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The Border Area Between Transvestism and Gender Dysphoria: Transvestitic 
Applicants for Sex Reassignment 
   Thomas N. Wise, M.D.1 and Jon K. Meyer, M.D.2 
   Clinical variants among the population of applicants for sex reassignment 
have been previously categorized.  These coherent entities were introduced in 
an effort to sharpen the clinical presentation of syndromic diversity as well 
as to enhance the specificity of prognosis and outcome.  The description of 
the so-called younger and aging transvestite has been further investigated.  
Although the initial group of reported transvestitic patients was small, it 
was suggested that these individuals constituted a coherent group definable in 
terms of demographic variables, past history, current crises, psychodynamics, 
clinical course, and special risks.  This investigation presents a 
supplementary series of aging and younger transvestites who have applied for 
sexual reassignment.  Since the original report, further elucidation of the 
characteristics of both groups have emerged.  The theoretical implications of 
these categories have become clearer.  The data support the original content 
of the classification as an aid to evaluation, prognosis, and treatment. 
   KEY WORDS: transsexualism; gender dysphoria; transvestism; sexual identity. 
   1Sexual Behaviors Department Consultation Unit, The Johns Hopkins Medical 
Institutions; Department of Psychiatry and Medicine, The Johns Hopkins School 
of Medicine; Department of Psychiatry, The Fairfax Hospital, Falls Church, 
Virginia 22046. 
   2Sexual Behaviors Consultation Unit, The Johns Hopkins Medical 
Institutions, Department of Psychiatry, The Johns Hopkins School of Medicine, 
Baltimore, Maryland. 
   Confusion surrounds the assessment, diagnosis, prognosis, and management of 
individuals requesting sex-reassignment surgery.  The existing uncertainty is 
related to the dramatic nature of the patient's request, the variability of 
clinical presentation over time, and the difficulties inherent in controlled 
studies where adequate control would require random assignment to surgical 
ablation of genitalia (Meyer, 1979).  Compounding the difficult is the fact 
that there is little agreement on the fundamental issue of etiology. 
   Views on the categorization of applicants for sex reassignment widely 
differ: Stoller and his associates have adopted a "bipolar" viewpoint, 
partitioning male applicants for sex reassignment into "transsexuals" proper 
and "nontranssexual men who seek sex reassignment" (Stoller, 1975; Newman and 
Stoller, 1973). 
   Transsexuals, Stoller believes, are the most feminine males who have never 
developed any sense of masculinity, even in rudimentary form.  Stoller 
suggests that such men never experience Oedipal conflicts, since there is no 
scaffolding of masculinity on which to erect such a structure (Stoller, 1975).  
He feels, however, that nontranssexual men demonstrate some masculine 
identification and conflict. 
   Meyer has adopted a "continuum" perspective, viewing applicants for sex 
reassignment as having in common fundamentally similar problems in gender 
identity although of greater or lesser severity (Meyer, 1974, 1975, 1977, 
1978).  He emphasizes the common features of gender dysphoria among applicants 
for sex reassignment but recognizes the clinical diversity by systematically 
subtyping the stable variations in the common gender dysphoric theme (Meyer, 
1974).  Meyer and his associates feel that a continuum approach has more 
clinical validity, since the applicants for sex reassignment present along a 
continuum, the clinician ordinarily being confronted with shades of gray, 
rather than a dichotomy.  Clinical management is facilitated by a recognition 
of those features which distinguish a given subgroup of applicants for sex 
reassignment, without losing track of the fact that the given subgroup of 
patients share features in common with other gender dysphorics which 
distinguish them in certain ways from the paraphilias, those with other 
character disorders, and the psychotics. 
   Among the clinical subtypes reported in 1974 were the "self-stigmatized" 
homosexuals, the "schizoid" group, the "polymorphous perverse," and the 
"sadomasochistic."  Among the clinical variants reported in 1971, the "younger 
transvestites" and the "aging transvestites" are of particular interest in 
this report.  This group is of importance theoretically since they illustrate 
the bridge between gender dysphoria and transvestism.  They are of importance 
clinically because the dynamics of their request for sex reassignment, their 
clinical course, and their management are particularly distinct.  
