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Behavioral Treatment in Gender Dysphoria (1994)

Behavioral Treatment in Gender Dysphoria (1994)

©1994, 2013 by Dallas Denny

Source: Dallas Denny. (1994). Behavioral treatment in gender dysphoria: A review of the literature and a call for reform. Presented at the 20th Anniversary Conference of the Association for Behavior Analysis, Atlanta, GA, 26-27 May.

Source: Dallas  Denny. (1994, Fall). Behavioral treatment in gender dysphoria: A review of the literature and a call for reform. TV-TS Tapestry, 54-56.


I worked for some thirty years as an applied behavior analysis—a modifier of human behavior.  In the late 1970s the field began a move from the liberal use of punishment techniques to positive-only approaches.  Aversive stimuli like those  by British behaviorists used on crossdressers in the 1960s were barbaric then and are unthinkable now—although they are still used by some conversion therapists. Professional organizations like the American Psychological Association have condemned aversion therapy, and some state are moving to outlaw it—none to soon, in my book.


Tapestry Pages (PDF)


Behavioral Treatment in Gender Dysphoria

A Review of the Literature and a Call for Reform

By Dallas Denny


Since the early 1970s, I have worked with persons with developmental disabilities—most of this time as a behavior analyst. Over a period of twenty or so years, I have seen persons who were considered untrainable move from institutions into productive lives and jobs in the community, and I’ve seen institutions change from human warehouses into training centers with individualized treatment plans for all residents. I’ve seen clients thought to be “uncontrollable” without neuroleptic medications weaned from then, and I’ve seen the use of aversive techniques like restraint and seclusion dramatically reduced. The use of applied behavioral techniques has made much of this possible.

As early as the 1970s, workers like LaVigna began campaigning for decreased reliance on aversive techniques (see LaVigna & Donnelan, 1986). They proposed a variety of alternative, non-noxious and non-aversive methods, arguing that they could be used as alternatives to punishment. Following the death of a young man with developmental disabilities while being subjected to noxious stimuli in an operant conditioning booth, it suddenly became much harder to get behavior programs containing any sort of punishment through the behavior management and human rights committees in the institution at which I —and in many other institutions as well.

Certainly, aversive methods continue to be used with persons with developmental disabilities, but the prevailing ethic is that there be peer review and human rights reviews of their use, that they not be used until non-aversive methods have been tried and shown to be ineffective, that their use be time-limited, that there be informed consent to treatment, and that aversive stimuli be applied with the minimal intensity and for the minimal amount of time needed to control the behavior. Griffith, in 1983, recommended that punishment be used only when the individual poses a danger to himself or others.

When I compare this sensibility to that of even twenty years ago, I am impressed at how far we have come.

And yet, for the past five years I have worked with another group of people who have not and do not have such safeguards. They have had few advocates, for their families and friends often turn away from them, and the lack of knowledge of caregivers makes asking for professional help a calculated risk. When they approach behavior analysts for help, they are likely to be subjected to aversive procedures designed to change something very fundamental in their natures, without any of the safeguards applied to persons with developmental disabilities. That sort of treatment is being done across the country, including Atlanta, even in 1994.

The persons I am speaking about are not criminals, although many of them have been arrested for the crime of being who they are. They are not sexual deviates, although they have been called deviates. They cause no harm to themselves or others. They are men and women who have a need or desire to wear the clothing of the other—crossdressers—and men and women who wish to actually become a member of the other sex—persons with transsexualism.

I use people-first terminology when talking about persons with transsexualism because to many Americans—and unfortunately, this extends to many helping—they are less human beings than curiosities, marginalized persons seen on daytime talk shows during sweeps week. They are transsexuals first, and their humanity is a distant second. And yet most persons with transsexualism do not fit the stereotypes we have of them. For every transsexual person who is a hairdresser or prostitute, there are a dozen or more who are computer programmers, retired military personnel, airline pilots, engineers, physicians, and, yes, even behavior analysts. Most were very successful in their lives as men and women. More likely than not, they have engaged in hypermasculine or hyperfeminine occupations, married, and had children.

