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Sex and Gender: The Development of Masculinity and Femininity

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In this book, Dr Stoller describes patients with marked abberrations in their masculinity and feminity--primarily transsexuals, transvestites and patients with marked biological abnormalities of their sex - in order to find clues to gender development in more normal people.

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1. BIOLOGICAL SUBSTRATES OF SEXUAL BEHAVIOR

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While the practice of sex has a venerable past, a more systematic understanding of its biology is still beyond us. Recently, however, and with increasing momentum, the study of biological aspects of this phenomenon is permitting us to see at least the dim outlines of the answers we shall be finding in the next years. This will permit us to take over a subject formerly the prerogative of philosophers, whose freedom from the responsibility of proof permitted them the assurance of certainty.

It is obvious that so many disciplines of biological research are now involved in studying problems of sex (for example, genetics, endocrinology, embryology, comparative anatomy, physiology) that in a short chapter one can only indicate some of the major areas in which significant investigations are taking place, and attempt to suggest the richness and promise of the field.

Forsaking the luxury of expressing all my confusions as to fundamentals, I should like to mention one: I do not know how to define the term “sexual behavior” or the related and even more frequently used term “sexuality.” One of the great contributors to (though undoubtedly one of the complicators of) the subject was Sigmund Freud, who in 1905 pointed out that significant parts of human behavior that seemed to common sense to be quite unrelated to sexual behavior, are in fact found, when one traces the thread out adequately, to derive from clearly sexual origins.1 It was Freud’s underlining the point that there is far more to sex than the coming together of a male genital and a female genital that put us in our present predicament of not being sure what should be termed sexuality or sexual behavior. This discussion, however, will restrict the meaning of these terms to that whose function is directly a prototype of, leads to, or accompanies either procreative behavior or that which is clearly a substitute for pro-creative behavior.

 

2. THE INTERSEXED PATIENT WITH NORMAL GENDER IDENTITY

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Now let us start changing variables. The first case is a person as biologically neuter as a human can be: chromosomally XO, with the resultant anatomic-physiologic neuterness to be described below.

And yet, when she was first seen at age 18 at the Medical Center she was quite unremarkably feminine in her behavior, dress, social and sexual desires, and fantasies, indistinguishable in these regards from other girls in Southern California.

There was one troubling condition that made her less than average. Her breasts had not begun to develop by the time she was eighteen, nor had menstruation started. After talking with her older sisters about this, and after some months’ delay while hoping maturation would show itself, she came for medical (not psychiatric) consultation.

Physical examination revealed a good-sized girl (140 pounds, 5′ 5½) with no unusual findings other than no breast development or areolar pigmentation and sparse pubic hair present only on the labia. Labia and clitoris appeared normal. Introitius was virginal. Uterus and adncxae could not be palpated per rectum. There was little axillary and no obvious leg or body hair. Pertinent laboratory studies were as follows: 17 ketosteroids—o.r mg/ 24 hours; FSH—greater than 80; buccal smear chromatin stain-negative (male pattern); vaginal smear—very low (atrophic) estrogenic activity.

 

3. THE DISRUPTION OF ESTABLISHED GENDER IDENTITY

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What happens when a person with no real question about her gender identity is suddenly robbed of that certainty? The history of this next patient is useful for such an exposition. Like the young woman described in the preceding chapter, her gender identity was intactly female and feminine despite the fact that she also was biologically neuter. Then, in her teens, she was told for the first time that her sex was genetically and anatomically incorrect.

When I first saw this patient, she was an 18-year-old girl who had been referred to the Gender Identity Research Clinic as a schizophrenic; she had been in treatment at two other clinics for the previous two years. She had gradually become psychotic, starting at age 14, when she was told by a gynecologist that she “might be a boy.” She had been brought for that physical examination because her breasts had not started to develop and her periods had not yet begun. Though she was concerned about this, she had no question about her proper sex. She was then examined gynecologically and found to be neuter.* The physician who did the examination talked with her and her mother, making every attempt to be honest, yet tactful. As many enlightened physicians do, he subscribed to the thesis that this information would not be disturbing, and that, with proper explanations, no psychological damage would result. So the child and her mother were told that she had no functioning ovaries and therefore no periods or completed secondary sex characteristics, but especially that her chromatin staining showed a male pattern and that her chromosomes were XO. To the patient, despite all accompanying explanations, this meant that she was genetically, and therefore in the most biological sense, no longer a female but a freak, with both male and female qualities. From the day of that pronouncement, she began ruminating on whether she was a female or a male; this rumination and her unsuccessful attempts to reestablish a fixed gender identity led to her gradually thinking and reacting in a more and more bizarre manner—the psychosis.

