossdressers. At least none has been reported in the literature, nor have I ever heard of or seen one. Many women, of course, cross-dress, especially masculine homosexual women and transsexual females. However, none become sexually excited by men's clothes. This finding correlates with the fact that, with the possible exception of homosexuality, sexual deviations are much rarer in women than in men.

Treatment. As with transsexualism, psychotherapies (including psychoanalysis) have not been successful in treating fetishistic cross-dressing; there are numerous reports derived from psychotherapeutic encounters, but these do not indicate that the condition was removed permanently.'4 On the other hand, recent optimistic reports have appeared on the use of behavior (aversion) therapy in this condition.' The more nearly the man is fixed on a single garment for his excitement, the better the prognosis; the more his fetishism is embedded in feminine behavior and transsexual fantasies, the poorer the prognosis.

I also know of several cases, not yet reported in the literature, of adolescent boys who were treated with psychotherapy (not psychoanalysis) and in whom the fetishistic desire seems to have disappeared.

DISCUSSION

I have referred to these two conditions, especially transsexualism, as having clear-cut clinical pictures and antecedent etiologies- a presentation which rnust now be explained and softened with some uncertainty. I minimized the fact that other feminine males and masculine females, considered transsexuals by many, neither fit the clinical definition nor present all the above etiological factors. In other words, the description attempts an artificial clarity, and does not attend to cases with mixed features of transsexualism and transvestism or effeminate homosexuality.

However, this has not been so much inaccurate as incomplete. The full clinical picture does exist in a number of subjects, and when it does most if not all of the etiological features are present." And the more the clinical picture is obscured by opposite-gender manifestations (for example, a feminine male transsexual who nonetheless has had a period of fetishistic cross-dressing and who was married as a man for some years), the less of the etiological features are present.'4 My position, therefore, is that as one changes the etiological factors, one changes the clinical picture.

This report arbitrarily defines the transsexual and transvestite as biologically normal. While most authorities would grant that these people have no biological abnormalities measurable by present-day tests, some have recently pointed to the exciting new information from animal studies, showing that irreversible, life-long changes in gender behavior occur with a single hormonal impulse to the hypothalamus, if the stimulus is given at the critical time (just before or just after birth) for that species. Is it then possible that such an energizer acts in the prenatal development of the future transsexual?

Since there is at present no way to test this hypothesis directly, we cannot say that it does not occur. However, I believe the burden of proof is now upon those wno claim this biological etiology;1, 2, a they must show that the parental factors described above are either not present or coincidental. They will have to show, for instance, that the most feminine of males, those without fetishism or any history of masculine behavior, do not typically have the excessively close symbiosis with mother or an absent father. They must show that these mothers do not have a predilection for attaching themselves excessively to this infant, and that the infant's beauty, which I think sparks the symbiosis, in fact plays no such part. Although they will be able to show that there are cases in which not every factor I have described is present, they will have to show that the constellation of factors is either not present or is coincidental.

Preliminary evidence does suggest that prenatal hormonal influences are involved in some rare cases. An unusually large number of males with congenital hypogonadism (Klinefelter's syndrome) are feminine from childhood on and as adults not only cross-dress but in some instances request sex-transformation procedures.9,14 In animal studies, male mammals grow up with feminine behavior if they are deprived of naturally-occurring fetal androgens; this suggests that males with congenita! hypogonadism develop feminine desires and behavior because they too are missing fetal androgen. In addition, I have been unable to find the typical parental influences when studying these patients' lives, so that their gender disorder is not due to the familiar family constellation.

On the other hand, Money' has shown that females exposed to androgenizing effects in utero- from hyperadrenalism or from progesterone given to their mothers to prevent abortion- have a masculine tinge to their behavior and fantasy life. Not, however, transsexualism.

So while it is possible that hormonal influences (congenital hypogonadism) can produce a transsexual syndrome, I believe that it is the exceptional case. The thesis In fetishistic cross-dressing is that the adult perversion is the result of childhood trauma, the humiliation of a masculine boy by dressing him as a girl. This history is found frequently but not invariably. The challenge (this time, for me) is to determine how often it occurs In the childhood of transvestites, and the main methodological problem is the question of validity of childhood memories: Did what is remembered happen, and did what is not remembered not happen? Some patients have given a negative history of being cross-dressed in childhood and then have returned later with family photographs showing that they had indeed been cross-dressed, or have questioned their families and been told that others recall having seen them cross-dressed. In both cases the subject has no memory of the experience. At any rate, this history is often given by transvestites, but interestingly not by transsexuals.

