E XT RE ME FE MININIT Y IN BO YS 58

Sex and Gender

VOLUME II
THE TRANSSEXUAL EXPERIMENT

Robert J. Stoller, M.D.

Professor of Psychiatry
DEPARTMENT OF PSYCHIATRY,
SCHOOL OF MEDICINE
UNIVERSITY OF CALIFORNIA AT LOS ANGELES

JASON ARONSON
New York
 CONTENTS

Acknowledgements page vii

Introduction
1
Part I
THE HYPOTHESIS

1. Bisexuality: The ‘Bedrock’ of Masculinity and Femininity 7

2. Extreme Femininity in boys: The Creation of Illusion 19
3. The Transsexual Boy: Mother’s Feminized Phallus 38
4. Parental Influences in Male Transsexualism: Data 56
5. The Bisexual Identity of Transsexuals 74
6. The Oedipal Situation in Male Transsexualism 94
7. The Psychopath Quality in Male Transsexuals 109

Part II
TESTS
8. The Male Transsexual as ‘Experiment’ 117
9. Tests 126
10. The Pre-Natal Hormone Theory of Transsexualism 134
11. The Term‘Transvestism’ 142
12. Transsexualism and Homosexuality 159
13. Transsexualism and Transvestism 170
14. Identical Twins 182
15. Two Male Transsexuals in One Family 187
16. The Thirteenth Case 193
17. Shaping 203
18. Etiological Factors in Female Transsexualism: A First Approximation 223

Part III
PROBLEMS
19 Male Transsexualism: Uneasiness 247
20 Follow-Up 257
21 * Problems in Treatment 272
22 Conclusions: Masculinity in Males 281
References 298
Index 313
 Part III
PROBLEMS
 21

PROBLEMS IN TREATMENT

By now, it should be obvious that the treatment of transsexualism raises

problems. We have looked at some. First, there was the question of
diagnosis: what is transsexualism? We were concerned whether it makes
any difference that one diagnose carefully or whether the various types of
conditions in which femininity or effeminacy are found in males will
respond well enough to treatment for precision not to be necessary.
Second, should treatment aim at gratifying the patient’s desire for sex
change or at making the patient find an identity congruent with the sex
given at birth ? Third, what differences are there in treating a child, an
adolescent, or an adult? Fourth, how should follow-up studies be
conducted? Behind these issues lies an assumption not yet manifest: are
we troubled about the treatment of transsexualism because of uneasiness
when society confronts extreme gender reversal more than for true reasons
of therapy ?
Children
Let us ponder this last question. It moved into the consciousness of our
research team only gradually as we became involved in the hard struggle
to treat very feminine boys. We found that by the time they were 5 or 6,
feminine aspects of their identity were so fixed, felt so normal to the
children, that they had no wish to change. When this is coupled with their
mothers’ terrible need to save themselves by keeping the boys feminine,
treatment was difficult, to say the least (see Chapter 5). We began to
wonder why we insisted on making the boys masculine. The answer had
seemed so obvious at first that we never asked the question; we agreed
with all society in the common-sense position that one’s identity must fit
his anatomy. Now, having faced the difficulties of making these children
masculine and our still not being certain if treatment succeeds for them,

272
 PROBLEMS IN TREATMENT 273

I wonder how much anguish we have a right to bring to them. I would not
ask, were our success in getting them to create masculinity deep and true.
But core gender identity is so fixed so early, and to try to remove it and
replace it with its opposite—masculinity, the most alien identity the boy
could create—is a cruel process. And how his mother, as well, fights us!
We still do not know what to do, but our lack of answers is in part
matched by useful questions. For instance, if one grants that the easiest
situation is the normative one in which sex and gender are congruent, then:
can we develop better methods of treating boys so that they become
masculine? At present, even this question depends on a theoretic bias for
which the data do not satisfy everyone. In my experience, the most
feminine boys have no masculinity to speak of, and I believe they develop
their femininity simply because it was created and encouraged without
trauma or conflict. But analytic colleagues say this cannot be. Some
suggest that transsexualism is homosexuality (8-10), which would mean
that in childhood there had been a period of masculinity (e.g. as
represented by castration anxiety), with femininity secondarily created
because of traumatic situations in the family that threatened this early
masculinity. They might talk in terms of primitive anxiety (4, 9, 10) rather
than in identity terms (i.e. masculinity). They could postulate that with
such a mother, the infant boy suffered overwhelming, paranoid anxieties—
fear of engulfment and destruction, and we have considered their
presumption that transsexualism is either a psychosis or a flimsy defense
against psychosis (8-10).
Such arguments raise the old epistomological problem that nothing can
ever be disproved. All one can do is mobilize his data and see how
convincing they are. But all the data in the world only increase
possibilities; they do not prove. How can I say that there is not a primal
anxiety; what tests are there in infants to measure degrees of anxiety ?
How reliable is observation: if a baby cries, is it suffering primal anxiety;
if it does not cry, is it suffering primal anxiety ? Always ? Sometimes ?
Which times? Does it suffer when it is asleep? Does it suffer it while
straining at stool (anal attack by father’s introjected penis in a 3 months’
infant) ? If there is such primal anxiety, how is it perceived and what are
its effects? Does it form character
274 THE TRANSSEXUAL EXPERIMENT

