E XT RE ME FE MININIT Y IN BO YS 58

Sex and Gender

VOLUME II
THE TRANSSEXUAL EXPERIMENT

Robert J. Stoller, M.D.

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

JASON ARONSON
New York
 CONTENTS

Acknowledgements page vii

Introduction
1
Part I
THE HYPOTHESIS

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

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

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

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

FOLLOW-UP

Being suspicious, I still await proper follow-up studies on the results of

sex-reassignment before feeling comfortable about the usefulness of the
hormonal and surgical procedures. But the suspiciousness suffered now is
in a different area, and that is: exactly how are the follow-ups conducted,
what is the nature of the data, and what are the connecting logical and
syntactical links between the data and the conclusions reached.
I am in no position to do such a study, not having seen enough patients
who were ‘sex changed’ or enough—a control group—who, wanting the
‘change’, were refused. In addition, patients I see are not selected to
represent the whole spectrum of those who wish ‘sex change’, so that who
is seen after the ‘change’ is a matter of chance.
On the other hand, the few patients I have worked with have, in most
cases, talked with me for years. I dislike seeing extended numbers of
patients for brief interviews, feeling that this is one of the riskiest (though
nowadays common and respected) methods of collecting clinical data on
sexual matters. So I know a few patients well, which gives a strength to the
clinical findings that others do not choose to match, but I do not see
enough patients to make the generalizations from my data more than
tentative.
As the years go by, male transsexuals, before they are able to live as
women, develop neurotic symptomatology, clearly recognizable in their
lives, in a psychiatric evaluation, and on psychological tests. Nonetheless,
immediately following ‘sex change’ procedures, much of this
symptomatology disappears. They pass silently as women and are not then
observed by their families, friends, or co-workers as overtly neurotic. On
psychiatric examination, they show no unusual symptoms (other than the
gender reversal), and psychological tests

257
258 THE TRANSSEXUAL EXPERIMENT

consistently show loss of anxiety and of depressive signs.* This being so,
the prognosis with ‘sex change’ should be fine, as reflected in the follow-
ups. Yet I have not found this true.
Others have. Those most experienced in follow-up are convinced that
‘sex change’ is successful, and so-called gender clinics have sprung up
around the country to promote ‘sex change’ operations,† This could only
have occurred given a general attitude that the results of treatment are, or
will be, of good quality.
I do not believe that this almost universal impression is wrong, only that
it is incomplete and unproven—and where it is incomplete and unproven
has not yet adequately been acknowledged. If patients are properly chosen
for ‘sex change’, the results will be good in that the patients will be more
content after surgery, will say that they would choose such treatment if it
had not yet been offered, that they would never want to go back to their
former anatomy, and that they have better relationships with friends and
are more employable than before. That information is easy to get by
simply questioning, and it is, I am sure, accurate. If one follows the patient
long enough, however, and in great enough depth, further information is
revealed.
C ASE O NE
I met this patient, a female transsexual, in 1957. Since he is the first
patient of my research, I present him now (keeping in mind that the female
transsexual is not the perfect case to exemplify issues in male
transsexualism). He was so unquestionably a man that it was his
appearance that began my research; up to that point I presumed the
transsexual to be nothing but a homosexual unwilling to admit to his
homosexuality. But the completeness of the gender reversal and its evident
presence throughout the subject’s character structure—as much as one
would see in a normally masculine person—forced me to look more
closely and thus reconsider theoretical

* Unpublished data collected especially in our research by A. C. Rosen, Ph.D.