Some theorize that fetishistic cross-dressing is biologically induced, but again there is no direct evidence, just the conviction that such condtions must be biologically produced because they are so fixed and difficult to treat.

Psychoanalysts will raise another question. In discussing male transsexualism I hypothesized that this ,bizarre condition originates in a non-traumatic mother-infant relationship. All other gender disorders are seen by psychoanalysts as the result of trauma (acute or chronic) and its resultant affects of anxiety and depression. It is hard to believe that the most extreme aberration of gender development could be created atraumatically. In addition, the idea that such a profound aspect of character structure, starting so early in life, may be at least partially due to non-dynamic processes of imprinting or conditioning, is alien to some analysts.

Next Is the question of controls. While there are some,'4 many are missingfor instance, cross-cultural studies or formal studies that try to determine if people without these gender disorders nonetheless come from similar family circumstances.

Proper treatment in transsexualism is another problem área. In no other condition are the endocrinologist and surgeon asked to create such extensive body change for purely psychological reasons. One is especially concerned because the body parts affected are of such intense psychological (not to say biological!) importance. The ethical problems are great; they are magnified by those physicians who feel femininity indication enough for radical treatment, even if overt homosexuality, fetishistic cross-dressing or even psychosis may also be present. This worry would only be academic If the end results of the sex transformation were uniformly good, regardless of the patient's psychological state. But this is not so.

A last warning. The arguments in this article rest ultimately on clinical features, but these cannot be adequately described in this short space. Thus the person with enough sense not to accept (or reject) statements such as these on faith would do well to read reports with more complete clinical data10,11, 14, 17 and even then withhold final judgment until personally familiar with transsexuals and transvestites. In other words, see for yourself.

BIBLIOGRAPHY

1. Benjamin, H. The Transsexual Phenomenon. New York: Julian Press. 1966.

2. Diamond, M. Genetic-Endocrine Interactions and Human Sexuality. In Perspectives in Reproduction and Sexual Behavior, ed. by M. Diamond. Bloomington: Indiana University Press, 1968.

3. Gelder, M. G., and Marks, I. M. Aversion Treatment In Transvestism and Transsexualism, in Transsexualism and Sex Reassignment, ed. by R. Green and J. Money. Baltimore: The Johns Hopkins Press, 1969.

4. Green, R. Conclusion, in Green and Money, op. clt.

5. Green, R., Newman, L1 and Stoller, R. J.: Treatment of Childhood Transsexualism: An interim Report of Four Years' Duration. Archives of General Psychiatry (in press).

6. Greenson, R. R, A Tranvestite Boy and a Hypothesis. Int. J. Psa. 47 (1966), 296-403.

7. Money, J. Sex Reassignment and Hermaphroditism, in Green and Money, op. eft.

8. Money, J. Sex Reassignment. Int. J. Psychiat. 9(1970), 249-269.

9. Money, J., and Pollitt, E. Cytogenetic and Psychosexual Ambiguity: Klinefleter's Syndrome and Transvestism Compared. Arch. Gen. Psychiat. 11 (1964), 589-595.

10. Pauly, I. B. Adult Manifestations of Male Transsexualism, in Green and Money, op. oft.

11. Pauly. I. B. Adult Manifestations of Female Transsexualism, In Green and Money, op. cit.

12. Prince, C. V. Survey of 390 Cases of Transvestism. Read before the Western Divisional Meeting of the American Psychiatric Association, Honolulu, 1965.

13. Randell, J. Preoperative and Postoperative Status of Male and Female Transsexuals, in Green and Money, op. cit.

14. Stoller, R. J. Sex and Gender. New York: Science House, 1968.

15. Stoller, R. J. A Biased View of "Sex Transformation" Operations. JWMD 149 (1969), 312-317.

16. Stoller, R. J. Parental Influences In Male Transsexualism, in Green and Money, op. cit.

17. Stoller, R. J. The Transsexual Boy: Mother's Feminized Phallus, Br. J. Med. Psychol. 43 (1970), 117-128.

18. Stoller, R. J. Pornography and Perversion. Arch. Gen. Psychiat. 22 (1970), 490-499.

19. Stoller, R. J. Psychotherapy of Extremely Feminine Boys. Int. J. Psychiat. 9 (1970), 278-280.

20. Stoller, R. J. The Term "Transvestism." Arch. Gen. Psychiat. 24 (1971), 230-237.

21. Stoller, R. J. Etiological Factors In Female Transsexualism: A First Approximation. Arch. Sex, Behav. 1 (in press).

10.3928/0048-5713-19711201-07

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