   "Aging transvestite" individuals are in middle age in contradistinction to 
the young adults who constitute the majority of individuals with gender 
dysphoria.  There was a striking coexistence of extreme masculine behavior 
along with their feminine wishes.  They were generally married and usually had 
sired children.  These individuals were not ego-syntonic transvestites who 
openly acknowledged and embraced their practices, but were largely guilt-
ridden crossdressers.  At the periods of request for sex reassignment, 
crossdressing had lost its capacity for sexual arousal; instead, the patients 
spoke of being more comfortable while "dressed."  They were often depressed to 
suicidal levels and presented with anxiety to the point of depersonalization.  
The request for sexual reassignment was dramatic in view of the serious mood 
disorder.  They often viewed surgery as an alternative to suicide or self-
castration.  Two patients in the original group had performed autocastration 
prior to any medical contact.  These individuals saw reassignment as a means 
of relief from an internal struggle. 
   In addition to the "aging transvestites," a "younger transvestite" clinical 
variant was also described.  These individuals more frequently had homosexual 
experiences than the "aging group," even though two of the initial cohort of 
three were married.  Surgery seemed to be a means of expressing passive 
longings toward men, as well as escaping from the "perversity" of erotic 
crossdressing.  Because of the small size of the originally reported cohort, 
it was particularly important that additional cases be examined to validate, 
amplify, or amend those observations. 
   Reports of men whose eroticism is related to wearing women's clothing 
and/or who request sex reassignment are found in both psychiatric and 
psychoanalytic literature.  Reports of the two conditions found in one 
individual, however, are notably more scarce than of the two conditions as 
separate phenomena.  Buhrich (1977) has reviewed the role of transvestism in 
history.  Psychiatric phenomenologists have focused on transsexualism over the 
past two decades since Caldwell coined this term and Benjamin popularized it 
(Caldwell, 1949; Benjamin, 1953).  Money has emphasized a longstanding sense 
of neutral cross-sexualism as the essential characteristic of the transsexual 
(Money and Primrose, 1968).  Some investigators have viewed the wish for 
sexual reassignment as a condition with strong biological determinants (Jones 
and Saminy, 1973). 
   The psychoanalytic literature discusses erotic crossdressing in relation to 
the theory of perversions.  For the most part, attempts have been made to 
account for the transvestitic symptom choice, with only secondary reference, 
if any, to wishes for sexual reassignment (Bak, 1968).  Greenacre (1968) feels 
that transvestism, as well as fetishism, is developmentally related to early 
disturbance in mother-infant relationships with subsequent faulty object 
relations.  She hypothesizes that identification with the phallic mother is, 
in part, the genesis of this behavior.  Socarides (1969) also considered the 
wish to appear as a woman to be a disturbance of very early life. 
   In the literature linking transvestism and transsexualism together, 
Lukianowicz (1959) feels transsexualism and transvestism are on a continuum 
differing only in the degree of desire to alter one's sexual anatomy.  Buhrich 
and McConaghy (1977) have attempted to systematically factor out clinical 
descriptors of applicants for sex reassignment in an attempt to partition them 
from transvestites.  They have found that transsexuals more frequently attempt 
to crossdress in public, to pass as the opposite sex, to have a greater 
conviction that they feel like the opposite sex, to have fewer heterosexual 
experiences, and to more commonly have homosexual experiences.  Additionally, 
transvestites rarely reported sitting down to urinate whereas males who 
considered themselves transsexual generally did.  Furthermore, the 
transvestite group showed significantly more penile erection to heterosexual 
films than did the transsexual group. 
   Recently investigators have attempted to better categorize gender dysphoric 
individuals who wish sex reassignment.  Bentler (1976) empirically subgrouped 
42 male-to-female transsexuals by behavioral characteristics.  He found marked 
differences in homosexual experiences, orientation, and heterosexual 
interests.  This concurs with other investigators who have described 
categories of applicants as heterosexual crossdressers, effeminate 
homosexuals, and asexual transsexuals. 
