Clinical Patterns Among Male Transsexual
Candidates with Erotic Interest in Males
Frank Leavitt, Ph.D.,1,3 and
Jack C. Berger, M.D.2
Male-to-female transsexuals who reported an erotic interest in males showed
different patterns of sexual activity. Sexual history was used to categorize
a transsexual sample into three groups: 44% abstained from sexual activity
(Inactive group), 19% were sexually active but avoided using their penis in
sexual activity (Avoidant group), and 37% were sexually active and derived
pleasure from their penis (Pleasure group). The groups were compared for
differences in gender identification, developmental patterns, and personality.
Transsexuals in the Avoidant group showed patterns of traits and experiences
that generally conformed to characteristics of the nuclear transsexual. They
were dissimilar from the other two groups on measures of feminine functioning,
heterosexual history, and fetishism. Transsexuals who interact with males in
ways that are viewed as more classically homosexual shared more in common with
the transsexual group which abstained from sexual activity with males. Both
groups displayed more masculinity in development and more evidence of
emotional disturbance. The implications of these findings for diagnosis and
treatment are discussed.
KEY WORDS: gender dysphoria; male-to-female transsexual; homosexual
transsexual.
1Department of Psychology and Social Sciences, Rush Medical College, 1653
West Congress Parkway, Chicago, Illinois 60612.
2Department of Psychiatry, Rush Medical College, Chicago, Illinois.
3To whom correspondence should be addressed.
INTRODUCTION
Male-to-female transsexuals meeting DSM-III criteria (APA, 1980) for the
gender disorder are heterogeneous in sex object preference. By far, the
majority of males seeking reassignment are attracted to males and labeled
homosexual transsexuals. Smaller percentages show heterosexual and bisexual
attraction. The rest are asexual (Blanchard, 1985). The homosexual
transsexual label is both confusing and controversial among males seeking sex
reassignment. Transsexuals, as a group, vehemently oppose the label and its
pejorative baggage (Morgan, 1978). As a rule, they are highly invested in a
heterosexual life-style and are repulsed by notions of homosexual relations
with males. Attention from males often serves to validate their feminine
status. For many biological male transsexuals, acts of intimacy with women
are truncated, because sexual attraction and relations with women pose the
homosexual issue.
Recent research presents a different view of sexual activity among male
transsexuals. In a study of 44 transsexual males (Langevin et al., 1977), 88%
(35/44) allowed a male partner to touch their penis, 29% (17/40) received
fellatio, and 2% (1/44) performed anal intercourse. These findings indicate
that erotic pleasure in the penis is more common among male transsexuals than
formerly assumed and suggest that the homosexual label may be justified in a
subgroup of transsexuals. These patients also differed on variables measuring
emotional stability and cross-dressing. Those patients who derived erotic
pleasure from their penis were more likely to be emotionally unstable, and
less likely to have switched to full-time living as women, suggesting that
clinicians may be dealing with different disorders that require separate
explanations. This is in line with Stoller's claim (1973) that erotic
pleasure in the penis does not exist in the true transsexual.
Patients with histories of deriving erotic pleasure from the penis voice
complaints of gender dysphoria that do not distinguish them from other
patients seeking gender reassignment. Most meet DSM-III criteria which are
broadly written. Their form of sexual gratification runs so counter to the
majority view of the fundamental features of the transsexual disorder as to
require clarification. At minimum, it may simply mean that popular notions of
transsexualism that developed on an anecdotal basis need to be revised. On
the other hand, the "atypical" pattern of sexual gratification could mean that
patients presenting with this history are pseudo-transsexuals who really
experience other disorders. In these cases, it may be legitimate to question
whether the disturbance is one of gender, sexual disturbance, or
psychopathology.
The purpose of this paper is to offer a broader view of male transsexuals
showing erotic interest in males. The general hypothesis is that transsexual
males deriving erotic pleasure from the penis represent a different diagnostic
entity and should show important developmental, gender, and personality
differences that distinguish them from male transsexuals who do not involve
the penis in sexual activity with males.
