Transvestism & Transsexualism: a dichotomy?
Dr. M.T.Haslam, MD, FRCP, FRC Psych
Medical Director, South Durham NHS Trust, Winterton Hospital, Sedgefield Co. Durham. Trustee of the Beaumont Trust. Gendys Network Associate Member.
There are many advantages in minority groups banding together. Yet often it seems that such groups define their boundaries rather strictly and seem to find security in putting up defensive walls around themselves and excluding others who may not entirely fit.
The boundaries which define transsexualism and transvestism as two separate entities seem at any rate in the United Kingdom to have been defined in a paper produced by Martin Roth, now Sir Martin Roth, and his colleagues in Newcastle in 1959 which was contained in a book on intersexuality.
The question is whether there are two separate conditions or whether, on the contrary, a continuum exists at the one end, from the cross dresser with largely fetishistic interests, to at the other end of the scale, the full-blown transsexual who perceives him, or herself, to be a female, locked in a male body, or vice versa. This is a not dissimilar issue from to that which raged in The British Journal of Psychiatry at around the same time, as to whether there were two types of depression, one endogenous biological and arising from within and the other purely reactive to environmental stress.
If two entirely separate conditions co-exist, for example epilepsy and appendicitis, then a Venn diagram (figure 1) will show an overlap, where some individuals will coincidentally suffer from both conditions at the same time. This does not imply a relationship between the two. If 1% of the population through some strange quirk in their constitutional make-up choose to play golf, whilst another one person in a hundred has ginger hair, then simple statistics will show that one person in ten thousand will be a ginger haired golfer but since this is a statistical coincidence there will be no need to create a new category of individual.
Similarly if 5% of the population are homosexual in their partner choice and 2% of the population for whatever reason cross-dress, then one in a thousand of the general population will be homosexual transvestites. Furthermore, if one were to extend Roth's argument then if one person in five thousand were transsexual then one in twenty-five thousand would be a transvestite transsexual. It seems to the author that when looked at in these terms the apparent nonsense becomes clear.
The author perceives the cross dressing continuum as having, at one end of the scale, the individual who is totally convinced of a male brain in a female body (or vice versa) and, at the other end of the scale, the occasional cross dresser with fetishistic inclinations. Rather than there being two clusters of individuals with separate problems, there is a continuum, with the bulk of such people with gender problems lying in an amorphous middle ground. The two examples are but two extremes of a gender distortion, and where one fits on this continuum is to a large extent a product of what questions the therapist asks.
Two studies which the author initiated will be referred to in this paper. The first was a survey carried out amongst Beaumont Society members some years ago and which was an anonymous survey of early history, character traits and current life styles of those who were members of what was purported to be a heterosexual transvestite club, which also included some gender motivated transsexuals. This was published in an article entitled Transvestism by Haslam M.T., British Journal of Clinical and Social Psychiatry, volume one, 1982, 1.1-9.
The second was a study of responses to an estrogen provocation test in a group of volunteers taken from the York - Leeds area who were living full time in the female role but who, for the purposes of the test, were not taking hormones and who were prepared to identify themselves by attending for four days in a row at the Clinic to have a blood test taken. This relatively rare breed were then compared with a control group taken from psychology students at Leeds University! This article was published in The British Journal of Social and Clinical Psychiatry under the title Hypothalamic Sensitivity in Transvestism and Transsexualism by M T Haslam, volume seven 1990, 2.113.
Referring to the former paper no other study had at that time researched a group of this kind in the United Kingdom. The only similar study had been one carried out by Prince and Bentler in the United States and published in 1970 in The Journal of Clinical Psychology.
The second paper was inspired by some work carried out by Dörner in Berlin. Dörner was interested in intersexuality, and had been working on a test which distinguished male and female brain patterns on the basis of the response of certain pituitary gland hormones to a loading dose of estrogen. He had wondered whether this test would be abnormal in individuals with homosexual inclination and gave the test to a series of such volunteers. Whilst in general the volunteers had produced a normal male response pattern he noted that what he described as effeminate homosexuals had a larger than expected proportion of individuals who showed the female response pattern although genetically and chromosomally male.
We had wondered to what extent this might apply not so much to homosexuality but to the effeminacy and whether this test would show differences in a group of volunteers who were transsexual or transvestite.
A group of volunteers was sought, therefore, within the Leeds - York area who were full time cross dressers, with the help of a research colleague Miranda Hughes who was doing a Ph.D project in Leeds on intersexuality at the time.
Our results in this small study showed a significantly larger number of cross dressing volunteers to have a female response pattern. There was no significant difference between those in the group who identified themselves as transsexual and those who identified themselves as transvestite.