 

4. THE HERMAPHRODITIC IDENTITY OF HERMAPHRODITES

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It is rarely questioned that there are only two biologic sexes, male and female, with two resultant genders, masculine and feminine. The evidence for biologic or psychologic bisexuality does not contradict this division, but only demonstrates that within the two sexes there are degrees of maleness and femaleness (sex) and of masculinity and femininity (gender). Thus, there is ascribed to each person at birth an absolute position as a member of one sex or the other, so that one develops a sense of belonging to only one gender. It is obvious that proper ascription of sex is extremely important; in those infants in whom ambiguous-appearing genitalia at birth make sex assignment uncertain, the proper sex must be diagnosed as soon as possible. Only by careful and rapid diagnosis can future emotional problems be avoided. Almost everyone starts to develop from birth on a fundamental sense of belonging to one sex. The child’s awareness—”I am a male” or “I am a female”—is visible to an observer in the first year or so of life. This aspect of one’s over-all sense of identity can be conceptualized as a core gender identity, produced by the infant-parents relationship, by the child’s perception of its external genitalia, and by a biologic force that springs from the biologic variables of sex. (See Chaps. 5 and 6 for further discussion of core gender identity.) The first two factors are almost always crucial in determining the ultimate gender identity.1

 

5. THE SENSE OF MALENESS

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For most psychoanalysts, it is axiomatic that the development of male sexuality is dependent on how the little boy manages the fantasied dangers and pleasures of having a penis. His pride in the power of his penis and his growing awareness of its value as a source of physical pleasure are threatened by his knowledge that there exist penisless creatures and his fear that he may be made into one. Recently, there has been increasing discussion in the literature, especially by Greenacre,1 of a period of phallic awareness earlier than the classic phallic stage. It is likely that from birth the infant boy becomes more and more aware of his penis, first by feeling that it is there, and later by endowing it with meaning.

The two theses presented in this chapter are derived from these beginnings of phallic awareness. The first is that the sense of maleness—the person’s unquestioned certainty that he belongs to one of only two sexes, the male—is permanently fixed long before the classic phallic stage (age 3 to 5). The second is that although the penis contributes to the sense of maleness, it is not essential. It should be noted that neither of these theses contradicts the importance, as contributions to the boy’s developing masculinity, of the phallic stage or the oedipal conflict and its resolution.

 

6. THE SENSE OF FEMALENESS

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The conclusions drawn in the last chapter regarding the sense of maleness apply as well to the development of the sense of femaleness. The first awareness of the sex to which she belongs develops in the infant girl from birth on, and, while having its biological sources (especially sensory perceptions of the genitalia), this awareness is the result primarily of parental confirmation—a fancy term for the myriad of expressions regarding her sex and gender that the girl senses from her parents from birth on. This is a nontraumatic learning experience in the beginning, as taken for granted by the infant as her learning that she has only one head, two eyes, a mouth, and so on.

The equivalent of the little boys who are born without penises, but recognized at birth to be males, are little girls who are genetically, anatomically, and physiologically normal except for being born without vaginas. While such a defect may cause a girl or woman great pain when it is discovered, I have not seen or heard of any such woman who had a disturbance in core gender identity—that is, a fundamental uncertainty as to whether she is

 

7. A BIOLOGICAL FORCE IN GENDER IDENTITY?

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The cases discussed so far confirm that gender identity is created postnatally as a result of psychological influences: First, the anatomy and physiology of the external genitalia, by which is meant the appearance of and sensation from the visible and/or palpable genitalia, and second, the attitudinal forces of the parents, siblings, and peers. This chapter will look more closely at a third possible determinant, a biological force, which, though hidden from conscious awareness, nonetheless seems to provide some of the drive energy for gender identity.

I have now seen seven cases in which a biological abnormality of one of the criteria for determining sex was present but unknown to the patient, and yet the patient’s gender identity was like that of a person raised in the opposite sex. The question arises in these patients whether the abnormality of sex influenced gender behavior in a biological manner or whether the observed effects were psychologically produced.