† The first gender identity clinic was established at UCLA in January 1964 and is
still, I believe, the only one whose purpose is to study gender identity. The rest
apparently like the laundered quality of that name to cover their prime function: ‘sex
transformation’.
 FOLLOW-UP 259

assumptions. This ‘man’ had done a great deal on his own by the time we
met, and he subsequently did much more, without my help. He had
arranged for himself (in those days, before the publicity, when such
arrangements were so difficult) a mastectomy, a pan-hysterectomy,
testosterone that had masculinized his secondary sex characteristics,
change of birth certificate, and subsequent change of other legal
documents, such as name, and eventually a legal marriage as a man. In
addition, he was able to be employed regularly as a man and had even
managed to get clearance from the Government in his work. No one could
have been more highly motivated or more successful in passing.
Ten years after we met and several years after our regular contacts had
ended, I received a letter from a friend of his, that said, in part:
It is my sad task to inform you of the suicide of George. He died on his
birthday, after spending the evening with us. He had spent the day before with
us and at that time was in gay spirits. However, Saturday when he arrived he
was very depressed and morose. He seemed to be in a better frame of mind
when he left, and, I now realize, was not nearly so nervous.
My husband found him in bed Sunday afternoon after he failed to call. I
found three empty and unlabelled pill containers beside the bed and he had left
a note to us in a prominent place. It says: ‘Forgive me for the inconvenience
this will cause you, but there is no one else I can depend on.’
His friendship spanned several years and my husband and I considered
George our closest friend. He confided his original sex to us only a few weeks
after our friendship began. At that time he seemed terribly lonely. Maybe he
sensed that his secret would be safe with us and was desperate for someone to
talk with. He was extremely careful that we had no inkling of his suicide. As far
as I can recall, he only gave one small clue and it was so insignificant that I
missed it. He once told me that he would find the easiest way out of this life and
would make very sure.
George seemed to have everything going his way at the time he chose to die.
He was due to start a new job the next day at an extremely good pay rate. He
had arranged for a nice apartment and seemed happy about all of it until the last
night. At that time he made the statement that it just didn’t seem worth all the
effort any more.
260 THE TRANSSEXUAL EXPERIMENT

I know that he was sexually frustrated in the extreme. He had regular

injections of testosterone. As he put it, ‘all dressed up and no where to go’. His
second wife visited him briefly in September, and it turned out that her motive
was money—not love. This was quite a blow to his ego.
George never realized how many friends he had and how much they valued
his friendship. In fact, only friends—not relatives— attended his funeral.
Also, George had a terrible fear of becoming too old to work. He could not
pass a physical examination for work as a permanent employee of a company
and a job shoppers’ effective years are limited.
I cannot isolate any one incident that could have been responsible for his fatal
depression. Maybe it was the accumulative frustration and disappointment of
battling an indifferent world. I did notice the final few weeks he seemed to be
withdrawing more into himself. Without proper psychiatric training as I am, I
hesitated saying too much for fear it would be considered meddling. I do think
he was seriously considering suicide last winter as I found a scrapbook
containing many articles pertaining to sex change—-and many more on suicide.
Of all the female transsexuals I have known, this person was the most
impressive in the degree of his masculinity, his lifelong commitment to
being a male and a man, his success in managing the almost insuperable
problems (in those days) of passing, and his successfully managing his life
as a man, in regard to occupation, finances, and even getting married. Yet
it was not enough.
CASE TWO (reported earlier in Chapter 5.)
A year later, 1958, I met my second transsexual, this time a male. At the
time, as reported elsewhere, I mistakenly thought this patient to be
intersexed, and in fact even the endocrinologists were fooled to the extent
that we reported her as a case of testicular feminization syndrome
(androgen insensitivity syndrome); even the biochemical studies and
histological examination of the gonads corroborated that diagnosis (1).
After becoming a beautiful woman, she married. Several years later, she
left her husband and embarked on a very active and successful sexual life,
during which no one questioned the normalcy of her ‘female’ genitals
except herself. She was forever
 FOLLOW-UP 261