   From a more dynamic perspective, Stoller (1971) considers the relationship 
among transvestism, transsexualism, and gender dysphoria.  As previously 
noted, he contrasts the clinical and dynamic characteristics of "fetishistic" 
crossdressers with individuals whom he feels present with "true" 
transsexualism.  Meyer, however, has emphasized the close develop mental and 
dynamic relationship between the paraphilias and the gender identity 
disorders, seeing them as more similar than different (Meyer, in press: Meyer 
and Dupkin, in press). 
   The ambiguity in the descriptive and dynamic literature may be partially 
resolved by the recognition of the intragroup consistency of the transvestitic 
clinical variants and their intergroup variations.  Careful inspection of 
transvestites who become gender dysphoric clarifies reports such as Newman and 
Stoller's on nontranssexual men who seek sexual reassignment (Newman and 
Stoller, 1973).  Buhrich's (1976) recent discussion on whether fetishistic 
behavior can occur in transsexuals is also coherently understood if one views 
their subjects as aging transvestites who have previously been fetishistic 
crossdressers.  Other reports such as Barr et al.'s (1974) study of apparent 
heterosexuality of two transsexuals is understood if this diagnostic framework 
is adopted.  Finally, the psychotic process, which Golosow and Weitzman (1968) 
described in an individual who was labeled a transsexual, becomes explicable 
if one recognizes that psychotic regression may occur in an aging 
transvestite.  These cases describe the regression of fetishistic 
crossdressers, a transvestite who seeks sexual reassignment due to gender 
dysphoria.  They document regressive behavior, not the spontaneous occurrence 
of "transsexualism." 
   The methodology utilized in this study is that of retrospective case 
review.  Since the Sexual Behaviors Consultation Unit (SBCU) was organized in 
1971, 403 individuals have applied for sex reassignment.  Sixty percent of 
these (241 individuals) were biological males.  Each of these patients was 
diagnosed as one of the reported clinical variants (Meyer, 1974).  Whenever 
present, psychiatric conditions were noted utilizing DSM II criteria.  Since 
the initial report in 1974, 17 additional individuals were diagnosed as aging 
or younger transvestites.  Three patients with transvestitic and gender 
dysphoric elements, but who do not meet diagnostic criteria, are reviewed by 
way of contrast.  The criteria for diagnosing an individual as a transvestite 
who becomes gender dysphoric include the following: 
   1.  Application for surgical sex reassignment. 
   2.  Evidence for longstanding crossdressing wishes and desires. 
   3.  A longstanding history, which may or may not extend to the present, of 
arousal when crossdressed. 
   4.  Absence of psychosis or manic-depressive illness. 
   5.  A longstanding history of active masculine pursuits vocationally, 
sexually, and otherwise in the past which usually stands in stark contrast to 
secret feminine longings. 
   6.  Clear exclusion of other clinical variants. 
   Among the 20 patients diagnosed as aging transvestites, three individuals 
had clear psychotic illnesses which antedated their gender dysphoria.  Thus 
the request for sexual reassignment may have arisen from their psychotic 
states.  A brief vignette of one of these patients is outlined below: 
   The patient presented at the Sexual Behaviors Consultation Unit requesting 
sexual reassignment.  He had begun to wear his mother's undergarments, with 
arousal, during his lonely adolescence.  Beginning at 12 he frequently drank 
his ejaculate while crossdressed and at 18 had one homosexual episode.  In 
young adulthood, he married, had regular heterosexual activity, and 
episodically crossdressed with erotic arousal.  One year prior to consultation 
the patient was hospitalized with what was diagnosed as a manic depressive 
psychosis.  In the year since hospitalization, the patient was described as 
slightly euphoric.  When interviewed, he presented with a slightly elevated 
mood and was dressed as a male.  His request for reassignment procedures was 
poorly organized.  During consultation he requested breast augmentation only.  
He gave a history of compulsive masturbation, hyperactivity, and crossdressing 
only at home. 
