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The Literature of Gender Dysphoria: A Survey (1994)

The Literature of Gender Dysphoria: A Survey (1994)

©1994, 2013 by Dallas Denny

Source: Denny, Dallas. (1994). The literature of gender dysphoria: A review. Decatur, GA: American Educational Gender Information Service, Inc.





The Literature of Gender Dysphoria: A Survey

By Dallas Denny


In 1953, the simultaneous publication of a pair of articles by Hamburger, Sturup, and Dahl-Iversen (1953a, 1953b), documented the surgical, psychiatric, and hormonal reassignment to the female sex of a young man who could only have been Christine Jorgensen [and was, in fact, later identified as such by name (Fogh-Anderson, 1969)]. It was not so much the articles themselves, but the publicity generated by the leaking of Christine’s “condition” to the lay press, which brought to the attention of physicians and the general public alike the possibility that a man might, through medical manipulation and resocialization, become a woman. And if a man might become a woman, might not a woman become a man?


The Literature of Transsexualism Before 1953

Although it was the Jorgensen case which opened the floodgates, early popular and scientific reports describe persons with gender dysphoria. The early sexologists, using a variety of descriptive terms, described case histories of persons who would doubtless be diagnosed as transsexual if they were living today. Among the most notable early work was that of Magnus Hirschfeld, who has been called a crossdresser by Leslie Lothstein (1983) and others, but, who, according to Vern Bullough (1991), was more likely simply gay. Hirschfeld coined the term transvestism, and wrote extensively on the subject in the early part of this century. His classic work, Die Transvestiten, written in 1910, has only recently (1991) been translated into English. Other early sexologists, including Richard von Krafft-Ebing and Havelock Ellis, also wrote about men and women who we would nowadays consider to be transsexual.

From our temporal vantage point, it is easy to look back at case reports and identify transsexual features in old case reports, but transsexualism was a condition undiscovered, and transsexual people were often considered to be homosexual or psychotic, or else lumped with crossdressers and considered sexually deviates. Many early reports (and a good number of reports between 1953 and about 1970) which allege to be about transvestism can more accurately be said to deal with gender dysphoria. Part of this problem is definitional, as the term transsexualism did not come into popular usage before the publication of Benjamin’s (1966) textbook (1).

In addition to papers and books which were published before 1953, modern day authors have written about persons who are retrospectively suspected of transsexualism. Some persons were known by their contemporaries to be dressing in the clothing of the other sex, but others were “passing” men and women who were discovered only after injury, death, or other misfortune. Lou Sullivan’s (1990) From Female to Male: The Life of Jack Bee Garland, gives an account of a turn-of-the-century California female whose gender identity seems to have been that of a gay man, and there are a number of biographies of other females who lived as men. Dekker (1989), has written an entire book on crossliving females, and Bullough and Bullough (1993) devote considerable space to the subject. Historical accounts from earlier centuries show extensive crossdressing in persons as disparate as Joan of Arc and the Governor of New York. Vern Bullough, who has been good enough to write an introduction to this book, has looked at the historical evidence more thoroughly than perhaps any other researcher, finding many instances of both male and female transgendered persons in the popular press (1974a, 1974b, 1975, 1976, 1987).

Hormonal interference with the secondary sex characteristics has been limited to the 20th century simply because that was when artificial sex hormones were first synthesized (and Dr. Bullough is quite correct in his statement in the introduction that it was hormonal therapy, and not surgery, which made modern-day sex reassignment possible). Surgical manipulation of the genitalia has been traced by Green (1966, 1969d) and others to the time of the Roman emperors, when Nero had his surgeons alter a boy who resembled his beloved dead wife. Castration, a procedure which halts masculinization, has been practiced by cultures as diverse as medieval Europe and India, with many of the castrati taking up female roles.