fearful some man would discover her secret, despite her body being
apparently—and spectacularly—normally female. She simply never felt
easy that she would always pass successfully; each new job where she was
accepted and each new lover who was pleased to live with her could only
temporarily remove the fear. In addition, she could never forget—nor can
any transsexual— that life began in the opposite sex. These patients are not
delusional, and they are not able to deny their past, especially the
knowledge that they are forever members of the sex into which they were
born. More than many researchers on transsexualism, these patients know
they will never be truly female, and therefore can never be, in the depths of
their identity, women (see Chapter 5).
Now she feels hopeless; most of the time, she can alleviate that affect by
simply feeling bored. Although highly employable, she no longer works;
she does not wish to be bothered with the routine. She rarely has boy
friends any more, for she knows she will break up the relationship because
of her boredom. Despite psychotherapy (she refuses any offers for
analysis), she is convinced that nothing will change inside herself. Here is
an example:
Dr. S: How are you?
N: Terrible. Miserable. I’m blowing it again. I’ve been here in Los Angeles two
weeks now just flopping around, no place to stay, no money. And last
Tuesday a girl I met through friends told me about this job. I went in and
applied. And the marketing manager saw me when I applied so he hired me
for a secretary. I went in yesterday, and it’s just beautiful, it’s a beautiful job:
executive secretary, good salary, everything. And I can’t do it. I took off
today at lunch and my salary is over right now; I won’t return.
Dr. S: Why did they hire you for that high a job when you just walked in off the
street ?
N: Because I wanted it. He checked my application and he thought my
qualifications were secretarial. I’ve seen the job. It’s fine; I can do it. I
managed to squeak through the application, which isn’t easy now for a good
secretarial position; they check your references and mine are so botched up
now that it’s practically hopeless except a situation like this. And this is one
of those situations I fall into; I fell into it.
262 THE TRANSSEXUAL EXPERIMENT

Dr. S: Theoretically you can do it; do you want the job? You look like you do.
N: I did. But I can’t stand being hit by a barrage of routine coming down in a
constant . . . telephones. . . . I’m not going to go back in. This is the third time
I’ve done this this year . . . being totally broke and not even collecting my
pay; I just don’t go back in. A good job gives me things to be annoyed at; it
gives me reasons to have to control my temper and not get pissed off. Now,
I’ll leave there, and I won’t really kick myself. But I passed up a beautiful
opportunity for a future exactly as I planned. But I’m not doing it. This was
an opportunity to settle in L.A. where I wanted to be. It took time and energy
to get myself together, and with the job that I wanted and with enough money
so that I could pay some of my bills, a hell of a situation. . . And I won’t do it.
The only way it hurts me not to go back in to work is I have ... no
independence. It keeps me dependent on other people. And I have no people
to be dependent on. I had a golden opportunity handed to me on a silver
platter, but it doesn’t turn me on right. So it doesn’t matter. That golden
opportunity on a silver platter has to be the right golden opportunity on a
silver platter. So I’ll wait for the next connection to come along in the next
two or three years.
Dr. S: What do you feel right now ?
N: Very bitter. Now I’m controlling my own fate. I’m making real decisions.
I’m doing something very specific, very definite: like not going back;
quitting; moving. Any time I’ve been able to do something like that, it’s
always been worse. . . . What more could I want, that I could ask for? To do it
right, to get a job, get a good job. I thought I was going to work like hell to
find it and here it just fell into my lap. But what am I going to do? Like what
am I going to do tomorrow when I have nothing more to wear? What am I
going to do ... I think that what I’m mostly afraid of is that if there are things
about the job that begin to pile up in the next couple of days or so, my nerves
are going to . . . not like I’m going to blow up, I never blow up . . . but I’m
going to sink into a real depression. I’ve done it. I can’t see how, in the past
couple of years, how I’m still alive; there’s no reason for me to be alive.
Every day goes by and I live another day and. . . .
Another problem for which adequate follow-ups have not yet been
published are the post-surgical complications. That the medical profession
can allow these operations to go on in
 FOLLOW-UP 263