METHOD
Subjects
The sample consisted of all biological males seeking presurgical
psychiatric evaluation for sex reassignment in a gender identity clinic; 112
males who were otherwise unselected formed the initial study pool. These
subjects were classified for erotic attraction to males using the Androphilia
Scale developed by Freund et al. (1982) and later modified by Blanchard
(1985). A score of 7.49 or higher on the modified Androphilia scale was
required for inclusion in the study. This score was set so as to exclude
patients with scores more than 1 standard deviation below the mean of
Blanchard's homosexual transsexual group (X 9.86; SD 2.37). On the basis of
the cutoff score, 81 subjects were erotically attracted to males and defined
the homosexual transsexual study pool. The 81 subjects were divided into
three groups on the basis of their answers to questions concerning prior
sexual contact with males. Sexual contact was operationalized along six
dimensions articulated by Langevin et al. (1977). These involve males
masturbating the subject, males performing fellation on the subject, males
performing anal intercourse on the subject, the subject masturbating other
males, the subject performing fellatio on other males, and the subject
performing anal intercourse on other males. These six areas were covered by
24 questions on a questionnaire. Based on answers to these questions three
groups were formed. Criterion for inclusion in the Pleasure group was
admission of five sexual experiences specifying sexual activity involving use
of the patient's penis in either masturbation, fellatio, or anal intercourse.
Admission of five sexual experiences with males, but not involving the
subject's penis resulted in placement in the Avoidant group. The remaining
subjects constituted the sexually Inactive group. This resulted in 30
Pleasure subjects, 15 Avoidant subjects, and 36 sexually Inactive subjects.
Subjects were also classified into the same three categories on the basis of
an extensive interview. All but four subjects were assigned to the same
category as derived from questionnaire data. These four subjects were not
included in the analyses. The three groups were comparable in age. The
Inactive group was slightly more educated than the Pleasure group (see Table
I).
The three groups were quite discrete even though the cutoff score was
arbitrarily set. In the Avoidant group, 10 never allowed their partners to
touch their penis, 2 admitted to one experience, 2 admitted to two, and 1 to
three. In the Pleasure group, the lowest number of experiences was 9, and at
least one third of the group reported more than 100 experiences. In the
Inactive group, over 75% reported no sexual experiences with males.
Table I. Demographic Data of Patients
in Three Transsexual Groups
Group
Avoidant Pleasure Inactive
(n = 15) (n = 30) (n = 36) F value p
Age Mean 29.9 32.8 34.5 1.7 ns
SD 4.2 7.5 9.6
Education 13.2 12.7 14.6 6.70 0.002
Months living full time as a woman 59.4 37.1 8.8 5.80 0.005
Age of cross-dressing onset 9.0 9.0 8.3 0.28 ns
The BEM Sex Role Inventory (BSRI), the MF scale of the Minnesota
Multiphasic Personality Inventory (MMPI), and the Draw-A-Person Test (DAP)
were used to measure aspects of gender identity. The BSRI (Bem, 1977) is a
self-administered 60-item scale consisting of 20 personality characteristics
that are stereotypically masculine, 20 that are stereotypically feminine, and
20 that are embedded as buffer items. Each item is scored along a 7-point
scale ranging from never or almost never true (1) to always or almost always
true (7). Two kinds of scores are obtained. One is a simple indicator of
masculinity or femininity derived by adding masculine and feminine items
separately. The other is obtained by classifying patient's scores as either
falling above or below normative (Bem, 1981) median-split scores (4.90 for
femininity and 4.95 for masculinity) and then classifying them as androgynous
(above median on both masculinity and femininity), feminine or masculine sex
typed (high on the named scale, and low on the other), or undifferentiated
(below median on both).
The MF scale of the MMPI provides a single measure of masculinity and
femininity based on respondents' answers to 60 true-false questions dealing
with interest, vocational choice, aesthetic preference, and activity-passivity
dispositions. High scores (> 70) on the male scale imply femininity of
emotional interest. Low scores imply masculinity of emotional interest.
On the DAP, the subject is asked to draw a whole person (Machover, 1949).
Following this drawing, the subject is asked to draw a person of the opposite
sex to the first figure drawn. The gender of the first figure drawn is
recorded and taken as an indicator of gender identification. It has been
shown that 80 to 90% of males (Fleming et al., 1979) draw a male figure first.