There are a number of instances of surgical sex reassignment in the earlier part of the 20th century. Neil Hoyer’s 1933 book Man Into Woman tells the extraordinary story of a Danish painter who became the woman Lili Elbe. Abraham (1931) reported the surgical alteration of two male “transvestites,” and Liz Hodgkinson, in two books, Bodyshock: The truth about changing sex (1987), and Michael nee Laura: The Story of the World’s First Female-to-Male Transsexual (1989), reported the surgical and hormonal reassignment of a British woman into a man who eventually became a Tibetan monk. He was not, as she claims, the world’s first female-to-male transsexual person, although he may have been among the first to receive phalloplasty.


The Literature of Transsexualism after 1953

Things changed dramatically in 1953, when Hamburger, Sturup, and Dahl-Iversen simultaneously published papers in Nordisk Medium and in The Journal of The American Medical Association, describing the hormonal, psychiatric, and surgical treatment of a patient whose identity they did not disclose, but who was obviously Christine Jorgensen. Responses and rebuttals sizzled and popped like firecrackers for several years, as the ethics and wisdom, and even the legality, of transsexual surgery were debated (see Ostow, 1953, and Wiedeman, 1953 for some immediate reactions). Although most caregivers now acknowledge that sex reassignment is of benefit for some patients, the process still has its critics (cf Cowan, 1983; McHugh, 1992).


Medical Studies

Medical studies since 1953 have tended to center on hormonal and surgical treatment of gender dysphoria, or else on etiology. Not being a physician, I have elected to omit discussion of this literature; however, I can say that while etiological studies have been disappointing, reports of hormonal and surgical manipulations have shown steady increases in sophistication.


Psychological Studies

The 1950’s saw important work from the laboratory of John Money at The Johns Hopkins University. Money and his colleagues (most notably the Hampsons and Anke Ehrhardt), in studying persons with intersexual (hermaphroditic) conditions, learned much about normal and variant sexual development, and made the critical distinction between sex and gender (Money, Hampson, & Hampson, 1955, 1957). This work logically led to the study of transsexualism at Johns Hopkins, eventually resulting in the opening of the first gender identity clinic in the United States there in 1967; other clinics soon followed.

The 1960’s brought a variety of published reports, including early studies of outcomes of sex reassignment surgery (usually based on case reports), the etiology and incidence of transsexualism, and the characteristics of persons presenting for sex reassignment surgery. By the end of the decade, John Money, Robert Stoller, Richard Green, and others were publishing extensively on transsexualism. I will not bother with citations here, as they would be numerous, and can be easily located in the bibliography.

What is generally considered to be the first textbook published on transsexualism was Harry Benjamin’s The Transsexual Phenomenon in 1966. Actually, as Tully (1992) has pointed out, Georgina Turtle’s Over the Sex Border. Change of Sex: A Comprehensive Study was the first, in 1963, although D.O. Cauldwell’s Transvestism: Men in Female Dress, published in 1956, included considerable discussion of transsexualism. The word transsexual had been used in 1949 by Cauldwell (and even earlier, as Bullough & Bullough (1993) have pointed out), but it was Benjamin (1953) who popularized the term.

In 1968, Robert Stoller published Sex and Gender, a monograph on transsexualism, (and he followed it with other books). Green and Money’s edited volume, Transsexualism and Sex Reassignment, which consisted largely of papers which had previously appeared in the literature, appeared in 1969, shortly after the opening of the Gender Identity Clinic at Johns Hopkins University. Green’s monograph, Sexual Identity Conflict in Children and Adults, appeared in 1974. Green’s longitudinal study of feminine boys who were believed to be pretranssexual was a remarkable undertaking. His major finding was that very few of the boys grew up to be transsexual, but that a significant percentage grew up to have a homosexual orientation. Green discusses his findings at length in his 1987 book, The “sissy boy” syndrome and the development of homosexuality.

As gender identity clinics sprang up throughout the United States in the late 1960’s and early 1970’s, the staff of the clinics began publishing in professional journals. Descriptions of surgical techniques began to appear, as did reports of the characteristics of persons requesting sex reassignment and the clinics’ methods of dealing such persons. More outcome studies were published. The reader is once again referred to the bibliography.