increasing numbers year after year and not demand further information
about the surgical results, much less the psychological, is evidence of a
terribly wrong and short-sighted opportunism. It is no excuse that
transsexual patients are so grateful for having been ‘sexually transformed’
that they can bear all sorts of physical pain and discomforts, chronic
infections, and reoperations and still be grateful that anyone cares about
them. (I met one patient originally following her first vaginoplasty. It had
not been successful, for the surgeon had perforated into the rectum. As a
result, a ‘recto-vaginal’ fistula developed, destroying the new vagina and
requiring a colostomy as a bypass to permit the wound to heal and the area
to become uninfected. When this had occurred, a second vaginoplasty was
attempted but another infection intervened, this time a severe cystitis and
urethritis. A year or so later, when again the tissues of the operative site
could bear it, a third vaginoplasty was done, this one without immediate
post-operative complications. She scarcely ever complained but was only
gently saddened by her physical suffering. However, she fled from Los
Angeles; I have not seen her for years and so do not know the subsequent
surgical history.)
Starting a year or so after her ‘sex transformation’, Case Two developed
a cystitis, a frequently reported condition perhaps due to the fact that it is
difficult to have the surgically-modified urinary meatus end up in the
proper anatomical position. (It may be either a bit out of place immediately
following surgery, or, after healing, scarring may pull it out of place.)
While this could be treated with antibiotics, the patient had frequent
recurrences, and in the last five years has never been free of laboratory
signs of infection, though she may have symptomless weeks or months
between flareups.
In addition she developed a complication routinely, perhaps invariably,
found in these surgically-created vaginas. They tend to become smaller
with time; without either constant use in intercourse or regular insertion of
a plastic mold (a moderately painful daily exercise) the vagina shrinks and
may even be obliterated. On the way to the final stage, patients, as did
Case Two, find the introitus narrowing so that penetration in intercourse
becomes difficult or impossible. This is, of course, accompanied by pain
during intercourse. But a far greater
264 THE TRANSSEXUAL EXPERIMENT

distress is the fear that the vagina is not female enough or will be
recognized as artificial by one’s sex partner.
Case Two has suffered these distresses for years, and despite continued
competent medical care, she is a bit worse off each month. In the last year,
as her vagina shrank, she sought help from a university medical center,
discussing with the surgeon her desire that her vagina be restored to its
former adequate dimensions. The surgeon told her of two operations to
relieve her; one would sacrifice tissue necessary for adequate depth, the
other would not. She chose the latter, but on recovering from surgery, she
found the first procedure had been done. She has been depressed ever
since. She believes there is no way the damage can be repaired. It all adds
up to this:
N: When I am not going with a guy, I think I am missing something, letting my
life slip by, or I am not being fulfilled. Then, when I am with him, just
instantly it changes; then I can hear the clock start ticking, those hands are
going really slow . . . and I know how it’s going to be, day after day, week
after week, month after month, and year after year. And time seems to drag.
Whereas now without a man time doesn’t drag; it is not boring, because I
have something to search for, in trying to find a satisfactory relationship.
Then when I get a satisfactory relationship, I turn somewhere else. I am not
goal oriented. I never am. Unless one just happens to plop in my lap; that’s
when I am.
Dr. S: You don’t even imagine in your daydreams sticking permanently with
one man ?
N: Oh yes, I think that would be really nice. It’s so easy now to daydream,
because I don’t think it’s going to be that long anyway, dragging on for thirty
or forty years.
Dr. S: It isn’t going to be that long?
N: Oh, I have no doubts: I’m not going to be around in a few more years.
Everyone says that, or feels that, once in a while. Then you get the other
feeling; life seems complete and precious. But now it seems like it’s merging.
Dr. S: Closing in?
N: Not closing in so much as just merging: all the diverse paths merging into
something; you know; it is getting easier to prognosticate. . . .
Dr. S: That you’re going to die within a few years?
N: I think so.
 FOLLOW-UP 265

Dr. S: Because of your urinary disease ?

N: Related. That will orient my life, or get my life off on a track that will create
other problems either in me physically or in my environment. It will organize
me along that line to where ... it will probably be because of failing health.
Dr. S: Are you frightened ?
N: No. Just I don’t want it to be messy.
Dr. S: Will you regret dying ?
N: Oh, yes (casual).