Two variables were measured from responses to the Rorschach test. Adequacy
of reality testing was assessed using the F + percentage and number of popular
responses seen by the subject. Sexual concern was assessed using the number
of sex responses elicited in evaluation. The Rorschach was administered and
scored according to Beck et al. (1961). Reliability of scoring has been
documented (Leavitt and Garron, 1982).
General psychopathology was assessed using the MMPI. The test was
individually administered and scored for 3 validity scales and 10 clinical
scales.
Demographic and developmental data were obtained from a questionnaire
included in the comprehensive psychological examination administered by a
clinical psychologist with more than 10 years experience in examining
transsexuals. The questionnaire consisted of items documenting age,
education, marital history, age when subject first started cross-dressing,
either fully or partially, years living full time in the cross-gender role,
repugnance for genitals, and history of sexual attraction to women. Cross-
gender fetishism was measured by an item borrowed from the work of Blanchard
(1985). "Did you every feel sexually aroused when putting on females'
underwear or clothing?" Developmental history involving preference for
feminine toy play, feminine play partners, and avoidance of masculine activity
was obtained using items on the Gender Identity Scales for Males (Freund et
al., 1977). These items are detailed in Table II.
Table II. Psychosocial Characteristics of Transsexual Males Varying in the
Sexual Expression of Their Erotic Preference for Males
Group
Avoidant Pleasure Inactive
(n = 15) (n = 30) (n = 36) Variable % % % X2 P
Never married 100.0 76.7 52.8 12.2 0.002
Avoids masculine activity 73.3 40.0 52.8 4.5 ns
Preference for feminine toy play 86.7 53.3 50.0 6.3 0.000
Preference for female play partners 86.7 63.3 52.8 5.8 0.050
Repugnance for own genitals 93.3 16.7 36.1 24.9 0.001
History of sexual attraction to women 0.0 33.3 58.3 15.7 0.001
History of fetishistic arousal 6.7 33.3 50.0 8.8 0.010
Table III. Sex-Role Identity Scores from the BSRI,
the MF Scale, and the DAP
Group
Pleasure Avoidant Inactive
(n = 30) (n = 15) (n = 36) F value p
BSRI Masculine scale 4.60 4.66 4.77 0.397 ns
Feminine scale 5.41 5.49 5.32 0.861 ns
MMPI MF scale 83.70 82.20 84.80 0.690 ns
X2 Value DAP Drew female first 60% 80.0% 65% 3.340 ns
RESULTS
Gender identity scores of the masculine and feminine scales of the BSRI
were analyzed in two ways following the work of Bem (1977). First, one-way
analyses of variance were used to test for gender difference among the three
transsexual groups. Results of separate analyses of male and female scores
are presented in Table III. There were no statistically significant gender
differences among the three groups. Subjects in the three groups scored below
the normative median for males (4.95) on the masculine scale and above the
normative median (4.90) on the feminine scale (Bem, 1981).
The second analysis used Bem's median-split scoring system to classify all
subjects into four sex role identity groups. Subjects were labeled as
masculine (high masculine-low feminine score), feminine (high feminine-low
masculine score), androgynous (high masculine-high feminine score), and
undifferentiated (low masculine-low feminine score) based on this separation.
Percentages of the three groups falling into the four sex role groups are
presented in Table IV. The relation between type of transsexual and sex role
identity was not significant, X2(6) = 3.32, p > 0.77. As seen in Table IV,
the majority of transsexuals in all three groups tended to be either feminine
or androgynous.