The 1970s and 1980s saw a significant increase in the quality of the literature, as definitions became standardized and surgical and hormonal treatments grew more sophisticated. Case studies became less common. Theoretical articles divided those requesting sex reassignment into clinical types based on clinical experience (Person & Ovesey, 1974a, 1974b); and researchers began to speak about gender dysphoria (Laub & Gandy, 1973), and then about the gender dysphorias (Meyer & Hoopes, 1974), rather than about transsexualism per se. Proceedings of national and worldwide congresses on gender dysphoria began to be compiled and published (cf Laub & Gandy, 1973), and a professional organization, the Harry Benjamin International Gender Dysphoria Association, Inc., formed in 1979 and immediately published Standards of Care for the hormonal and surgical treatment of persons with gender dysphoria (see the Appendix).

The 1980’s brought more textbooks, including Lothstein’s (1983) insensitive treatment of female-to-male transsexualism, an edited volume from the Clarke Institute of Psychiatry in Toronto (Steiner, 1985), and an Australian compilation with the same title as Green and Money’s 1969 Transsexualism and Sex Reassignment (Ross & Walters, 1986). All were clinical in scope.

The early 1990s have seen a continuing emphasis on the clinical management of transsexualism. A recent (1990) edited textbook by Blanchard & Steiner is entirely clinical in nature. So also is Brian Tully’s Accounting for Transsexualism and Transhomosexuality (1992), which is largely a collection of quotations from the files of England’s Charing Cross Hospital. Ray Blanchard has published extensively on gender dypshoria, and particularly on the differences between those with prior homosexual and heterosexual orientations (1988b, 1989a; Blanchard, Clemmensen, & Steiner, 1987), and on what he calls autogynephilia— in which a male individual is erotically aroused by the thoughts of himself as a woman (1989b, 1992)


Sociological Studies

The real ground is being broken, in my opinion, not in medical centers by men in white coats, but by ethnologists, by other researchers without a clinical focus, and by transgendered persons themselves. The works of Bolin (1988), Kessler & McKenna (1978) Nandas (1989), Newton, 1979, Roscoe (1990), and Williams (1986), as well as recent books by Vern and Bonnie Bullough (1993) and Marjorie Garber (1991) and writings by transgendered persons themselves (cf Stone, 1991) provide a molar view of gender dysphoria that has been lacking in clinical treatments, and which clinicians would be well-advised to incorporate into their viewpoints. Transgendered persons have come to realize that the inevitable end to living in the opposite gender role is not genital surgery (Bullough & Bullough, 1993), and clinicians, who have typically dismissed those who didn’t want surgery, are also coming to understand this (Bockting & Coleman, 1992).


The Literature of Crossdressing

Studies of crossdressers are much less common than are studies of transsexual people. This is probably because fewer crossdressers come under the scrutiny of the medical establishment. Crossdressers typically keep their activities private, showing up on the doorsteps of the helping professionals only when they have legal or emotional problems, or on the relatively rare occasions when their infatuation with crossdressing leads them to think they might be transsexual (Person & Ovesey, 1974a, 1974b). There did seem to be a bootstrap effect, however, as increased attention on transsexualism after 1953 led to more papers on crossdressing.

In the 1960’s, several articles reported the use of behavioral attempts to “cure” crossdressing. The severity of the presenting symptoms, as described by the authors, do not, in my opinion as an applied behavior analyst, justify the extreme aversive measures which were often used for a behavior which is benign, and which was in fact sometimes not really a major problem in the life of the subjects, who were shocked and given noxious substances like apomorphine, which made them violently ill (cf Barker, et al., 1961; Cooper, 1963).

Buhrich & McConaghy Vern Bullough, Bentler, Shearman, & Prince, and others did much-needed descriptive studies in the 1970’s (cf Buhrich, 1976, 1978, 1981; Buhrich & McConnaghy, 1977a, 1977b; cf Bentler, Shearman, & Prince 1969, 1970a, 1979b). Bullough did historical analyses of both crossdressing and transsexualism (Bullough, 1974, 1975, 1976). Some of these authors did comparisons of the characteristics of transsexual people and crossdressers (cf Buhrich & McConaghy, 1977a). I have cited only a few of the existing studies.