This study was done some years ago and it is interesting to note that recent use of more sophisticated scanning techniques has shown differences in male and female brain structure which can now be identified. Work in Holland has shown on a group of male to female transsexuals that again many show a female type of brain configuration. It would be interesting to know whether patients who show the female kind of response to estrogen are also those who have the female type of brain configuration on the scanner.
Turning again now to the first paper referred to, a survey of Beaumont Society members carried out anonymously and reported in The British Journal of Clinical and Social Psychiatry, this was a survey one must remember of an organisation that purported to be for the heterosexual transvestite, although a number of transsexual individuals were members. Some six hundred individuals were surveyed and responses received from some two hundred and fifty volunteers. The study surveyed such areas as early history, current life style and attitudes, and administered a simple personality inventory (the MPI). Presented in this paper are those results relevant to the theme of this title. The full survey is available in the Beaumont Society library.
Paternal age averaged 32 for the age when the respondents were born, and 30 for the age of the mother. This is rather older than the average age of a female parent.
The average age for the first recalled cross dressing experience was 9, which is well before the age of puberty.
Twenty two per cent of respondents had had a father who had died or been absent for some other reason in childhood, the mean age of this occurrence being 4.4 years. In 10% the mother had died during childhood with a mean age of 4.7.
We looked at sexual orientation. Remember that The Beaumont Society purported to exclude those of homosexual orientation at that time. The issue as to what sex a transsexual should be attracted to in order to be homosexual is of course arguable. Does homosexuality relate to brain sex or genital sex when a sexual act is carried out?
At any event 2% of the respondents stated that they were homosexual in their orientation and 31% saw themselves as bisexual. Fifty seven per cent however saw their sexual orientation as being different when cross dressed as opposed to when in their genitally appropriate clothing. i.e. when identifying as women over half identified themselves as being female, or wishing to be, in any sexual encounter. Another myth that has abounded is that those with gender problems are less sexually active than the general population. Our respondents were at a mean age of 44. Ten percent claimed an orgasm rate of more than twice a week, 30% twice a week, 20% weekly and 40% less than once a week. Sixty-three percent had an ongoing relationship.
In the family histories of the groups it was interesting to find that 5% of the respondents knew of first degree relatives who also cross-dressed. If the incidence in the general population is around one in a hundred and allowing for the fact that cross dressing habits in first degree relatives often would not be known in other members of the family, then this seems a higher incidence than one would expect by chance.
Another myth often used in the past was that individuals who cross-dress were forced into the role perhaps by elder sisters or female relatives at a young age and thus, as it were, acquired the habit. Only 10% of the respondents commented that their first experience had been imposed upon them, in their early history. Put another way 90% of those responding who were members of The Beaumont Society had no such history in their early life.
Relationships with parents were also examined. Ninety-three per cent of respondents considered that they had a good relationship with their mother but 34% described their mother as strict and 44% perceived the mother as a dominant partner within their parents. Eight per cent perceived themselves as having had a good relationship with their father but in 42% the father was perceived as being the strict one and in 33% the father was perceived as having been ineffective. Thirty four per cent of the respondents understood their parents to have wanted a girl during the pregnancy and this gave a positive correlation in subsequent analysis of the data with the transsexual end of the spectrum.
Twenty three per cent of the respondents (i.e. nearly a quarter) had experienced early separation episodes during the first five years of life (i.e. a parent missing for a significant length of time during this early stage.) This compares with a level seen in another study (Haslam: Psychiatric Illness in Adolescence) and compares with 10% in the general population.
Twenty four per cent of the respondents were only children and again analysis shows the significant positive correlation existing in an only child and a tendency to be transsexual. Thirty per cent had a sister as their only sibling and 24% a brother as their only sibling. Six per cent of the respondents were first born.
Bearing in mind the hypothesis in this paper that transsexualism and transvestism occupy a continuum on a linear scale rather than being discrete conditions, a series of questions were asked about the individual's gender concept. Again one must be reminded that the survey group was from a society for heterosexual transvestites. Forty per cent of the two hundred and fifty respondents felt that they were a female trapped in a male body. Sixty per cent said that they wished they had been born a female though they perceived themselves as male. Twenty nine per cent perceived themselves as having moved from being a transvestite to being transsexual at least in their own mind. Forty-eight per cent were living as full time as was possible in the female role and would be completely full time if their social circumstances had allowed it. Thirty per cent had at one time or another considered a possibility of going for gender reorientation surgery though only 2% of the respondents had actually done so.
This sort of data does raise the question as to how much of an individuals' self-perception relates to information gleaned from others, the concept of gender often ill-formed in a young person's mind, and to the fact that one tends to bend the type of answer to the type of question one asks.