Table IV. Incidence of Sex-Role Identity in Transsexuals
Varying in Sexual Activity with Males
Group
x-role Inactive Avoidant Pleasure
identity (n = 36) (n = 15) (n = 30)
Androgynous n 13 4 10
% 36.1 26.7 33.3
Feminine n 13 9 15
% 36.1 60.0 50.0
Masculine n 4 1 2
% 11.1 6.7 6.7
Undifferentiated n 6 1 3
% 16.7 6.7 10.0
Table V. Mean Scores of the Three Transsexual Groups
on the MMPI Scales and Rorschach Variables
Group
Variable Avoidant Pleasure Inactive F value p
(n = 15) (n = 30) (n = 36)
MMPI scale
L 54.4 50.1 49.9 1.81 ns
F 51.0 60.1 57.5 2.40 0.05
K 56.9 56.1 57.1 0.09 ns
Hs 48.2 58.2 56.0 2.47 0.05
D 64.9 64.0 65.1 0.07 ns
Hy 58.5 62.5 62.9 1.21 ns
Pd 61.1 70.4 68.3 2.52 0.05
Pa 55.5 62.8 63.3 2.59 0.05
Pt 58.8 62.8 62.9 0.66 ns
Sc 57.7 70.1 68.3 2.84 0.05
Ma 52.4 59.2 55.6 1.65 ns
Si 55.4 52.3 54.3 0.43 ns
Rorschach
Responses 42.8 44.6 43.9 0.87 ns
F + % 70.5 57.8 51.1 9.60 0.001
Popular responses 7.4 6.6 7.2 0.63 ns
Sex responses 0.7 6.4 5.7 4.87 0.01
Gender scores from the DAP and the MF scale of the MMPI are presented in
Table III. At least 60% of each group drew the female first indicating a high
degree of femininity in all three groups. Differences among groups were not
statistically significant. In a similar way, their mean T scores of over 80
on the MF scale of the MMPI is consistent with their identification with the
female sex. The differences among groups were again nonsignificant.
A series of one-way analyses of variance were performed on MMPI scale
scores transformed into K-corrected, T-score equivalents. Significant
differences were observed among groups on five MMPI scales (see Table V).
Post hoc testing using Duncan Multiple Range Test revealed the following
significant (p < 0.05) between-group differences, with higher scores
reflecting greater psychological impairment. The Pleasure and Inactive groups
both scored higher than the Avoidant group on scales F, Hs, Pd, Pa, and Sc.
The differences between the Pleasure and Inactive groups were nonsignificant
on these five scales.
The Avoidant transsexual sample produced a mean MMPI profile indicative at
best of a modest level of psychological impairment. Only scores on Scales D
and Pd were more than 1 standard deviation (T score of 60) above the normative
mean score of 50. On the other hand, the peak scale scores on the Sc and Pd
scale in both the Pleasure and Inactive transsexual groups are often obtained
by males who show significant psychopathology in areas of general functioning.
Rorschach variables are presented in Table V. Inspection revealed that the
F + % and number of sexual content statistically distinguished the three
groups. A control for number of responses was not needed as all groups
produced approximately the same mean number of responses.
Chi-square analyses with 2 degrees of freedom were used to compare
frequencies of the three groups on variables listed in Table II. Chi-square
tests for two independent samples were used for pairwise comparisons. To
minimize overestimating chi-square values, Yates Correction for Continuity was
applied to each analysis involving cell sizes of less than 5. The groups were
significantly different on six of the seven variables listed. The Avoidant
group differed from the two other groups on six of the seven variables listed.
All 15 patients in this group were single and all denied a history of sexual
attraction to females. By comparison, 10 of the 32 patients in the Pleasure
group reported a history of sexual attraction; 8 of these had tried married
life. In the Inactive group, 21 of the 30 patients reported a history of
sexual attraction and 17 of these had married. Differences between the
Pleasure and Inactive groups of these two variables were also significant.
There was less attraction to females and fewer marriages in the Pleasure
group.
The Avoidant group also showed a much smaller incidence of erotic arousal
to cross-dressing. Only one patient in the Avoidant group reported a history
of fetishistic arousal. This compares with 10 of 30 in the Pleasure group and
18 of 36 in the Inactive group. The difference between the Pleasure and
Inactive group was nonsignificant, X2(1) = 1.86, p > 0.17.
The Avoidant group also differed from the other groups in the amount of
feminine sex-typed behavior in the developmental history; 86% of the group
reported a developmental history involving cross-sex preference for both play
partners and play toys.
The three groups also differed relative to attitudes regarding the penis.
In the Avoidant group, 87% stated that the penis was repulsive, compared to
36.2% in the Inactive group, and 16.7% in the Pleasure group. The difference
between the Pleasure and Inactive group was nonsignificant, X2(1) = 2.21, p >
0.14.
Data relating to cross-dressing are presented at the bottom of Table I.