Dr. S: Are you hopeless now? [Nods head slightly.] What do you know that
makes you hopeless ?
N: It’s very clear. Then was then, and now is now. I am a different person now. I
am heavier. I am more drunked out; I am more doped out. I am used up. I am
farther down the line.
C ASE T HREE (reported earlier in Chapter 18, Case Ten.)
I have known this female transsexual for 12 years, having worked
regularly with him and his parents for over three years (1, Chapter 17). I
am now seeing him in regular appointments for several months a year,
when his business brings him to Los Angeles. As with all transsexuals I
see, he does not come in in order to change character structure, and
especially not to be changed to a feminine woman. They all come back
because I am a safe person, who knows their secrets and who can
sometimes give practical assistance.
In adolescence this was a wild child, unbearably enraged at his parents
(when he was living as a girl), unable to function at school and without
friends, capable, when desperate, of threatening his father with a loaded
gun. Not long after, on his own, without help from his parents or me, he
made an appointment with a plastic surgeon, arranged for a mastectomy,
and then convinced his parents to pay for it—all this at age 17. Having
forced his parents to accept him as a boy, he went to school as a boy,
getting high grades for the first time in his life. On finishing high school,
he set out upon his profession (a purely male profession related to his
greatest childhood interest), and is now a leader in this field; no one there
knows he is not a biologically normal male.
266 THE TRANSSEXUAL EXPERIMENT

He would never turn back, but there is never a day free from fear of
discovery* or from the struggle with managing the process of passing. That
struggle never ends; one can only successfully defend against the present
emergency. This would be less acute if surgeons could create an
anatomically and physiologically normal body, but since they cannot, the
difficulties never stop. And even if complete biological normality could be
reached, I think transsexuals would still believe they were not ‘natural’
members of their new sex. This sense of unalterable flaw and the feeling
that they were liars forever about the core of their existence would blight
their lives (see Chapter 5).
When he got his mastectomy, he was happy, not the least because he had
resourcefully arranged with an outstanding surgeon to do the job.
Unfortunately, the result was uncosmetic. First, the nipples ended up
distorted in the attempt to make them smaller, and second, the operative
site became infected. Infections there came and went for several years;
now his chest is so scarred that he can never bare it.
On seeking out surgeons to create a penis, he learned that he could not
have a urinating, erectile, or erotically sensitive penis. Most urologists and
plastic surgeons said they could not even make a skin graft ‘penis’ that
would resemble, in flaccid or erect state, a normal penis. New gadgets are
being invented, and he hopes that in time he will have a prosthesis that will
erect automatically in sexual circumstances.
So far, he has remained precariously lively and hopeful, but each step
forward brings with it one more realization that there is no happy end;
each step proves no step is adequate. And this may wear him down, as it
did Case One.
C ASE F OUR
I have worked steadily with Case Four, a male transsexual, for nine
years, since he was 15. The surgical and hormonal results, which she
arranged for on her own (though with the financial support of her parents)
have been brilliant. She is a beautiful and successful woman, working as a
model and sought after by the men she meets. She has had several pro-

* e.g. What do you say if stopped and asked for your draft card ?
 FOLLOW-UP 267

posals for marriage.* Except for suffering minor urinary problems,

shrinkage of her vagina, and a need for a second vaginal repair, she
worries especially if anyone will know that she is a transsexual. (The
skeptic may believe transsexuals’ worry about being discovered is
evidence of a paranoid state. In addition to their having no other paranoid
qualities, I do not judge their fear pathological. Perhaps they are
oversensitive, but then so too are spies trying to pass in an enemy land.)
Having taken female hormones, she had a very feminine and female
appearance by late adolescence. Before surgery, she met a man, who
believed her to be a normal female. Becoming committed to him after
some months, she revealed her anatomic state. He survived the revelation;
they decided to live together. Since the patient hated her male genitals, it
pleased her, as it pleased her partner, to keep them covered—hidden —
during their sexual relations. Nonetheless, her lover of course knew
completely her anatomic and psychologic state, and he accepted it. During
the difficult months while she was arranging on her own for surgery, he
comforted her. He brought her to the hospital for the operation and stayed
with her many hours a day as she recovered.
But within a few months, she felt so much more naturally female that the
relationship between the two became strained beyond repair: she was
disturbed to be so close still to one who knew her male past and who had
been able to make love to her despite her known maleness, and he began
expressing envy of her transformation to a female.† Finally, she dropped
him and went on her way to relationships more appealing to her in that her
partners accepted her enthusiastically without knowing her secret.
I did not see her for several months. Then she returned, sad, crying,
wondering whether the long life she still had ahead would be worth much.
In time, she spoke of what had started