In reality there is no way that an 'in between' can claim to be entirely of one or other sex. If there is indeed such a thing as a female or male brain, whatever this really might mean, there is certainly such a thing as a female or male body in terms of general structure and in terms of identifying chromosomes. Were there an individual with a female brain, male chromosomes and male genitalia, are they female therefore because the brain was female, or male because the body was male, or a mixture of the two? It would seem self evident that such individuals are at best a mixture of the two and whether it is entirely logical to try and move everything towards brain sex rather than try to move the brain towards the body sex is not necessarily written in tablets of stone. It depends rather on how an individual may most successfully be able to integrate in a society which still remains polarised (for very good reasons) for individuals to be one or the other. The brain is only a part of one's totality and many more people who answer to the question "Are you male or female" and "Do you wish you had been born male or female" are likely to move towards saying that they are female locked in a male body once this concept has been put to them. What will happen to a cross-dresser so indoctrinated who finds in the years to come that his brain anatomy and his response to estrogen provocation tests is clearly masculine male and unequivocal. Yet he cross-dresses? I would put it to the meeting that these issues remain yet to be fully elucidated.
Finally the respondents completed a short personality questionnaire looking particularly at areas of introversion and extroversion and neuroticism. The results were not dissimilar from those found by Prince and Bentler in the United States. A group of respondents clustered at the introversion end of this scale and some 25% clustered at the neuroticism end of the scale, these groups forming a cluster of neurotic introverts whose characteristics were somewhat different from the 75% who had a normal profile. The neurotic introvert cluster correlated positively with being first born, with being full time cross dressers, and with being submissive in the sexual role.
The data was submitted to a factor analysis and twelve principle factors were identified in the first analysis of which the largest were a matriarchal family structure, a high parental age, only children and first born. A passive role appeared to correlate with the earlier cross-dressing experience.
When irrelevant general factors were removed from this initial analysis and the data subjected to a further principle factor analysis, eleven factors were then identified. The largest of these took up 11% of the variance and related a strong need to cross dress (i.e. a severity of transsexualism if one likes to put it this way) with early age cross dressing and a progression from transvestism to transsexualism. There was also a wish to have been born female, a desire to be full-time and a desire for sex change.
The second strongest factor which accounted for 8% of the variance was an identification of weaker sexual drive with an earlier age of identified cross dressing and with a preference for a transvestite role in love-making experiences.
In summary therefore, a much larger percentage of members of The Beaumont Society perceived themselves as at the transsexual end of the spectrum than might be expected from the Society's professed purpose at the time. The profile of those who returned the questionnaire was the same in nearly all respects as the general population, apart from a few possible clues which might be effect, rather than cause of the gender problem.
Thus being the child of older parents, and a related tendency to have less siblings were noted.
The personality profile showed some 75% of respondents to be in the normal range, with a small cluster of introverted individuals with some neurotic tendencies as portrayed by the M.P.I. in addition. This was much as was found by Prince and Bentler in their United States' study. The factor analyses produced small clusters of not unexpected groupings with certain features more apparent at the transsexual end of the continuum.
There is little to suggest a clear distinction between those who described themselves as transvestite and those as transsexual, except in degree and in the type of answers to certain questions. Those aspects examined in the questionnaire failed to distinguish clearly between the groups, and similarly in the second research study where responses were sought to an estrogen provocation test, although a larger number of the volunteers showed a female response pattern, this again did not distinguish between those individuals who described themselves as transsexual and those who perceived themselves as transvestite.
Minority groups have enough problems to deal with without trying to subdivide themselves to their own disadvantage. The transsexual intent upon gender restructuring and the transvestite intent upon living the 'as if' should, along with others who suffer from society's attitudes towards gender and sexual preference, support each other whenever the opportunity arises, rather than as often seems the case in minority writings, bicker about their minor differences.
Bentler, P.M., Prince, C., (1970) Psychiatric Symptomatology in Transvestites. Jour Clin. Psychol. 26, 434
Dörner, G., (1979) Sex Hormones and Behaviour, Symp. 62, Ciba Foundation, 81-101, Excerpta. Medica. Amsterdam.
Haslam, M.T., (1982) Transvestism, British Journal of Clinical and Social Psychiatry, Vol 1., 1-9.
Haslam, M.T., Psychiatric Illness in Adolescence, London: Butterworth.
Haslam, M.T., (1990) Hypothalamic Sensitivity in Transvestism and Transsexualism, British Journal of Clinical and Social Psychiatry, Vol 7., 1, 113.
Roth, Martin and Ball, (1964) Psychiatric Aspects of Intersexuality: Intersexuality in Vertebrates Including Man. London: Armstrong, New York: Marshall.
Haslam, M., (1996), Transvestism & transsexualism: a dichotomy?, GENDYS '96, The Fourth International Gender Dysphoria Conference, Manchester England. London: Gendys Conferences.