While the groups did not significantly differ on mean age of onset, patients
in the Avoidant group had lived significantly longer in the feminine role than
patients in either of the other two groups. Differences in full-time living
between the Pleasure and Inactive group were also significant (p < 0.05).
DISCUSSION
Level of gender disturbance is not a clinically discriminating variable.
Whether measured by the Draw-A-Person Test, the MF Scale of the MMPI, or the
Bem Sex Role Inventory, comparable levels of gender disturbance are found
among the three transsexual groups, with a higher incidence of femininity and
a lower incidence of masculinity noted. All three male groups are clearly
more feminine than heterosexual males when comparisons are made to normative
data (Gravitz, 1966; Bem, 1981).
Clinically, however, transsexuals in the Avoidant group are different from
transsexuals in the other two groups along a number of important clinical
dimensions. On measures of feminine functioning, they appear to follow a
different developmental pattern. They show greater amounts of cross-gender
behavior early in life and more consolidation of feminine identity later in
life. Feminine toy play and feminine playmates are almost universal in their
histories; whereas only one in two report this in the Inactive group, and only
slightly more in the Pleasure group. The Avoidant group also seems to have
experienced less difficulty adopting the cross-gender role as a full time way
of living. On average, they have been living full-time as women for 5 years;
this contrasts with 3 years in the Pleasure group and less than a year in the
Inactive group.
Transsexuals in the Avoidant group are also distinguishable on the basis of
heterosexual history. This group is remarkable for the absence of
heterosexual behavior. As a group, they totally deny sexual attraction to
females, and none report marriage. This compares with an attraction and
marriage rate of approximately 50% in the Inactive group and 33% in the
Pleasure group. Similar patterns are found for the variables measuring
fetishistic arousal and attitudes towards the penis. Transsexuals in the
Avoidant group share a common aversion to their penis and rarely experience
fetish arousal. By contrast, at least 33% of the transsexuals in the other
two groups report a history of fetish arousal and at least 60% deny being
repulsed by their genitals.
The Avoidant group also differs from the Inactive and Pleasure group on the
basis of psychopathology. Transsexuals in this group appear psychologically
healthy by scores on both the MMPI and the Rorschach. There is no evidence
that their disorder is based on psychopathology as suggested by some (Roberto,
1983). Transsexuals in both the Inactive and Pleasure group show significant
psychiatric impairment and interestingly emphasize sex content in responding
to Rorschach stimuli. Prominence of sex content in protocols is generally
interpreted as an indicator of disruptive problems in sexual adjustment
(Philips and Smith, 1953).
Transsexuals who are sexually active with males but do not allow their
penis to be involved in sexual activity share a constellation of traits and
experiences that generally conform to characteristics of the nuclear
transsexual (Buhrich and McConaghy, 1977). The picture of the nuclear
transsexual conveyed by the literature is that of sustained, nonfluctuating
femininity, developmental patterns involving a preference for girls' games and
company, aversion to rough-and-tumble activity in early childhood, later
patterns involving a desire to posses a women's body, to live in society as a
woman, and to attract heterosexual male partners. The nuclear transsexuals
experience intense disgust and aversion for their penis and deny a history of
heterosexual orientation or fetish arousal. If patients in the Avoidant group
are accepted as nuclear transsexuals, then only 18.5% of our sample meet those
criteria. This implies that most of our sample seeking reassignment are not
nuclear transsexuals (Newman and Stoller, 1974). This supports Lothstein's
claim (1982) that most "patients seeking surgery are secondary transsexuals,
i.e., transvestite or effeminate homosexuals."
Transsexuals who derive pleasure from the penis are clinically more
puzzling. They interact with males in ways that are more classically viewed
as homosexual, yet they share more in common with transsexual males who have
been the least sexually active with males and the most heterosexually
oriented. They are particularly similar to this group on variables involving
early developmental patterns and psychopathology. Both display more
masculinity in their developmental patterns and more emotional disturbance
probably rooted in the sexual sphere. They are somewhat less alike in respect
to repugnance for their genitals and for fetish arousal, but these differences
are not statistically significant. Transsexuals who derive pleasure from the
penis however display substantially less in the way of heterosexual patterns
than do transsexuals in the Inactive group. They were less attracted to
women, fewer had married, and most have lived longer in the feminine role on a
full-time basis. The level of psychopathology in this group is similar to
that of other transsexual groups who have involved their penis to a
considerable degree in sexual relations. Langevin et al. (1977) reported
significantly more suicide preoccupation and more abnormal MMPI patterns for
this subset of transsexuals. The prominence of fetishism in this group is
unusual since it is considerably higher than typically reported for
transsexual groups. A fetish rate among homosexuals of only 8% was reported
by Hellman et al. (1981). It was noted that the homosexuals who exhibited
arousal to cross dressing also scored higher on femininity. This may suggest
that one feminine form of homosexuality is fetishistic. If individuals of
this nature come to look upon themselves as transsexual, this could explain
the puzzling as sociation of penile pleasure and fetishism in this group.