* These descriptions of superficial successes should not be interpreted as my

thinking that such measure the real qualities of the patients. I recognize these items,
rather, show mostly how successful a surface can be acquired and have no more
psychological validity than the fairy tales ending, ‘and they lived happily ever after’.
† No one working with a male transsexual is surprised to hear that the man with
whom she is having an extended liaison who knows she is transsexual, while
appearing ‘straight’, talks of his own wishes for sex change.
268 THE TRANSSEXUAL EXPERIMENT

and lay behind this reaction. She was living with a handsome and
masculine man, intelligent, and financially successful in a fascinating
business that would have given the patient—had she accepted his proposal
of marriage—a glamorous and full life. He was the sort of man about
whom she had daydreamed for years, and now that she could have him,
she became aware of a problem from which, as a transsexual, she would
never escape: she could never have an honest relationship with him. He
had no inkling of her past, and she could never tell him. While many
marriages can survive the hiding of a secret, it certainly throws a burden
on the person who is by nature open. And in this case, the secret was
perhaps one that would have to harm the marriage at its core, i.e. that it
was a relationship between a male and a male. So she had found herself
increasingly preoccupied with thoughts of the man she had known and
lived with before and just after she completed her ‘change’. She recalled
the sweet comfort, the frankness their relationship had provided, and even
as she reminded herself of the bitter arguments that had poisoned the last
months, she discounted them in favor of what now seemed an unbearable
advantage: that she had once had an open and uncomplicated relationship
with a man who knew her as she truly was, a biological male.
While I have only sketched in this issue, the reader may empathize with
the existential dilemma this person can never escape. The perfection of her
passing was the very quality that doomed her never to have the
relationship that that perfection should have produced—an honest, open
freedom instead of continuation of the risks and falsity of passing.

These are the only adult transsexuals whom I have studied for years and
with the help of a therapeutic—i.e. trusting-relationship. There are others,
but I see them only every year or at longer intervals, which makes the
information they give less complete or dependable. Transsexuals before
surgery are so desperate for sex change that what they relate must be
treated with caution, and even after ‘change’ they still have points of view
that must at times be defended against the trust. (In my experience this has
been more true of male than female
 FOLLOW-UP 269

transsexuals, perhaps for the reason given in Chapter 7.) When, however,
one makes himself available indefinitely and under any circumstances, the
patient will come back for help and over the years will give what seems
like more accurate information. For example, the newly operated male
transsexual, anxious to prove that the procedure was correct, will try to
convince the observer with the validity of her femininity; one way she
does this is to describe the marvels of her vaginal sexual experiences. In
contrast, when Case Two contacted me for help one time, she said she was
troubled because her orgasms, which had been strong, were now less
intense and more difficult to bring off. The latter way of putting it, with
sadness and pleading, had a ring of truth.
My impression from too few patients—some with what I would consider
adequate follow-up and many with only superficial follow-up—is that one
should suspect follow-up studies that simplistically report either
enthusiastically or grimly. My knowledge of the literature, which I think is
complete (in English) informs me that as yet there are no adequately
performed or adequately reported follow-ups. But the total weight of the
reported cases gives the impression that the patients will probably benefit
from this radical treatment more than if deprived of it. The benefits are
reduced anxiety and depression, improved interpersonal relationships as
measured by the patients now being able to live with another person in a
continuing sexual and affectionate relationship, employability, and
improved relationships with their families. One can expect such results
routinely (though by no means inevitably); but the lingering question is
whether such results hold or whether new and unhappy qualities, like
hopelessness, gradually take over. Yet even if adequate follow-ups will
reveal the latter to be usual, I believe the patients are better off for the
happier years they were granted than if deprived of any hormonal and
surgical treatment.
Each of the above four patients exemplifies an important source of
anguish that can only increase as the years pass and that at present cannot
be adequately treated. Case One shows that even the most committed
patients, those able to pass with the greatest success, in time may become
hopeless. The endless process of passing wears them down, and they
become obsessed
270 THE TRANSSEXUAL EXPERIMENT