By a “biological force,” I mean energy jrom biological sources (such as endocrine or CNS systems), which influences gender identity formation and behavior. We will look at these seven cases to see what clues we can find and also what questions can be asked that may jeopardize a proposition that a biological force plays a part in the development of gender identity.

 

8. MALE CHILDHOOD TRANSSEXUALISM

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So far, all of our “natural experiments” have been intersexed patients, with biological abnormalities being the changed variables. Now I want to shift to people who have no biological abnormalities of sex (so far as any present-day tests can reveal), but with whom life has experimented by changing certain psychological variables that play a part in creating gender identity.

To most readers, there can be few individuals more outlandish than those who insist that their sex is wrong, that they (that is, their sense of identity) are trapped in the wrong body by some grotesque trick of fate, and that the world should permit and even assist them to become members of the opposite sex. Since these persons—transsexuals—are usually quite sane, their claim is more disturbing to the normal members of society whose struggles regarding gender identity are much less intense, more secret, and more or less unconscious. Yet these rare people have brought insights to understanding some of the origins of gender identity that I had not been able to find in more normal people.

 

9. THE MOTHER'S CONTRIBUTION TO BOYHOOD TRANSSEXUALISM

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We shall now look more closely at a family in which a transsexual boy was created, and in a more detailed way see some of the forces that possessed these people.

Almost all psychoanalytic studies concerned with the causes of marked cross-gender behavior in males (e.g.1) have been based on the analyses of adult transvestites. Until that of M. Sperling,2 none had been published on children, though recently there have been some nonanalytic reports.3 Despite the surge of papers in the literature concerning the influence of parents (especially mothers) on their children’s perversions,4 only Sperling5 has reported at length on the analysis of such a patient.

Feeling that it might help us understand the genesis of cross-gender identity problems, we arranged in our research team to analyze the mother and son in such a family.* (See also Sperling.6) The data from this mother’s analysis confirm the work of Green-acre, Khan, Sperling, and others7 regarding the effects of a mother’s unconscious wishes on the infant who is later to become perverse.* By the time he was a year old, this boy’s gender needs already mirrored those his mother unconsciously wished upon him: His marked femininity was caused primarily by his mother’s wishes.

 

10. ARTISTIC ABILITY AND BOYHOOD FEMININITY

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The thesis that artistic ability or interest is linked in men to identification with their mothers is a familiar one to analysts. In this brief chapter, observations gathered from our three little transsexual boys will be presented that support data found in the analyses of adults. While three cases do not prove a theory, they permit one to remain attached to that theory while awaiting the certainty provided by more cases.

You recall that our three boys manifested overt transsexual behavior by age 2-3 at the latest, wanting to be girls and to have the bodies of females. They were not simply indulging in the occasional, experimental, low-voltage cross-dressing seen in many little boys but rather were expressing a passionate need to put on as much of women’s (girls’) apparel as could be managed, a fascination with playing exclusively with female dolls and with daydreams of being a girl, and a frankly stated wish to become a girl (“I want to be a girl. Why wasn’t I born a girl? Aren’t I really a girl? Gin I be a woman when I grow up?”). This remarkable identification with women was found in these little boys to be associated with (i) mothers who acted and dressed like boys until adolescence; (2) fathers who were almost literally absent from the home, day or night, weekdays or weekends; (3) the parents’ excessive permissiveness, so that the developing femininity was openly encouraged by allowing the boys to dress as girls whenever they chose (“He’s so beautiful; wouldn’t he look lovely as a girl?”); and especially by (4) excessive and intimate body contact for many hours, day and night, from birth to the time they were seen at age 4-5, this delay in mother-infant separation perpetuated by the little boys’ constant touching of their mothers’ nude bodies and clothes.

 

11. ETIOLOGICAL FACTORS IN ADULT MALE TRANSSEXUALISM I3I

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Even having seen the three little transsexuals, it did not at first dawn on me that these little boys might be the adult transsexuals of future years. In attempting to write up the first case, I found myself, on calling the child an “infantile transvestite,” continuously having to explain that although he cross-dressed, he did not have essential qualities of the adolescent or adult male transvestite (e.g., love of and anxious regard for his penis). While thinking of this, it suddenly became apparent to me that these little boys did, however, seem to have the essential stigmata in character structure and psychodynamics of the adult transsexual; if these boys are the transsexuals of the future, it would be necessary either to follow them without treatment until they grew up or to find cases who would fill in the gap between these little boys and adult transsexuals. If this could be done, we would go a long way toward understanding some of the specific etiologies of an adult psychiatric condition.