structure? Which character structure? Is it defended against? By what and

how much ? What do the defenses look like ? These sorts of issues cannot
be answered. All we can do is present our observations. But these are not
reliable; how are they to be interpreted? Do the observations tell us what
the infant feels or thinks ? Or the adult ? When a person reports what he
thinks or feels, an observer knows that the opposite may lie below the
surface and the opposite of the opposite lower still. The discovery of the
unconscious not only enlarged our understanding but has also given us a
potentially fatal trap; is something unconscious or just not there? And also,
still other explanations cannot be discarded, including some not yet
invented. Perhaps transsexualism is the result of the baleful influence of a
two-headed turtle upon whose back the earth is carried; try to disprove
that.
At any rate, whether the little boys are the way they are because of
trauma and conflict or because of a blissful symbiosis, whether their
femininity is the result of imprinting or conditioning or identification or
reaction formation or delusion, how should it be treated ? What treatment
works ?
Our next insoluble problem is how to judge an adequate trial of
treatment. Suppose behavior modification techniques are attempted on the
child or adult to rid him of femininity and to build masculinity. Do they
fail because inadequately applied or because under no circumstances could
they have worked ? If psychodynamic treatments fail, is that because the
analyst was not good enough or because analysis cannot ever succeed in
such cases? These questions have never been answered for any conditions
(much less for transsexualism) and perhaps never can be. I report having
never been able to get an adult transsexual, male or female, into analysis,
or into a psychotherapy where I would use whatever analytic skills and
knowledge the circumstances would permit. Since no one else has reported
analyzing a transsexual, I have no choice so far but to rely on these
impressions.*
But back to our question whether we should even try to

* Socarides reports an attempted psychoanalysis of a non-transsexual, though with the statement

the patient was a transsexual and the implication he was analyzed. In any case, in its six months, the
treatment failed to change the patient’s gender identity (10).
 PROBLEMS IN TREATMENT 275

make the boys masculine. There ought to be no argument if we could do

this without agonizing our patients. But at present, our treatment is hard
and uncertain. So one begins to wonder: might it not be no worse, and
perhaps a bit better, if one encouraged the feminization process. So far
neither we nor anyone else—probably—has dared. The ‘transformation’ of
the patient’s body would be managed in the same way we do with certain
intersexed children.* Were one to follow this course, there is still the
question of post-operative complications, so troubling for the adults. (It is
my impression that when the procedures are done on children, as in the
hermaphrodites just footnoted, such complications do not result.)
I, however, could not recommend such drastic treatment for a child; but
my reasons may be irrational, based on nothing more reliable than
dreading so to change a biologically intact child.
Our present treatment of the children, psychotherapy, relies primarily on
superficial, simple-minded behavior modification tailored with knowledge
developed from understanding the family’s dynamics. We may be better
off if we could develop more effective techniques to create the absent
masculinity in the little boy and to make masculinity more valuable than
his present femininity, rather than retreating in despair to the route of
hormones and sex surgery. Should we turn to behavior modification
(which is such a powerful factor in normal development anyway), proper
diagnosis will be especially important, for it will be necessary to discover
the condition as early in life as possible. I cannot but believe that the
longer the femininity is present, the less the chance of removing it by any
technique.
In contrast to adolescent and adult male transsexuals, whom

* For instance, there is a form of hermaphroditism in which an otherwise completely biologically

normal male is born with apparently female external genitals. Raised as a girl, she has an
uncomplicated feminine gender identity. If the true sex is discovered in mid-childhood or later,
treatment should be styled to conform with identity, not chromosomes: her body should be
converted to female appearance (13). This is done in stages throughout childhood and adolescence by
removing the testes, creating an artificial vagina, and at puberty starting lifelong administration of
estrogens. The result is a girl who grows up to look like a normal adult female. (All this is easier
when one wishes to create a ‘female’ body; the attempts to make a ‘male’ body founder on the
presently insoluble problem of an anatomically and physiologically normal penis.)
276 THE TRANSSEXUAL EXPERIMENT