with reaching toward a goal that cannot be reached—true membership of

the opposite sex. Case Two exemplifies the post-operative complications
—the continuing infections and the cosmetic and functional inadequacy of
the surgery. Case Three demonstrates the never-ending and frantic chasing
for anatomic perfection so that one can appear genitally normal and
perform sexually normally. Case Four represents a problem of identity—
that we not only have to be ourselves but must be free to let others know it.
Without that freedom, which most of us take for granted, the transsexual
grows toward despair, knowing there will never be the chance to reveal
oneself with the most important people.
The significant follow-up for this research on transsexualism has so far
not been done. If and when it is, it will make the other studies in this book
obsolete. It consists of a researcher finding cases of boys, the earlier in life
the better, who, with their parents, fit the criteria for transsexualism
defined in this book. Then, in the absence of treatment, these boys should
be followed closely, so that one has a clear idea of the family’s dynamics
and whether these persist over the years, whether they are modified,
whether opposing or concurring forces develop in society (e.g. in school)
that play on the developing boy, and finally whether a transsexual
adolescent or adult results. My thesis is that if in these cases the mother is
in personality as I describe, the father likewise, the child beautiful and
cuddly in infancy, and the mother creating a blissful symbiosis, then
extreme femininity will result in the first few years of life. If this mother is
allowed over the years to encourage the developing femininity and the
father does not interrupt the process, it will flower. Then, if the process is
not interrupted by an artifact such as treatment, transsexualism will result.
The study will require that other feminine little boys be followed in the
same way, but with these little boys, one or more of the variables will be
different in the three main actors than is the case in the classical situation.
As such a family is followed, if the thesis is correct, the boy’s femininity
will be revealed as different from that of the true transsexual. Some of
these boys will show fetishism, some will become effeminate
homosexuals, some will be gentle, perhaps effeminate, passive
heterosexuals. If the thesis is correct, we shall find that the exact
 FOLLOW-UP 271

nature of the boy’s masculinity and femininity can be traced to observable

influences in the family.
While not this ideal experiment, there is a study in progress— started in
1958—in which feminine boys have been followed at regular intervals to
the present. Green and Money, who have published in-progress reports of
this work, are continuing this research. When they began, the hypothesis I
have proposed did not exist; they could not have built tests (such as
appropriate questions) for it into their work (and especially, they did not
differentiate types and degrees of femininity in a systematic manner or
observe for family dynamics that might contribute). But they are
developing unique, crucial data. They have found this: feminine little boys
are very likely to grow up carrying that femininity within them through the
years. By no means are all, or most, of the boys transsexuals when they
become adolescent or adult. A few seem to be, while most are overt
effeminate homosexuals. So, while this essential study does not completely
or directly test the hypothesis, it certainly contributes a powerful
confirmation that the gender aberrations of childhood persist in the adult
(2).
Perhaps the most important research method now needed in the study of
gender development is the long-term follow-up. It is more direct, more
powerful, and more convincing than all the attempts at controls which I
have described; the ‘experiments’ of this book are only substitutes for
endless direct observation.

Chapter 20
1. Stoller, R. J. (1968). Sex and Gender. New York: Science House;
London: Hogarth Press.
2. Green, R. (1974). Sexual Identity Conflict in Children and Adults. New
York: Basic Books.