   Table I.  Transvestism and Major Mental Illness with Associated Requests 
for Reassignment Procedures 
                   Marital Number of               Psychiatric 
   Patient Age     status  children        Occupation      diagnosis       
   A       35      Married 5       Electronic      Acute   Not clear 
                                   technician      psychotic 
   B       45      Separated       3       Accountant      Manic   Extra-
                                           depressive      marital 
   C       34      Married 2       Machinist       Manic   Not clear 
   The patients represented in Table I including the individual outlined in 
the illustrative clinical vignette do not qualify for the diagnosis of either 
aging" or "younger" transvestite.  In each instance, their transvestism, 
although longstanding, was bizarre or fragmentary.  The request for sex 
reassignment was similarly poorly organized, fragmentary, or bizarre and 
seemed clearly a product of the psychotic interlude.  The psychotic illness 
appeared to be of insidious onset, and immediate life stresses were not always 
readily identified.  In such situations, prompt attention must be directed to 
the underlying psychiatric illness, with consideration of rehospitalization, 
if needed. 
   Seventeen patients were considered to have one of the two clinical 
syndromes characteristic of transvestism associated with gender dysphoria.  
They fell naturally into two groups on the basis of age, characteristic 
prehistory, and clinical course.  Ten of the individuals were classifiable as 
"younger" transvestites, thereby materially expanding on the original cohort 
of 3, and the remaining 7 were "aging" transvestites.  In terms of age, 
statistical analysis revealed a significant difference between the mean age of 
35.9 for the younger group and 51.1 for their older subset (t = 4.825, df = 
15, P < 0.001).  There was no significant difference in terms of socioeconomic 
status or number of children. 
   The ten younger transvestites had all been married, although two were 
separated.  Five had children.  Their occupations were generally of the type 
considered masculine; although one was a nurse, he functioned as an 
administrator.  Concurrent psychiatric illnesses were primarily affective 
disorders.  Although information about erotic crossdressing was not 
sufficiently accurate or confirmable to submit to statistical analysis, the 
patients reported longstanding and well-organized, primarily covert "dressing" 
going back to early adolescence or latency.  The uniform request was for 
sexual reassignment because of unhappiness with their maleness and a wish to 
be female.  Although great dependence on wives and other important people 
seemed evident, the relationships were characterized by isolation, 
intellectualization, and hollowness.  As a group they often displayed 
histrionic, dramatic characteristics.  They were also quite narcissistic.  An 
illustrative clinical vignette is presented below: 
   The patient was initially seen in the SBCU requesting sexual reassignment.  
The patient had been married for 9 years and had a son 5 years old.  He was 
the middle of two children.  His father was a hard-working, often absent 
individual.  His mother, who was perceived as depressed during his early life, 
occasionally dressed him in curls and allowed him to wear lipstick.  She was 
remembered as proud of him for being such a "cute young man."  Crossdressing 
began at age 6 following the birth of a sister who received much attention.  
Thereafter, crossdressing was pursued episodically throughout life.  
Heterosexual activity began at 14 and there was no evidence of any homosexual 
behavior or fantasy.  He served in the Army 2 years without difficulty and had 
a successful business career in a "masculine" field.  Crossdressing became 
increasingly frequent following the birth of his son.  As his son became more 
active and Oedipally competitive, the patient concurrently found crossdressing 
of increasing pleasure although without overt erotic excitement.  It was 
during this time that he began to feel "truly" himself when crossdressed.  A 
year prior to the consultation, when his son was 4, he noted markedly 
increased libido and increased masturbation frequency.  He also initiated an 
extramarital affair and separated from his wife for a few weeks.  During the 
separation he occasionally crossdressed.  After a trial reconciliation with 
his wife he felt that he would no longer remain married because of his wish to 
undergo sex conversion and be female himself.  He then divorced his wife, 
noting increased wishes to become a woman on the heels of the separation.  He 
entered psychotherapy but crossdressed even more frequently.  He ultimately 
came to living and working as a female, being quite successful in his own 
business.  He changed his name and underwent breast augmentation.  There were 
no relationships with men, however.  The patient's wife subsequently remarried 
and moved with the child to a distant city.  Following this, his ardor for 
sexual reassignment abated.  He returned to the male role, and abandoned plans 
for further surgery.  During the clinic visits, the patient spoke words 
indicating an attachment to wife and son, but they seemed devoid of feeling.  