Some definitions: anyone who wears the clothing of the other sex can be said to be crossdressed, but persons who do so voluntarily, for personal reasons, can be said to be a crossdresser, a term crossdressers prefer over transvestite.

A transsexual person is an individual who wishes to have the social role and primary and secondary characteristics of the other sex. Transsexual persons and those with similar, but less intense desires, are said by medical professionals and psychologists to have gender dysphoria, or alternatively, gender identity disorder, but those actually affected prefer to say that they are transgendered or transsexual.

Crossdressers, like 19th Century European explorers in Africa or American tourists in France, make only episodic excursions into the clothing and territory of the other gender, but transsexual persons are like colonists. They inhabit that territory and claim it for their own.

Before this century, the hormonal and surgical techniques to modify the human body to resemble the other sex had not been developed, and even in this century, it was not until 1952, when Christine Jorgensen made headlines after undergoing hormonal and surgical sex reassignment in Denmark, that it was commonly understood that the process we now call sex reassignment was even possible. Now, in the 1990s, sex reassignment is fairly common and easily obtainable, and tens of thousands of American men and women find it, for all its difficulties, less objectionable than remaining in their original gender.

The causes of transsexualism are unknown, and hotly debated. The efficacy of the various methods of dealing with the condition are likewise debated. Psychoanalysts have been particularly hostile towards transsexual persons, for only in transsexualism is a condition of the mind treated by bringing the body into consonance with that condition—with what they consider a delusion, or at best, an overvalued idea. There have been many papers written by psychoanalysts detailing how transsexual persons exhibit global psychopathology, but their presentations are not data-based and seem to reflect more their frustration and anger at their powerlessness to treat the condition than the true nature of transsexual people. It was clear from the presentations at the most recent conference of the Harry Benjamin International Gender Dysphoria Association, an organization of professionals who work with transsexual people, that data-based research is not showing the profound psychopathology that psychoanalysts have predicted. Transsexual people and crossdressers are, bottom line, not much different than anyone else.

It can be compellingly argued that gender dysphoria is not a disorder. In fact, the case is often made, using cross-cultural and historical data, that gender dysphoria and crossdressing are just behaviors that characterizes a certain percentage of the population. In fact, I am phasing out my use of the term gender dysphoria, as it is suggestive of psychopathology which many transgendered persons feel they do not have. Many transsexual persons and crossdressers—transgendered persons—come to see their cross-gender issues as an integral part of who they are, and would not be any other way. They would not take a cure, even if it were immediately, permanent, free, and painless, for they do not consider a cure a “cure,” but rather an eradication of an integral part of themselves, in the same way they would consider they would not truly be themselves after a lobotomy. And yet this is just the sort of thing that behavior analysts specialize in—making what transgendered persons have come to consider a very basic part of their nature go away.

Early in their transgender careers, there is a great deal of shame and guilt associated with crossdressing and transsexualism. Just like the rest of us, persons who exhibit these behaviors have a need to fit in, to please their friends and family and the state. They deny their feelings and may wish them to go away. Their family and friends, and social institutions like their church, school, and employer, may reject them, adding to these feelings.

Because of their inner turmoil, transgendered persons are extremely vulnerable, and when they encounter a helping professional who knows little or nothing about their condition, or who knows nothing but thinks that he does, or when they encounter someone with strong personal, religious, of moral feelings about the issue, they can be, and often are, done great harm. And it is precisely when they are so confused that they begin to seek help.

Psychoanalysts have done and continue to do a great deal of damage to transgendered persons. But so have behaviorists. And so begins my discussion of the literature.

I have not read as much of the literature of behavioral treatment of crossdressing and transsexualism as I might otherwise have, because I have found the reading aversive. My behavior has been decelerated. But I will report on what I have read. My purpose today is not to give an exhaustive review in twenty minutes, but to share what I have learned with those who will listen.

