from Gender Identity Disorders
By Sander Breiner, M.D.
Member, NARTH Scientific Advisory Committee
Sander Breiner, M.D.
Simple direct definitions are: 1. Homosexuality -- primary sexual attraction for members of the same sex by adults; 2. Transvestism - cross-gender dressing to improve sexual gratification and/ or reduce anxiety; 3. Transsexuality -- believing one's body is of the wrong sex (e.g. "externally I am a male who inside is really a woman that needs to be 'changed' surgically and hormonally.").
Homosexuality has many forms of expression. The essential element is the emotional and psychological conception of an adult that their primary sexual gratification would be in some sexual activity with a member of the same sex. This does not require any actual activity in fulfilling that desire. As with any major psychological emotional (dynamic) force in an adult, you can have a variety of manifestations. The expression of homosexuality is determined by two basic elements: 1. What that particular society supports or restricts, and 2. The degree of psychological health of the individual.
Transvestism is not just cross-dressing. Cross-dressing, when a male dresses as a female, can be part of a Halloween party, or some theatrical performance. It can be a way of seducing or manipulating some male to participate sexually with them who has no interest in homosexuality and thinks they're having some romantic activity with a female. Wearing makeup and some effeminate style of attire (but still clearly being a male) also is not transvestism.
In fact, none of the preceding is transvestism. Transvestism involves an emotional need that requires a male to wear female attire to meet a sexual need or reduce one's anxiety. There are various forms of transvestism which can be either heterosexual or homosexual. To name just two forms (of many) would be: 1. A heterosexual male who will wear a woman's brassiere or panties while having some romantic activity with a woman, and 2. A married man with children who, with the help and support of his wife, will on occasion completely dress himself as a woman (makeup, wig, etc.). We even sometimes see conventions of such people who gather together with similar interests and activities. These men have no interest in functioning homosexually -- either in their fantasies and least of all, in their sexual behavior.
An adult man who is psychologically a transsexual is in a different category with a different expression of psychological problems. Transsexuality is far from rare and therefore deserves some discussion. As a psychiatrist and psychoanalyst, I have seen transsexual patients in my private practice as well as while working as a consultant to a university and medical school program which evaluated and "treated" these individuals (at least, with surgery and hormone replacement).
Significant Numbers Of Homosexuals Seek Sex Changes
There are a significant number of male homosexuals who would like to be a female with a penis. There are others who would like to be completely transformed into a female, but can't arrange to have such a complex surgical procedure. Both groups will obtain hormones from various sources; often it will be illegally from a pharmacy.
The transsexual male who was not part of a university/medical school treatment program, will often take hormone treatment (self-prescribed and administered), and play a feminine role with unsuspecting heterosexual males (often as a prostitute). They will play the part as if they are a passive feminine object. Their approach has many masochistic behavioral qualities. However, their thinking about how they are tricking, fooling and using others has a clearly sadistic dynamic as well. Their histories almost invariably demonstrate a mother figure who is at least domineering, manipulative and controlling.
Such men have little to no relationship with their family. Unfortunately, their lifestyle has a clearly self-destructive quality. These individuals usually do not stay in any adequate psychotherapy program (i.e., once per week for at least three months). They also have significant problems in certain areas of reality perception; therefore, long-term intensive therapy is the best choice, and long-term supportive therapy with medication is the bare minimum required to prevent them from destroying themselves.
There is a smaller group of transsexuals that includes those individuals who have been involved with a university-sponsored, medical-school treatment program. They have had much more appropriate study and evaluation. In general, what takes place is that the individual applies to the program, and agrees to participate with full disclosure to one or more psychiatrists, social workers, psychologists and various medical specialists during the entire extended period of evaluation, treatment and follow-up. This usually will extend for about one year before surgical treatment is carried out. No medical or surgical intervention is begun until there is months-long prior evaluation and clearance.
My clinical experience in participating with the Wayne State University program has been corroborated by others at the University, as well as at Johns Hopkins University--a medical school even larger and with a longer-lasting program. The following will be a summary description of my experience that is typical of the cases seen at both of these university programs.
A single male in his middle 20's to early 30's with at least one college degree and some financial and professional success applies to the program. He has had some homosexual experience with partial gratification. He has attempted heterosexual activity with little sexual gratification, if any. His chief complaint is that as long as he can remember he has never felt that his body was "right." By the time he got to be an older teenager, he was certain that something was wrong with his body. The more he thought about it and explored the subject, the more he believed that he was actually a woman inside that needed to somehow come out and be expressed.
Cross-dressing, however, did not make him feel comfortable. He recognized that cross-dressing could produce problems for him socially and economically, so he avoided it.
He is a well-spoken and reasonable, dependable historian regarding the details he reports in all areas -- except how he feels about himself in terms of his gender and his body image. He describes himself as somehow feeling that something inside is trying to come out; that somehow or other, the "real self" is being restricted and limited. More and more "it" is conceived as the woman inside him who has somehow always been there. He thinks that some mistake in genetic expression or development (in some not understood way) has prevented this true womanly self from being expressed. It is as if the real woman inside of him is imprisoned.