He was narcissistically quite preoccupied with himself, including his 
appearance, the impression he was making, etc.  It is worth noting that there 
was no evidence of grief, sadness, or lowered mood! 
   Table II.  "Younger" Transvestites: 
   A Clinical Variant of Gender Dysphoria 
                   Marital Number of               Psychiatric 
   Patient Age     status  children        Occupation      diagnosis       
   D       38      Separated       4       Taxicab Neurotic        65-Wife 
                                   driver  depression      leaving; 
   E       37      Married 1       Mechanic        Neurotic        29-Work 
                                           depression      stress, 
                                                   with pro-
   F       30      Separated       2       Insurance       None    44 - 
                                   agent           Oedipal 
                                                   with wife 
   G       38      Married 2       Systems Neurotic        44 - 
                                   analyst depression      Oedipal-
                                                   aged son 
   H       49      Married 0       Nurse   Schizoid        50 - 
                                           character       Mar-
                                           disorder        riage; 
                                                   to have a 
   I       35      Married 2       Computer        None    44 - 
                                   programmer              Oedipal-
                                                   age son; 
                                                   of mar-
   J       33      Married 0       Policeman       Neurotic        100 - 
                                           depression      First wife 
                                                   died 3 
                                                   yr ago; 
   K       32      Married 0       Computer        Neurotic        40 - Wife 
                                   programmer      depression      preg-
   L       33      Married 0       Salesman        Neurotic        35 - 
                                           depression      Marital 
   M       34      Married 0       Program Neurotic        35 - 
                                   analyst         Marital 
   The patient recalled his mother, a depressed, lonely, and angry woman, as 
having cultivated his curls and being proud of his cuteness.  Unfortunately, 
there was no access to material which would allow us to verify these reported 
memories.  Verification is important in such instances because of the tendency 
to project fantasies retrospectively to form screen memories rather than 
actual recollections.  It seemed clear, nonetheless, that crossdressing did 
begin with the birth of the sib at a time when the patient might have been 
expected to be going through the very difficult competitive and rivalous 
(Oedipal) phase that characterizes transvestitic patients. 
   It was clear later that crossdressing increased in frequency with its 
driven quality during the pregnancy of his wife and following the birth of his 
son.  This is a common enough finding, generally, in the paraphilias (Meyer, 
1979), but in this case the progression is typical for the younger 
transvestites who are vulnerable to decompensation into gender dysphoria.  
There was a flurry of erotic crossdressing, driven hypermasculine behavior (an 
affair, elevated masturbation rates), and finally separation and the request 
for sex reassignment. 
   In our experience the birth of the child and the child's passage through 
critical developmental stages reactivate the patient's own childhood, 
generative struggles.  In those transvestites vulnerable to gender dysphoric 
decompensation, the collapse usually comes as the child enters the Oedipal 
phase.  In the patient's recapitulation of his earlier conflicts he abandons 
his aggressive masculinity, separates from his mother-surrogate (his wife), 
and repairs his loss by becoming a woman himself.  In the clinical vignette, 
once the sources of conflict were removed, sex reassignment was no longer 
necessary.  Among the "aging transvestites," all individuals had been married 
previously but at the time of request only three of the seven were married.  
They all had "masculine" to "hypermasculine" occupations.  Their concurrent 
psychiatric illnesses were primarily affective disorders.  The following is a 
clinical vignette which illustrates the clinical course of such patients: 
   The patient was initially seen in the SBCU requesting sex reassignment.  