we have so far found untreatable by psychotherapy (if the goal is to make

gender identity compatible with sex), the situation is more hopeful in
children. We see these little boys when they start school, when the
condition becomes ego-dystonic to the family.
We feel it important to treat the boy immediately, and hopeless to do so
without involving at least his mother. Even that is inferior to having his
father as well. By rushing the family into treatment, we spoil the
‘experiment’, but we dare not do otherwise. If we did not take all families
we can into treatment, we would be able to learn whether in fact these
boys, who we think are transsexuals, will actually grow up to be adult
transsexuals. By insisting that the boy’s therapist be male, we can never
find out if our theory—that identifying with a man is a crucial part of the
treatment—is in fact correct or not. By trying to treat the parents, we do
not have the control situation in which the child alone is treated. However,
adult transsexualism is such an irreversible condition that we must apply
our beliefs as if they were proven fact.
In brief, the rules guiding our treatment are as follows. These mothers
are treated so that they can bear separation from their feminine son, with
whom they have an excessively close relationship. They sense that
treatment, which drives a wedge into their relationship with this favored
son, threatens their only happiness. In wishing to cooperate they
acknowledge that the femininity endangers the boy. But from within
themselves comes the sabotage: they continue surreptitiously to encourage
his feminine ways. So the first task of treatment is to sustain the mother to
allow us to get on with the second, her long-delayed separation from her
son (11).
The treatment of the boys is aimed much less at insight than at
‘reeducation’. We believe the therapist should be male, to offer the boy
masculinity with which to identify. But more than simply being a male
who is there, the therapist expresses pleasure in his own masculinity. In
addition, he discourages feminine behavior and asks the boy’s mother to
discourage femininity and encourage masculinity (6). Unfortunately, most
of the mothers so far have undercut this effort, some more and some less;
but as treatment progressed, undercutting has died down, accompanied by
increasing masculinity in the boys.
 PROBLEMS IN TREATMENT 277

The third effort in the treatment has been to involve fathers. Being very
distant men in the family anyway, it fits their habitual role to be not there
in treatment. Still, we have drawn two fathers into treatment, though so far
this has occurred only years after mothers and sons had started—and both
quit in a few months. Our goal with the fathers is to have them return, truly
as fathers, into the family.
Our results have been mildly encouraging, though only one boy (out of
eight) has finished treatment (6).
Ideally, the goal would be to shift the boy to the same degree of
masculinity we like to see in any boy (forgive the vagueness). But we
would consider any masculine development as an improvement. I presume
that in our most successful cases we shall have a moderately feminine but
rather heterosexual man, whose appearance and interests (including
occupation) would be on the gentler side of masculinity. Where we are less
successful but still create some permanent sense of masculinity, perhaps
we shall end up with homosexual men, a happier outcome, we believe,
than the unalterable condition of adult transsexualism (see Chapter 6).
Adolescents
We meet here a painful predicament. Although we can use psychotherapy
and behavior modification in children and although present knowledge
indicates that we are forced to use hormones and surgery in adults, what
should one do in an adolescent, especially one not far from puberty? First,
it is the wont of adolescents to act out severely when suffering; they have
less capacity to contain themselves by intrapsychic maneuvers. Second,
more important, as time passes, androgens are rapidly masculinizing the
adolescent’s body. He grows taller, his voice deepens, his features become
heavier, his muscles and skeleton broaden in an unfeminine manner, body
and facial hair appear. If in adulthood he will go the route of hormones and
surgery, these techniques will be less effective the more time androgens
have to play. But, as with the child, how can one ‘transform’ an
adolescent? Would it not be better to take a chance and try the non-organic
treatments? In the actual case, the answers are so difficult. If only we knew
we could create a masculine identity, then we would not mind the
278 THE TRANSSEXUAL EXPERIMENT

passage of time but would be pleased as the child’s body developed male
secondary sex characteristics. But if we cannot create a masculinity to go
with the male body, then we do no one a favor.
Very few adolescent transsexuals have been described; I know of three.
The first by Barlow et al. (1), was treated by behavior modification alone,
and although follow-up is short, the researchers believe they have changed
a 16-year-old boy from a transsexual to a heterosexual. They describe him
as fitting my criteria for a transsexual; if true, then a new and great hope
has surfaced in this presently malignant condition.
The second case is reported by Newman (7), who followed my desperate
recommendations that we proceed as one might with an adult and give the
patient female hormones followed by ‘sex change’ surgery. We felt forced
into this decision because the child’s body was masculinizing so rapidly
and because the child was acting so frantically and dangerously that
psychiatrists where he was hospitalized for alleged paranoid schizophrenia
feared if he could survive. When our extended evaluation convinced us of
the profundity of the femininity, the absolute determination of the child to
change sex, and the unusual cooperativeness of his parents' in assisting in
the process, I decided we should assist the family to make the necessary
arrangements.
The change in the child’s behavior, when she was allowed to be a girl,
was instantaneous and profound (literally in a moment the ‘psychosis’ was
completely gone and has never returned). She slipped immediately into a
normal feminine appearance and behavior, and on changing schools, was
within months elected one of the cheer leaders! She has since (for 7 years)
lived as an unremarkable woman, with a ‘normal’ feminine sex life and
employed as a woman. So far, she has done well.
The third case, again one whom I evaluated and who has then been
treated by Dr. Newman up to now, was given hormones but no surgery.
This was possible because, although the child refused to live as a boy and,
constantly traumatized in school for femininity, had become a social
isolate, she did not act out or otherwise express disturbance severe enough
to force us to consider surgery.
 PROBLEMS IN TREATMENT 279