 

12. THE TRANSSEXUAL'S DENIAL OF HOMOSEXUALITY

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It is frustrating but not unpleasant, having studied patients with severe problems in gender identity, to find myself unable to answer so many important questions. Of these, few have more theoretical or practical interest than the problem of homosexuality, an issue that needs to be faced when one is trying to understand these people who, with their marked cross-gender behavior, are attracted to people of their own sex.

As early as 1905, Freud1 put us on notice that it is too naive to think that homosexuality can be defined as simply sexual relations between two people of the same sex, for that avoids taking into account what people do in fantasies, both conscious and unconscious. Homosexual impulses, especially unconscious ones, play a tremendous part in Freud’s theories. Originally, under the influence of Fleiss, Freud developed a theory that personality, arising out of a biological bisexual matrix, is an interplay of heterosexual and homosexual impulses, the resulting psychological bi-sexuality essentially influencing both normal and abnormal development.

 

13. IDENTITY, HOMOSEXUALITY, AND PARANOIDNESS

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It is well known that the man who is unable to permit himself to become aware of desires for sexual relations with other men may, in the struggle against such awareness, become paranoid. There is no need to review the theories and the observations that have become so commonplace since Freud’s great insights into the Schreber case. While probably only a few diehards would still maintain that the struggle against the awareness of homosexual impulses is the etiology in the paranoid psychoses, most experienced psychiatrists will on occasion have seen patients who became grossly paranoid in the midst of such a struggle.

One can scarcely be satisfied with the explanation that it is the awareness of social disapproval of homosexuality in our society that produces the paranoid reaction. Certainly there are other desires that a human can have that are as socially disapproved as homosexuality, and yet these other desires are not considered to cause paranoidness. In addition—the issue we were worrying in the last chapter—one is still left with the question of how most homosexuals manage to be so very unpsychotic; that is, how do they come to terms with this allegedly overwhelming social stigma? It seems to me that it is not simply internalized social disapproval that can make the threat of succumbing to homosexual pleasure so disrupting to some people, but rather that something more profound than social disapproval is threatening the person. I think that that threat is not that of being a homosexual, though that is what the patient tells us. Maybe it is the threat that one will no longer be himself; that is, that he feels he is losing his identity.

 

14. A FEMININE MAN: A CONTROL CASE

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A single case certainly cannot be used convincingly as a control unless one has assurance that the single case represents a whole class. I want to do something of that sort now, to compare one class—the extreme form of transsexualism that the three little boys and the adult transsexuals described represent—with another class: all males who want sex-transformation procedures, but who are less totally feminine. If the “experiment” is successful, then it will be found that transsexuals—adult and child, who are extremely feminine, who are nonfetishistic, who started their feminine behavior before age three, and who are not by choice intermittently masculine—have mothers and fathers like the ones our little boys have.

On the other hand, if a male requesting sex transformation is less totally feminine, his parents will not fit the described picture. To stick my neck out well beyond where the data should encourage dangerous living, I will predict that if this person is fetishistic (i.e., gets an erection from women’s clothes), if he has lived intermittently as a man and during this time was not considered feminine or even effeminate, if he has ever been married, if he has had children, if he has ever appreciated having a penis, if he would not go through great hardship to get his operation, if he is uncertain whether he is ready for it if the opportunity is offered to him, if he willingly permits another man to handle his penis, if he does not recall being feminine as far back as his memory reaches, if he publicizes before or after the operation the fact that he was born a male, if he calmly settles for less in the way of medical procedures than he has heard is technically possible, then he will not have the kind of parents the little boys have—and, depending on how many of the above points characterize him, the more likely he will be to have postoperative emotional difficulties, up to and including psychosis.

 

15. A BISEXUAL MOTHER: A CONTROL CASE

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None of the data presented in earlier chapters on the causes of transsexualism in boys proves anything. We must always remember that while they help us to make a logical argument, they are not firsthand observations of the special mother-infant relationship which I am stating may at times lead to transsexualism. Until we are able to observe a mother and infant from the latter’s birth on in a relationship that results in, creates, transsexualism, we do not have reliable data (yet the reader undoubtedly realizes that if we could simply stand around and observe such a process, our presence would itself probably radically change the mother-infant relationship). So for the present, our answers lie where we arc unable to look—in the moment-by-moment, day in-day out physical contact of mother and infant and in the exact way in which the mother is felt by the infant’s sensory apparatus and what these sensations come to mean as communications of affects: the warm, moist, peaceful respiration of a mother who loves and needs the infant to be enfolded by her (and how long does she do this today, and is “today” every day, and is “every day” extended for several years?); the tense mother whose stiff muscles, less pillowy skin, and jerky respirations thrust the baby away prematurely; and so on over the infinite range of mothering styles.