His career had been in one of the military services.  He had recently begun to 
wear feminine apparel in public and remarked on the constant daydreams of 
himself as a woman, but denied any fantasies of intercourse with men.  The 
patient was married and having intercourse (without crossdressing) at the time 
of the request for reassignment.  His three children, ages 14 to 21, had no 
history of sexual deviance.  The patient was the fifth of twelve children but 
described a lonely childhood.  He began trying on his sister's underwear at 8 
and episodically masturbated while dressed.  He pursued a successful career in 
the military but retired after a myocardial infarction.  Following his illness 
and retirement, he noted an increase in wishes to crossdress.  His wife 
tolerated his crossdressing at home as long as his three children or the 
neighbors were kept unaware of his secret.  When examined, the patient was 
dressed as a male but was wearing panties.  He had no suicidal or 
autocastration ideation.  There was no evidence of a depressed mood, but he 
was preoccupied with the notion of sexual reassignment. 
   This patient's wish for sex-reassignment surgery began after two major 
losses, his retirement and serious illness.  His premorbid history shows clear 
masculine identifications with episodic eroticized crossdressing.  
Furthermore, his wife appeared comfortable with his perversion as long as it 
was controlled.  She is similar to the "succorer" style of women who accept 
transvestitic behavior in their partners because of their anger toward 
competent mates (Stoller, 1967). 
   Although the patient had several children, there was no history of the 
degree of crisis around conceptions, pregnancy, childbirth, and early 
childhood development that characterizes the younger transvestites.  
Similarly, there is no history suggesting the onset of crossdressing in 
relation to sibling birth or more dramatic conflicts.  It seemed to have had a 
rather quiet, autogenous onset in midlatency. 
   Table III.  "Aging" Transvestites: 
   A Clinical Variant of Gender Dysphoria 
                   Marital Number of               Psychiatric 
   Patient Age     status  children        Occupation      diagnosis       
   N       52      Married 3       Accountant      Neurotic        Illness 
                                   Business        depression      (carci-
                                   college         noma) 
   0       49      Divorced        2       Steel worker    Alcoholism      Job 
                                   High            47 - 
                                   school          illness; 
   P       48      Separated       6       Machinist       Neurotic        38 
                                           depression      Mone-
   Q       66      Separated       2       Clerk   Neurotic        52 -
                                           depression      Illness 
   R       45      Married 3       Retired None    53 - 
                                   Army            Career 
                                   officer         retire-
                                   Store           ment; 
                                   manager         illness 
   S       52      Married 2       Business        Neurotic        S3 -
                                   executive       depression      Illness 
   T       46      Separated       0       Naval   Neurotic        Separ-           
officer depression ation 
   The nature and quantity of life stresses which are effective in producing 
gender dysphoric decompensation in vulnerable transvestites represent one 
factor which appears important.  Quantitative estimation of the major 
stressors in the 2 years prior to request for sexual reassignment was done by 
computing the number of life change units utilizing the Social Readjustment 
Rating Scale (Holmes and Rahe, 1967).  No significant difference in 
quantitative life stressors between the two subsets appeared.  On the other 
hand, the two groups, "younger" and "aging," differed markedly in the kind of 
stresses identified as contemporaneous with the request for sex reassignment.  
The younger transvestites were more often involved in overtly conflictual 
marriages.  Their wife's insistence on intimacy appeared to be a factor in 
three of the cases.  In one case, the patient was being pressured by his 
wife's insistence that he father a child.  Three patients had Oedipal-age sons 
who were troublesome to them.  Losses were present in only one patient who was 
recently separated from his wife. 
   In the "aging" group, illness and physical loss, as well as separation, 
were common to each member of the sample.  Illnesses varied from myocardial 
infarction (two patients) to neoplastic disease (two patients).  The illness 
of a parent or retirement was also a stressor.  Although all of the aging 
transvestites except one had children, there was no history obtained of the 
same kind of cataclysmic reaction to their children that was true of the 
younger group.  Whether more careful histories will reveal such episodes is a 
question for future clinical inquiry.  It is also not clear whether the 
younger transvestites, as they age, will show vulnerability to the stresses 
characteristic of the aging group. 