The 1980’s saw increased attention paid to the partners of crossdressers, who had been previously neglected. Dr. George Brown, among others, has published significantly in this area (cf Brown, 1991; Brown & Collier, 1989).


The Psychiatric Literature of Transsexualism

Psychiatrists, and particularly psychoanalysts, have been among the most vocal critics of the surgical and hormonal treatment of transsexualism. For a representative selection, I refer the reader to the various books and papers of Leslie Lothstein, Walter Meyer, Charles Socarides, and Robert Stoller, and to McHugh (1992) for a recent critique and to Bak & Stewart, 1974, for the “rescue,” via psychoanalysis, from “his pathological feminine identification,” of Richard Raskin, who later became Renée Richards. Curiously, while psychoanalysts have been the most vocal critics of transsexual people, and have done the most to pathologize them, they have had little to offer them except unsubstantiable and unsubstantiated theories of causation involving fathers, mothers, castration, and penises. If my analysis sounds overly harsh, it is because of the untold human misery these attitudes have caused transsexual persons. The countertransference is there, in the literature, for those who care to look for it.


Other Important Contributions

In 1979, Meyer & Reter published a controversial but influential paper, in which they concluded that there was “no objective advantage” to sex reassignment surgery. Their study had serious methodological flaws, and has been refuted by many authors, the latest and most comprehensive critique being that of Ray Blanchard and Peter Sheridan in 1990, who also reviewed earlier analyses of Meyer & Reter (1979).

Despite its problems, Meyer & Reter (1979) is arguably the work which has had the greatest impact on the treatment of transsexual people, for as a consequence of the press release which attended the paper, the Gender Identity Clinic at Johns Hopkins closed. Other clinics followed, with the ultimate result that there are no longer, to my knowledge, any university-affiliated gender clinics in the United States (the Stanford and Texas programs, although still existent, are no longer officially affiliated with universities. I am unsure about the Minnesota program). Meyer & Reter (1979) is still quoted widely by those who use it as if it were the absolute authority on outcome, rather than the seriously flawed study that it was.

There are many others important and influential papers. Walinder, Lundstrom, and others in Sweden did extensive follow-up on operated transsexual people. Barlow and his co-workers did two intriguing studies, in which they achieved apparent change of gender identity in apparent transsexual males by use of a behavioral treatment package that included aversives. This is highly significant work that should be systematically replicated. Richard Green, Kenneth Zucker, and others conducted longitudinal studies of feminine boys, discovering they were much more likely to have homosexual adjustments in adulthood than to be gender dysphoric. Robert Stoller, a psychoanalyst, described the family characteristics of “pretranssexual boys” in a series of articles in professional journals, and in his books. Leslie Lothstein published prolifically, seemingly specializing in identifying minority (aging, adolescent, black schizophrenic, drug-abusing, physically deformed) sub-groups of transsexual people. Ira Pauly, Donald Laub, Milton Edgerton, Jon Meyer, Walter Meyer, David Gilbert, and others have published descriptions of surgical techniques and their outcomes. Meyer & Hoopes (1974) coined the term “the gender dysphorias,” pointing out that requests for sex change (transsexualism) can result from any number of underlying conditions (the gender dysphorias).

In a series of papers, Person & Ovesey (1974a, 1974b) divided transsexual males into “primary” and “secondary” groups, and further divided the secondary group into heterosexual (crossdresser) and homosexual categories. Blanchard (1990) wrote of “homosexual” and “nonhomosexual” gender dysphorias, and of autogynephilic (loving the feminine self) transsexualism.

Two important events were the publication of the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc., in 1979, and the inclusion of transsexualism as a diagnostic category in The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM III) in 1980 (updated in 1987, in the DSM III-R). These standardized, respectively, treatment and diagnostic criteria of transsexualism.