Other studies have found similar subgroups of transsexuals who show sexual
patterns that conform to those of nontranssexual homosexuals. Bentler (1976)
in a study of 42 postoperative male-to-female transsexuals classified 36% of
this sample as homosexual on the basis of a five-item sex questionnaire. All
members of this group admitted to viewing themselves as homosexual prior to
surgery; following surgery, they were much more sexually active than either
the heterosexual or asexual comparison groups. Sexual activity involving
fellatio and anal intercourse was prominent, with pleasure reported by 73 and
33%, respectively. A 23% incidence of fetish arousal was observed among these
patients. Their postoperative adjustment was poor. One-quarter reported that
life as a female was not up to expectations in comparison to none in the two
contrasting groups.
Transsexuals in the Inactive group report characteristics that most depart
from the nuclear transsexual pattern. Strong heterosexual orientations and
fetish histories are prominent. They show the most difficulty in making the
transition to full-time feminine living. Despite reporting erotic interest in
males, the pattern exhibited generally conforms to that exhibited by patients
referred to as heterosexual transsexuals (Buhrich and McConaghy, 1978).
Studies by Blanchard et al. (1985) suggested that some heterosexual
transsexuals adjust their histories of erotic preference to bolster their
chances of receiving a positive decision on sex reassignment surgery. Since
this group accounts for 40% of the sample and shares little in common with
homosexuals, except a stated erotic interest in males, the use of the
homosexual label for patients with a stated erotic attraction to males seems
to have little merit; the label with its pejorative baggage may guide clinical
thinking in a misleading direction. Adoption of more neutral descriptive
terms such as androphilia (Freund et al., 1982) to indicate erotic preference
for physically mature males may be desirable.
The present study contains a potential methodological flaw that needs to be
considered in evaluating the heterogeneity of results concerning fetish
arousal. The study selected transsexuals with strong sexual attraction to
males using a cutoff score of 7.49 on the Androphilia scale. It is possible
that some transsexuals with a strong sexual attraction to males are bisexual
rather than homosexual. Sexual attraction to females was not directly
measured in this study. Instead, the 7.49 cutting score was calculated to
eliminate 77% of bisexuals in our study using Blanchard's normative data
(1985). His bisexual transsexuals had a mean score of 4.15 (SD 4.18) on the
Androphilia scale. Based on probability statistics of the normal curve, it is
estimated that only five patients in our final sample are bisexual. While
fetish arousal is common among bisexuals, an n of 5 cannot account for the
fact that 18 of 36 subjects in the Inactive group, 10 of 30 in the Pleasure
group, and 1 of 15 in the Avoidant group report fetish arousal (see Table II).
It remains possible that the cutting score selected was not as successful as
planned in excluding bisexual transsexuals.
The data suggest several kinds of clinical patterns among candidates for
sex reassignment surgery who are erotically attracted to males that need to be
differentiated in the development of topologies. These types cannot be
understood on the basis of different levels of gender disturbances, since high
levels of femininity are experienced by all groups. It appears clinically
important to carefully document history of sexual activity with males since
this variable seems to separate this part of the "presenting transsexual"
population into three forms that are sufficiently distinct to raise the
possibility that clinicians may be dealing with separate and distinct
entities. Our data point to the centrality of sexual disturbance and
psychopathology in two of these groups and raise the question whether
clinicians should be more cautious when history places candidates in either
the Pleasure or Inactive groups. Beyond that lies the question of whether
these are genuine transsexuals or pseudo-transsexuals. Patients label their
gender states in terms of the limited cognitions available and/or acceptable
to them. Should clinicians accept the same? There may be entirely different
paths for shaping feminine gender in males, and these paths may reflect
entirely different etiologies and disorders. The data point to no specific
etiology for those transsexuals who seem to fit the nuclear transsexual
pattern best. Though speculative, they show the consolidation of feminine
behavior and the stability of personality functioning that one might expect to
see in a condition with an organic cause. They may represent the most
appropriate group for surgical intervention.