Articles about behavioral treatment of gender dysphoria and crossdressing began appearing in the 1960s. British authors typically used extremely aversive methods in attempts to reduce the frequency of crossdressing. I am about to make an extreme statement, but I feel it is justified, for these attempts to create social conformity are written in black-and-white in journals like The British Journal of Psychiatry. Some of their experiments might have been done by Nazis, had applied behavioral techniques been available to them.

In the first published account of aversion therapy with a crossdresser, Lavin, et al. (1961) kept a 22-year-old married man awake for days with amphetamines, giving him frequent injections of apomorphine to make him violently sick to his stomach while he was forced to look at slides of himself in a crossdressed state. Treatment did not stop until the subject became confused and his vital signs became abnormal. Barker, et al. (1963) required a heterosexual crossdresser who sought treatment for his transvestism to dress and undress 400 times in six days. He was given electric shock to his feet (or, after it had become conditioned to become an aversive stimulus, a buzzer sounded) to signal him to undress. In both studies, the subjects reported themselves “cured” at follow-up six months post-treatment. I think I might have reported myself cured also.

We must remember that this extremely aversive treatment was given for behaviors which were essentially harmless and which could have been dealt with in any number of less aversive ways. It’s not as if crossdressing behavior is life-threatening—but behavioral treatment for it can certainly be. Clark (1963), for instance, gave apomorphine to a man with anxiety and marital stress produced by his wearing of girdles. Considering even the relatively limited repertoire of behavioral techniques available at the time, it’s difficult to understand why such extreme treatment were used in these studies, and especially why other, less aversive techniques were not tried.

Despite the extreme aversiveness of the treatment, these workers never questioned whether what they were doing was justified. In 1965, Barker compared the effectiveness of electrical shock and purgatives in the treatment of transvestism. He never mentioned the use of nonaversive techniques, and he certainly never discussed the possibility that the subjects might be counseled to accept their need to crossdress and integrate it into their lives rather than being repeatedly shocked or made nauseous.

The British workers came very close to disaster. In 1963, A.J. Cooper published a paper about an incredibly aversive and even life-threatening behavioral treatment of a crossdresser. The subject was kept awake for one week with amphetamines and given drugs to make him violently nauseous on an hourly basis. He developed cardiac problems and had to be hospitalized for a month in a cardiac unit. The author suggests frequent EKGs for persons being given nausea-producing drugs. He did not suggest that his treatment may have been a bit extreme.

If you have a bit of imagination—a word, I know, I should not use at a meeting of behavior analysts—you can see this man, this crossdresser, wild-eyed and perspiring from the amphetamines, smelling of vomit, going into cardiac distress. It’s a scene straight out of Stanley Kubrick’s A Clockwork Orange—but let me remind you that the protagonist in the film brutalized and killed people. Cooper’s patient merely sometimes wore women’s clothing.

In 1969, Gelder and Marks reviewed aversion treatment in transvestism and transsexualism. They noted that while aversion was a valuable treatment with crossdressers, it was less useful in persons with pronounced transsexualism. This was because there was little or no motivation to change in this population. They did not question whether it was appropriate to attempt to make such changes in persons who did not want to be changed, although they did discuss the conditions under which they considered it ethical to use aversive and noxious stimuli.

As the field of applied behavior analysis became more sophisticated, so did the treatments—although let me say that aversive procedures delivered as part of a treatment package are no less aversive than aversion delivered alone. Barlow, Reynolds, and Agras (1973) used such a treatment package consisting of a variety of nonaversive methods and electric shock to alter a variety of measures of a 17-year-old boy’s transsexualism. In 1979, Barlow, Abel, and Blanchard followed up the subject and presented data from two additional subjects treated with a similar treatment package. One subject, a genetic male, while successfully crossliving, developed anxiety about passing as a woman and came into treatment. After treatment, this individual was highly sexually active as a homosexual—but as a male, despite pronounced breasts and a lack of facial hair.