 

16. DIFFERENTIAL DIAGNOSIS: TRANSVESTISM AND TRANSSEXUALISM

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Transvestism and transsexualism are each severe disturbances in gender identity sharing two features so distinctive and bizarre that the conditions are often taken to be the same: first, an abnormally strong identification with women, and second (resulting from the first), cross-dressing. Since homosexuals (both “masculine” and “effeminate”) also have abnormally strong identifications with certain aspects of femininity, many psychiatrists mistakenly consider transvestism and transsexualism to be simply homosexual variants.

It will be the purpose of this chapter more carefully to describe and thus distinguish these conditions from each other.

Let us define adult male transvestism as completely pleasurable; it is fetishistic, intermittent cross-dressing in a biologically normal man who does not question that he is a male—that is, the possessor of a penis.

Within this definition there are two common forms (and a number of infrequent variants). Probably the most frequent is that of the man who, in addition to the above criteria, has learned a woman’s role so well that he can or wishes to successfully pass undetected in society as a woman; when he does so, the activity alternates with living most of his life in a man’s role. While his transvestism started in childhood or adolescence with sexual excitement precipitously provoked by a single garment, there is gradual emergence over the years of a nonerotic desire to sense himself intermittently as a woman (with a penis) and to pass as one.

 

17. FEMALE (VERSUS MALE) TRANSVESTISM

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The purpose of this chapter is to share some impressions to which a group of unusual patients have introduced me. These people, living permanently as unremarkably masculine men, are biologically normal females and were so recognized as children. In the process of passing successfully as men, they dress completely in the same sort of clothes as do normal men. Thus they would seem, from the obvious fact that they always wear men’s clothes, to be fine examples of transvestism in females. And yet this chapter is about a condition that may not exist—female transvestism.

No one claims that female transvestism is common. It has rarely been written about,1 and ideas about its causes are almost as sparse as is interest in it. Still, it is an accepted condition, a form of behavior that implies a specific character structure and psychodynamics. The least sophisticated idea about it (as with male transvestism) is that it is simply a peccadillo indulged in by certain homosexuals with more than their share of gender confusion.

 

18. TRANSVESTITES' WOMEN

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In the pornographic literature of transvestism, there is a certain genre of illustration that repeatedly shows cruelly beautiful, monstrous-breasted, stiletto-heeled women, often with phallic-like whips dangling beside their pelves, bullying the poor, pretty, defenseless transvestite.

This chapter will try to analyze such illustrations, using data collected from and about the women of transvestites—their mothers, sisters, girl friends, and wives—in order to show what in this fantasy excites transvestites; in tracing back to the roots of this excitement, we shall come upon the essential role these women play in the cause and maintenance of transvestism. The women studied all share the attribute of taking a conscious and intense pleasure in seeing males dressed as females. All have in common a fear of and a need to ruin masculinity. Very envious of males, such women or girls revenge themselves by either dressing their males in female clothes or encouraging such dressing once it develops “spontaneously.” Thus, it is a woman or girl who first dresses many of these men in women’s clothes, though the women deny any knowledge that they might have damaged their sons or brothers. However, whatever similarities these women have, it must be emphasized that they are very different in many aspects of their personalities. For example, one is a forceful leader of ladies’ clubs; another, a crabbed masochist; a third, a tired, graceful, faceless housewife; a fourth, not clinically psychotic, has truly believed since childhood that she is a witch. And so on. One can discern two categories of such women: i. The malicious male-hater: There are those who start a boy’s cross-dressing activities by themselves putting the clothes on the child without his entering upon the activity spontaneously. As girls and later as women, they are ruthless, angry, competitive, and hating toward all males, whom they humiliate whenever possible. These women do not do this damage to infants but only to boys who have grown enough to have developed a masculine gender identity. Only after this masculinity has appeared are these females’ rage and need for revenge excited. This same hatred is also found in the mothers of adult tranvestites who say that as boys they were never dressed by their mothers in girls’ clothes.

 

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