This individual is not passive and effeminate in bearing, carriage, or in his approach to life. He is assertive and successful, and competitive socially and intellectually as a man (except in his pursuit of female companionship). He is convinced that he is a woman who somehow or other is trapped in a man's body. His external genitalia, he believes, are an impediment. He wants the body configuration and genitalia to be that of a woman. He desires the full quality of being a woman with all her curves and her qualities.
His discussion is not irrational. His desires, wishes and self-concept on a feeling level are presented in a logical manner. He does not have any scientific proof of his position; he "just knows" that he was meant to be a woman.
All tests by psychologists and psychiatrists in testing his judgment of reality (except in his body image) are within normal limits. There is no evidence of psychosis or any significant problems in any other area than his body image (related to gender only). He is cooperative and patient and helpful in his manner. His only area of insistence is concerning his belief about his body and the need to become a woman. He is not afraid of psychological and psychiatric evaluation. However, he is not interested in intensive psychoanalytic/psychotherapy for a period of months or years. He firmly believes that his problem is not psychological but that it is truly on an organic basis.
After the initial phase of evaluation and study, the patient is instructed to begin dressing himself and living his life (gradually more and more) as a woman. Despite the physical, social and economic discomforts, he is positive and cooperative in every way in the program.
During this entire period, the patient is followed by the medical and surgical teams and by the psychiatrist. This follow-up continues during each phase of the program, including the follow-up period after the completion of all surgical and hormonal treatment. The next phase is the beginning of hormone replacement. This is followed by the addition of surgical change of the perineum from that of a male to a female with a vagina. To do so, procedures are done to form it into a receptive organ with lubrication. This is followed by surgical intervention (if needed, usually) for breast enhancement, etc.
For a period of time after surgery, there is less tension and discomfort psychologically experienced by the patient. He begins to feel better about himself and hopeful about his future as a woman. Upon completion of the program and taking on a new life (which usually includes a legal change of his name), he feels relieved and hopeful and eager to continue his relationship in the follow-up part of this research.
Between six months to two years following the completion and healing of the surgery, the surgeons begin to request more evaluations from the psychiatric division of this program. The surgeons do not understand what is transpiring because the patient is now asking for more surgery.
During the entire pre-surgical treatment the only psychological problems that were clearly defined were related to body image. This is not insignificant from a psychodynamic standpoint. It was considered understandable as a logical response of somebody with this "organic" problem. Since there was no obvious psychological break with reality in any other area, the program continued with each individual.
However, now the surgeons and other medical team members begin to observe that although this patient is now considered a woman, he isn't satisfied with the job that was done. He feels that he now needs something more from medical science. He needs the size or shape of his calves, his hips, his arms or his breasts, etc. "improved." More and more it becomes apparent that no matter how successful the procedure and continued hormone replacement have been, it seems that each patient still feels that something is lacking -- that though they were now a woman, it somehow isn't enough.
However, after some minor attempts at surgical assistance by surgeons and endocrinologists, the surgeons finally refuse to do any more. In their judgment, nothing further should or could be done.
Typically, the surgeons were all pleased initially with the success of their transformation of a man into a nice--if not a beautiful--young woman. Now, the medical staff becomes dissatisfied with the patient's dissatisfaction, and they turn the case back to the psychiatric division to "solve" the problem.
The Problem Is Psychological, Not Organic
At this point in the process, I, along with other psychoanalyst colleagues, must tell the surgeons that the disturbed body image was not an organic at all, but was strictly a psychological problem. It could not be solved by organic manipulation (surgery, hormones), no matter how well-intentioned or brilliantly successful it was done.
In psychologically evaluating any patient, it is always important to understand how the patient sees himself. There are certainly age variations as well as gender and cultural elements involved in this evaluation. However, when an adult who is normal in appearance and functioning believes there is something ugly or defective in their appearance that needs to be changed, it is clear that there is a psychological problem of some significance.
The more pervasive and extensive is this misperception of oneself, the more significant is the psychological problem. The more the patient is willing to do extensive surgical intervention (especially when it is destructive), the more serious is the psychological problem. It may not be psychosis. It may not require psychiatric hospitalization. But the significance of the psychological difficulty should not be minimized by a patient's seeming success, socially and professionally, in other areas. This principle of isolated significant psychopathology indicating serious psychological problems (despite their ability to function in all other areas of life) is well known psychiatrically, historically, and by the judiciary.
This conclusion became so well established at Wayne State University that the program was eventually discontinued. The much larger and more extensive program at Johns Hopkins University and medical school in Baltimore, Maryland was discontinued for the same reason. [See Dr. Paul McHugh's essay on his experience at Johns Hopkins.]
The psychological problems that are focused on issues related to gender need to be better understood -- not denied.