Barlow et al.’s techniques have been replicated as recently as 1987, but no researcher, so far as I know, has looked at the differential effectiveness of the aversive and nonaversive components of their treatment package in transsexualism or crossdressing.

In their introduction to a 1979 review by Barlow and Abel, Craighead, Kazdin, & Mahoney mentioned Davison’s 1973 criticism that intervening in particular behavior patterns can be interpreted at an index of a therapist’s values. I would argue that this has been blatantly the case in the behavioral treatment of crossdressers and transsexual people. Craighead, et al. ask, “Does society have the right to prohibit certain behaviors among consenting adults? Are there any legitimate grounds for endorsing some sexual behaviors and condemning others? What are the psychological implications of labeling individuals as ‘deviant’ if they prefer less conventional modes of sexual expression? Is the psychologist supporting the ‘establishment’ as the status quo by offering therapy for culturally prohibited sexual patterns?” (p. 342). Barlow and Abel’s answer—Naaah! Abel, to this day, continues to use aversion therapy in his treatment of transgendered persons.

The literature with children—although due to time limitations I will not present it—is even more worrisome than the literature of adults. Children with gender identity disorders have no say in their treatment, and are often subjected to humiliating procedures in clinics at the authorization of parents who are acting out of fear and ignorance. Clinics for the treatment of children exist in the United States,Canada, and England and possibly still Australia, and attempt to reprogram boys who are extremely feminine. Since Richard Green (Green, 1987) has clearly shown that these boys are much more likely to grow up to be homosexual than to be crossdressers or transsexual persons, these clinics are a back-door way for researchers to have access to a population with which it has become politically inexpedient to intervene—homosexuals.

Certainly not all behavioral treatment of transgendered persons has had as its goal the eradication of their crossdressing or transsexualism. But although the subject has not recently made an appearance in professional journals, the literature, which has never seriously questioned when it is and when it is not appropriate to intervene, and perhaps more appropriately, how it is and is not appropriate to intervene, gives a green light to aversive treatment designed to change the basic nature of transgendered persons. Moreover, there do not seem to be the constraints on aversive treatment that exist for other populations.

Because transgendered persons are such an undervalued segment of society and because their voices are often stifled, there has been no outcry or even commentary on their behavioral treatment. It is important that someone urge caution in the use of behavioral techniques with persons with transgender issues. That is what I am doing today. I would like to make some suggestions:

First, the same safeguards which protect persons with developmental disabilities should be applied to transgendered persons. When doing research, there should be peer review and human rights review of treatment—but ordinary peer review and human rights committees have the same sort of blinders as the general population, so I suggest that there be additional reviews by a committee consisting of professionals who have worked extensively with transgendered persons, and by a committee considering of transgendered persons themselves.

Second, care should be taken that shame and guilt is not used as a tool to convince the individual to enter a treatment program designed to eradicate his or her crossdressing or transsexualism. Such shame and guilt should be dealt with in therapy before any behavioral attempt is made to extinguish the behavior.

Third, the individual should be made aware that it is possible to embrace their crossdressing or transsexual issues. I would go so far as to suggest that the individual should be urged to attempt to adjust to their condition and given the names and addresses of some of the considerable number of support groups and clinics which specialize in transsexualism and crossdressing.

Fourth, the therapist should consider the totality of the individual’s life and the amount to which his or her crossdressing or transsexualism interferes with other life goals. Simply not passing in the other gender role is no reason to attempt to eradicate the behavior in transsexual persons, for there are medical techniques which can change physical characteristics, and because successfully passing is not necessary in order to live productively in the other gender role.

Fifth, the therapist should carefully monitor his or her feelings about crossdressing and transsexualism. If there are strong feelings of disgust or anger, it might be appropriate to refer the individual and future clients with the same issues to another therapist.