   This is an important issue.  While it is clear that parentage and children 
on the one hand and illness and retirement on the other are age-dependent 
stressors, the absence (so far) of a history of reaction to pregnancy, birth, 
and development among the aging group suggests that the two groups are 
differentially vulnerable to certain stresses.  This, in turn, suggests that 
the two groups are dynamically and etiologically somewhat different.  This is 
by way of contrast to the notion that they may be the same group merely at 
different stages of the life cycle and, therefore, vulnerable to the different 
stresses that characterize their different ages. 
   Along the lines of the two-population hypothesis is the suggestion that 
overt symptomatology in the "younger" group may start at an earlier age be 
related to sibling birth, and be more flamboyant.  It is certainly true that 
for both groups their sexual histories included use of feminine garments for 
sexual excitement. 
   The family constellations varied.  What emerged, however, was a picture of 
a father who was distant or absent and a hovering mother who was basically 
lonely.  Maternal attitudes toward the fathers were often hostile or 
indifferent.  The patients were utilized to make up for the maternal 
loneliness.  The mothers clearly formed symbiotic relationships with the 
   The histories of aging and younger groups revealed no early unhappiness 
with their assigned sex or the classical stigmata of the reconstructed 
childhood "transsexual" history.  They did not play "girlish" games or give 
histories of wishing or asserting that they were girls.  Rather, evidence of 
feminine identification was found in their early, and continuing, attachment 
to women's garments (Meyer, 1979).  Similar evidence of feminine 
identification is, of course, found in other transvestites, including the bulk 
of such men who, while they almost universally have episodes of yearning to be 
female, do not endorse the wish with action even under situations of 
extraordinary stress.  The vulnerability or the need of those transvestites 
who are basically gender dysphoric to make concrete their feminine 
identification theoretically bespeaks earlier and more continuous trauma in 
their relationships with early figures, more primitive defenses, harsher self-
criticism, and more poorly sublimated urges.  (See Meyer, 1979, and Meyer and 
Dupkin, 1979, for more detailed theoretical treatment of such issues.) 
   None of the seven aging transvestites had homosexual experiences, although 
seven of ten in the younger group had such relationships.  However, none of 
the 17 individuals had homosexual fantasies during any form of sexual 
activity.  The fact that the "younger" transvestites had homosexual 
experiences whereas the "aging" did not may be related to the propensity of 
the former to decompensate in relation to their sons.  The younger group seems 
more able to form narcissistic identifications with other males (as in 
homosexuality), living vicariously through them.  We propose that they 
similarly identify with their sons.  When the sons, quite naturally, become 
aggressive and competitive, their own conflicts are vividly reexperienced.  
The "aging" transvestites are more self-involved and do not form similar 
identifications with other men or their sons.  Their world collapses when they 
are no longer able to maintain the hypermasculine side of their personality 
(because of illness, infirmity, retirement, or loss of prestige) as a 
counterbalance to their feminine side. 
   It is our impression that it is most useful to regard the "younger" and 
aging" transvestites as having a borderline personality organization 
(Kinderberg, 1967, 1970, 1975).  Their masculine and feminine identifications 
and self-images are kept split, as are, respectively, their aggressive and 
loving urges.  They are not psychotic even in the gender-decompensated state 
since there is no falsification of physical or external reality.  It is not an 
example of multiple personalities since there are always both the masculine 
and feminine sides, even when one is dominant.  This pathological result is 
compatible with the type of long-range consequence of profoundly disturbed 
early relationships described by Kernberg (1966).  We believe from our 
clinical experience that the transvestism has served a function of 
symbolically expressing maternal identification in order to ward off very 
early anxieties (Mahler, 1963).  Under sufficient stress the symbolic 
expression is insufficient and collapses into a demand for real expression of 
the maternal identification through sex reassignment (Meyer, in press). 
   These disorders are episodic, recurring at times of dynamically resonant 
stress whether the stress be from the intimacy of a marriage, the Oedipal 
flowering of a son, or losses in vigor or status.  Proper diagnosis is the 
essential in management.  The history of masculine identification and 
eroticized crossdressing, with the characteristic precipitant, is critical. 