Some Problems With the Literature

Despite tremendous advances and many well-written, methodologically sound papers, there is much to criticize in the literature. Studies tend to suffer from the usual problems of applied research. Numbers of subjects are small, and intervening conditions and variables are rarely controlled, or even identified. Studies have not been carried out under blind conditions (that is, with the data collectors being ignorant of the hypotheses of the research or assignment of subjects to treatment or control groups). Group studies are rare, and, when they do exist, have sometimes collapsed individual case studies rather than forming a true group. Authors of early outcome studies, in particular, were guilty of this; this resulted in the same subjects being used in various studies. There is rarely extensive follow-up of treatment (and transsexual people, rather than researchers, are still being blamed for this). Most studies have been retrospective (backwards-looking) rather than prospective. Longitudinal studies have been very rare. Group studies using controls are especially rare, and single-subject, repeated measures studies are almost nonexistent.

There are difficulties other than with reliability. Problems of validity have been rampant. Most studies have a clinical bias, viewing the transgendered individual in a specialized and highly artificial situation. This skews the subject population, as only those seeking “help” show up and are studied in conditions which are quite unlike those in which they normally function. Researchers, with the exception of Bolin, have been for the most part blind to the way their own needs and prejudices influence the treatment setting, and have placed all the blame on their transgendered clientele.

The individual and vocational biases of authors tend to be reflected in their work. Psychoanalysts, for example, have been the most vocal opponents of surgical treatment of transgendered people (perhaps because they have contributed the least to understanding and treating them). Lack of specialized training programs in human sexuality in general and gender dysphoria in particular have doubtless had an impact on the quality of the research questions asked by researchers of all theoretical orientations.


A Prescription for the Future

Transsexual people are not particularly common, and are not particularly cooperative when they are denied their way— and most crossdressers never make it to the treatment setting. This makes the already considerable problem of doing group studies in applied settings even more difficult. Certainly, group studies are needed, but they must be more rigorous than those which have gone before. Poorly-designed studies were better than nothing when there was no literature of gender dysphoria, but now there is a literature of gender dysphoria. The time for sloppy work is past. Future studies must replicate, confirming or not confirming already existing studies, as well as breaking new ground. The definitive outcome study, for example, has yet to be done and replicated— and until that happens— until the problem of the “disappearance” of postoperative transsexual persons is solved— no one will really know how effective the surgical treatment of transsexualism is. (1)

Single-subject studies, using the methodology of applied behavior analysis, are quite as rigorous and scientifically convincing as group studies (some would say more so), and would be much easier to do— yet they remain rare. Systematic replication of such studies would build the knowledge base in a rapid manner, just as such studies quickly yielded a reliable and valid technology of controlling persons with severe behavioral pathology. More should be done.

The publication, in 1978, of Kessler & McKenna’s Gender: An Ethnomethodological Approach, and Anne Bolin’s In Search of Eve: Transsexual Rites of Passage a decade later, were of great import, for they had fresh (and much-needed) viewpoints that have gone unnoticed, or at least largely uncommented on, in the clinical literature. Kessler & McKenna’s theory of gender drew heavily upon their observations of transsexual persons. Both they and Bolin studied transsexual people in context, in their natural settings, rather than in the highly artificial setting of a physician’s office or a gender clinic. Bolin, in no uncertain terms, pointed out the major flaw in the literature—its almost exclusive reliance on clinical reports.

For centuries, biologists observed and collected and categorized their subjects. Only after a rigorous period of classification did they start in any great measure to theorize. Psychologists, on the other hand, began to theorize without bothering to assemble such a knowledge base. Consequently, biological theories such as Charles Darwin’s and Alfred Russel Wallace’s theory of natural selection have withstood the test of time, while entire schools of psychology (for example the Hullian) have withered and disappeared, leaving no legacy.

Researchers in the field of gender dysphoria should follow in the steps of the biologists and take the time to learn what transsexual people are like before soaring off into the delirious heights of theory. We should avoid the bad precedence of mainstream American psychology. If we do so, we will build something that will endure. If we do not, then our work will be forgotten.




(1) Many transsexual persons have told me they found their treatment at the hands of gender clinics insensitive and manipulative. Such treatment is hardly conducive to voluntary follow-up. I believe the percentage of persons available for follow-up will increase with the better handling that is characteristic of treatment in the 1990s.



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