REFERENCES
American Psychiatric Association. (1980). Diagnostic and Statistical Manual
of Mental Disorders, 3rd ed. APA, Washington, DC.
Beck, S. J., Beck, A. G., Levitt, E. E., and Molish, H. B. (1961).
Rorschach Test: 1. Basic Processes, 3rd ed., Grune and Stratton, New York.
Bem, S. L. (1977). On the utility of alternate procedures for assessing
psychological androgyny. J. Consult. Clin. Psychol. 45: 196-205.
Bem, S. L. (1981). Bem Sex-Role Inventory: A Professional Manual,
Consulting Psychologist Press, Palo Alto, CA.
Bentler, P. M. (1976). A typology of transsexualism: Gender identity theory
and data. Arch. Sex. Behav. 5: 567-584.
Blanchard, R. (1985). Typology of male-to-female transsexualism. Arch. Sex.
Behav. 14: 247-261.
Blanchard, R., Clemmensen, L. H., and Steiner, B. W. (1985). Social
desirability, response set and systematic distortion in the self-report of
adult male gender patients. Arch. Sex. Behav. 14: 505-516.
Buhrich, H., and McConaghy, N. (1977). The discrete syndrome of
transvestism and transsexualism. Arch. Sex. Behav. 6: 483-495.
Buhrich, H., and McConaghy, N. (1978). Two clinically discrete syndromes of
transsexualism. Br. J. Psychiat. 133: 73-76.
Fleming, M., Koocher, F., and Nathans, J. (1979). Draw-A-Person Test:
Implications for gender identification. Arch. Sex. Behav. 8: 55-61.
Freund, K., Langevin, R., Satterberg, J., and Steiner, B. (1977). Extension
of the Gender Identity Scale for Males. Arch. Sex. Behav. 6: 507-513.
Freund, K., Steiner, B. W., and Chan, S. (1982). Two types of cross-gender
identity, Arch. Sex. Behav. 11: 49-63.
Gravitz, M. (1966). Normal adult differentiation patterns on the figure
drawing test. J. Proj. Tech. Pers. Assess. 30: 272-273.
Hellman, R. E., Green, R., Gray, J. L., and Williams, K. (1981). Childhood
sexual identity, childhood religiousity, and 'homophobia' as influences in the
development of transsexualism, homosexuality, and heterosexuality. Arch. Cen.
Psychiat. 38: 910-915.
Langevin, R., Paitich, D., and Steiner, B. (1977). The clinical profile of
male transsexuals living as females vs. those living as males. Arch. Sex.
Behav. 6: 143-153.
Leavitt, F., and Garron, D. C. (1982). Rorschach and pain characteristics
of patients with low back pain and "conversion V" MMPI profiles. J. Pers.
Assess. 46: 18-25.
Lothstein, L. N. (1982). Sex reassignment surgery: Historical, bioethical
and theoretical issues. Am, J. Psychiat. 139: 417-426.
Machover, K. (1949). Personality Projection in the Drawing of Human
Figures, Charles C. Thomas, Springfield. Ill.
Morgan, A. J. (1978). Psychotherapy for transsexual candidates screened out
of surgery. Arch. Sex. Behav. 7: 273-282.
Newman, L. E., and Stoller, R. J. (1974). Non-transsexual men who seek sex
reassignment. Am. J. Psychiat. 131: 437-441.
Phillips, L., and Smith, J. G. (1953). Rorschach Interpretation: Advanced
Techniques, Grune and Stratton, New York.
Roberto, L. G. (1983). Issues in diagnosis and treatment of transsexualism.
Arch. Sex. Behav. 12: 445-473.
Stoller, R. J. (1973). Male transsexualism: Uneasiness. Am. J. Psychiat.
130: 536-539.