   The disorder of the aging transvestite is clearly episodic, and close 
support will see the urge for sexual reassignment abate.  It seems probable 
that the "younger" transvestite's request for sex reassignment is also time 
limited.  As the patient's desire for surgical sexual reassignment declines, 
the idea of sex change will become increasingly ego dystonic.  It must be 
remembered, however, that this disorder is recurrent and the therapist should 
always be available for exacerbations of this condition. 
   Psychotherapy, much as has been outlined for the borderline individual 
(Kernberg, 1975), is the treatment of choice.  It is rarely helpful to include 
the patient's wife in his treatment.  The symptomatic request for sex 
reassignment is in part a hostile gesture toward her.  Sensing this hatred, as 
the wives usually do, nonetheless may make her own treatment useful for her.  
Another reason for individual treatment for the patient is that it is more 
difficult to establish a successful therapeutic alliance if the wife is 
present.  The therapist will be seen as trying to convince the patient of the 
undesirability of undergoing sex change.  Often the wife's hostility will 
create disruption in the therapeutic situation.  It is essential to maintain a 
nonjudgmental attitude.  The therapist must sympathize with the patient's 
emotional pain but also must convey the need to explore the reasons for such a 
drastic change.  Strict enforcement of gender identity clinic criteria can 
also give a valuable "breathing period."  The Johns Hopkins Gender Identity 
Committee requires 2 years of crossdressing, working in the opposite gender 
role, and receiving hormonal medication and psychotherapy prior to 
consideration of surgery.  Once these prerequisites are stated, it is up to 
the patient to carry them through while he and the therapist can work on the 
various issues that present themselves.  This allays the urgency of the 
request for both patient and therapist.  Often enough the patient's relief at 
the criteria is palpable.  Because of some integration of his personality, he 
cannot fully endorse conversion since the masculine "side" of his personality 
still fosters the ambivalence. 
   The initial phases of the therapy should include identification of stresses 
which provoked the regression.  The therapist should be well aware of the 
potential of suicide and autocastration in such patients.  Medications should 
be utilized if concurrent psychiatric illnesses are present.  Patients also 
must be hospitalized if they become acutely suicidal, nonfunctioning, or 
psychotic.  This condition is episodic and often will remit in time. 
   After an initial phase of therapy where there is a clear agreement of a 
didactic relationship, the aging transvestite will often experience a 
depression.  This occurs as a individual begins to react to the various 
stresses which had created his wish for sexual reassignment.  Whether this is 
a specific loss, an aging process, or the Oedipal rivalry of a child, the 
individual will often initially experience the mood disorder and then 
cognitively deal with the content of his mood changes.  Initially this 
depression is rationalized as being due to the realization that immediate 
surgery is not forthcoming.  Furthermore, the initial euphoria from the 
fantasy of changing sex roles becomes a more realistic problem.  The 
tremendous difficulties in actually crossdressing in public, consideration of 
new employment, and reaction of family and friends modify this euphoriant is 
during this period that suicide and autocastration can occur.  Ongoing 
supportive therapy, potential use of antidepressants, and possible family 
support or hospitalization may be needed.  Exploration of the realistic 
difficulties that the patient has at present plus past difficulties in develop 
mental and interpersonal relationships not directly related to gender 
dysphoria are areas which can allow useful working through of this stage of 
   This report supports and expands Meyer's earlier classification of the 
"younger" and "aging" transvestites as clinical variants of gender dysphoria.  
These categories make comprehensible certain discrepant findings in the 
literature regarding transvestism, gender dysphoria, application for sex 
reassignment, and the nature of the relationships among these phenomena.  
These findings also enlist the vast literature on the borderline syndromes in 
the effort to comprehend the psychology of these patients.  On the clinical 
level, the need for an accurate diagnosis is essential if one is to adequately 
map the course of any individual requesting sexual reassignment and prescribe 
appropriate treatment.  Recognition of the episodic course of the gender 
dysphoric transvestites allows rational management and prevents needless, 
irreversible surgery, which would provoke further suffering in these troubled 
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