Let us hope that the first report of successful treatment by behavior

modification techniques indicates the proper treatment for the future. If
that turns out not to be the case, then our general rule for the treatment of
transsexualism holds: whatever you do, it is wrong (12).
Adults
My opinion about the treatment of adult transsexuals has not changed
since I last wrote at any length about the subject in 1966 (12). In the years
since, there are still no published reports of any treatment that has
successfully converted an adult transsexual male into a masculine,
heterosexual person or even into a less feminine person. This statement
depends, as has been emphasized throughout this book, on the proper
diagnosis of transsexualism; of course, if one finds other, non-transsexual,
feminine or effeminate males, there may be a chance in some subjects of
modifying their femininity, especially by psychodynamic treatment.
Apparently, the rule stills holds, enunciated long ago by Freud (3)* and
then by Ferenczi (2)†, confirmed nowadays in the work of behavior
modification experts (such as Gelder and Marks [5]) that the more
feminine a male, i.e. the more transsexual dynamics are present, the poorer
the prognosis for masculinity developing. In brief, my feeling about
treatment of adult transsexual males is that, having properly established
the diagnosis, they should receive hormones, electrolysis, and ‘sex change’
surgery. Everything should be done to assist them in passing. And when all
this has been accomplished, one can expect the patient to have a calmer
life, more useful to herself, her family, and society. To forbid this change is
to doom her to an agonized, useless existence. To help the patient make the
change, however, may perhaps be to doom her in the long run (as was
considered in Chapter 20).
The treatment of the adult transsexual is palliative; we must bear this
and not, in our frustration, impatience, or com-

* ‘It is safe to assume that the most extreme form of inversion [i.e. femininity in males and
masculinity in females] will have been present from a very early age and that the person concerned
will feel at one with his peculiarity’ (p. 137).
† ‘Inversion is to be regarded as a condition incurable by analysis (or by any kind of
psychotherapy at all)’ (p. 305).
280 THE TRANSSEXUAL EXPERIMENT

mitment to theoretical positions, fail even to provide that much comfort to

our patients.
All this is tentative; we need more time to collect more data and to try
more treatments. Those who disagree will serve best if they can provide us
not only with theory or polemical statements but if they will also, at the
least, put their criticism in terms of propositions that can be tested in the
real world or, even more exciting, if they will do some of the work
themselves.
 PROBLEMS IN TREATMENT 281

Chapter 21
1. Barlow, D. H., Reynolds, E. J., and Agras, W. S. (1973). ‘Gender
Identity Change in a Transsexual’. Arch. Gen. Psychiat. 28.
2. Ferenczi, S. (1914). ‘The Nosology of Male Homosexuality
(Homoerotism). Sex and Psychoanalysis. New York: Basic Books,
1950.
3. Freud, S. (1905). Three Essays on the Theory of Sexuality. S.E. 7.
4. Galenson, E. Discussion of paper, ‘The Male Transsexual as
“Experiment” ’. American Psa. Assoc. Meeting, New York, 1972.
5. Gelder, M. G. and Marks, I. M. (1969). ‘Aversion Treatment in
Transvestism and Transsexualism’. In Transsexualism and Sex
Reassignment. eds. R. Green and J. Money. Baltimore: Johns Hopkins
Press,
6. Greenson, R. R. (1966). ‘A Transvestite Boy and a Hypothesis’. Int. J.
Psycho-Anal. 47.
7. Newman, L. E. (1970). ‘Transsexualism in Adolescence’. Arch. Gen.
Psychiat. 23.
8. Ostow, M. (1953). Letter to the Editor. JAMA 152.
9. Socarides, C. W. (1969). ‘The Desire for Sexual Transformation: A
Psychiatric Evaluation of Transsexualism’. Am. J. Psychiat. 125.
10. — (1970). ‘A Psychoanalytic Study of the Desire for Sexual
Transformation (“Transsexualism”): The Plaster-of-Paris Man’. Int. J.
Psycho-Anal. 51.
11. Stoller, R. J. (1966). ‘The Mother’s Contribution to Infantile
Transvestic Behavior’. Int. J. Psycho-Anal. 47.
12. — (1966). ‘The Treatment of Transvestism and Transsexualism’. In
Current Psychiatric Therapies, ed. J. Masserman. New York: Grune
and Stratton.
13. — (1968). Sex and Gender. New York: Science House;
London:Hogarth Press.