Finally, let me say this. Persons with developmental disabilities were long abused. This changed because of advocacy activities of professionals and parents. Gay men and lesbians were once powerless. This changed in 1969, with the riots at the Stonewall Bar inNew York City. Crossdressers and transsexual persons were once powerless. This is rapidly changing. Although there has been no Stonewall for transgendered persons, the transgender community is now a reality, and is becoming organized, just as has the gay and lesbian community. Professional organizations, advocacy organizations, political activists, and especially the emergence of radical groups like Transgender Nation and The Transexual Menace, with their in-your-face tactics, will increasingly make their presence known. Certainly the experiments done in Britain in the 1960s would no longer be tolerated, but even nonaversive treatment packages may come under fire in the future.

In my opinion, the treatment of transgendered persons at the hands of behavior modifiers brings to life the worst fear of the critics of the science of behavior—that our science will be used for purposes of social control. When, in our attempts to make them “normal,” we subject harmless people to aversion therapy and occasionally send them to the cardiac unit, something is very, very wrong in Walden Two.*

Thank you.

* Walden Two is the name of a utopian novel written by B.F. Skinner many years ago. In it, Skinner described the idyllic life of a commune in which the behavior of its inhabitants was controlled using the same principles of reinforcement that he had discovered in his work with rats and pigeons.


Barker, J.C. (1965). Behaviour therapy for transvestism: A comparison of pharmacological and electrical aversion techniques. British Journal of Psychiatry, 111, 268-278.

Barker, J.C., Thorpe, J.G., Blakemore, C.B., Lavin, N.I., & Conway, C.G. (1961). Behaviour therapy in a case of transvestism. Lancet, 1, 510.

Barlow, D.H., & Abel, G.G. (1976). Sexual deviation. In E. Craighead, A. Kazdin, & M. Mahoney, Behavior modification: Principles, issues, and application, pp. 341-360. Boston: Houghton Mifflin.

Barlow, D.H., Abel, G.G., & Blanchard, E.B. (1979). Gender identity change in transsexuals: Follow-up and replications. Archives of General Psychiatry, 36(9), 1001-1007.

Barlow, D.H., Reynolds, E.J., & Agras, W.S. (1973). Gender identity change in a transsexual. Archives of General Psychiatry, 28(4), 569-576.

Clark, D.F. (1963). Fetishism treated by negative conditioning. British Journal of Psychiatry, 109, 404-407.

Cooper, A.J. (1963). A case of fetishism and impotence treated by behaviour therapy. British Journal of Psychiatry, 109, 649-652.

Craighead, E., Kazdin, A., & M. Mahoney, M. (1976). Introduction to Sexual Deviation by Barlow & Abel. In E. Craighead, A. Kazdin, & M. Mahoney, Behavior modification: Principles, issues, and application, pp. 341-342. Boston: Houghton Mifflin.

Davison, G.C. (1973). Counter-control in behavior modification. In L.A. Hamerlynck, L.C. Handy, & E.J. Mash (Eds.), Behavior change: Methodology, concepts, and practice, pp. 153-167. Champaign,IL: Research Press.

Gelder, M.G., & Marks, I.M. (1969). Aversion treatment in transvestism and transsexualism. In R. Green & J. Money (Eds.), Transsexualism and sex reassignment, pp. 383-413. Baltimore: The Johns Hopkins University Press.

Green, R. (1987). The “sissy boy” syndrome and the development of homosexuality.New Haven,CT: Yale University Press.

Khanna, S., Densai, N.G., & Channabasavanna, S.M. (1987). A treatment package for transsexualism. Behavior Therapy, 18(2), 193-199.

LaVigna, G.W., & Donellan, A.M. (1986). Alternatives to punishment: Solving behavior problems with non-aversive strategies. New York: Irvington Publishers, Inc.

Lavin, N.I., Thorpe, J.G., Barker, J.C., Blakemore, C.B., & Conway, C.G. (1961). Behavior therapy in a case of transvestism. Journal of Nervous and Mental Disease, 133, 346-352.

Skinner, B.F. (1948). Walden two. New York: Macmillan Publishing Co., Inc.