A general survey with an attempt to define, diagnose, and classify
Transvestism (TVism) as a medical diagnosis was probably used for the first time by the German sexologist, Dr. Magnus Hirschfeld, about forty years ago when he published his book, Die Transvestiten. The term is now well known in the sexological literature, indicating the desire of some individuals - men much more often than women - to dress in the clothes of the opposite sex. It is, therefore, also described as "cross-dressing."
Most writers on the subject refer to transvestism as a sexual deviation, sometimes as a perversion. It is not necessarily either one. It also can be a result of "gender discomfort" and provide a purely emotional relief and enjoyment without conscious sexual stimulation, this usually occurring only in later life.
Hirschfeld and his pupils saw many of these persons in his Institute of Sexual Science in Berlin, Germany. This memorable Institute with its famous and rich museum and its clinic and lecture hall (Haeckel Saal) was destroyed by the Nazis rather early in their march to power (1933). (This destruction occurred soon after the first and only issue of Sexus, an international sexological magazine, was published by Hirschfeld while he was away from Germany.) The Institutes confidential files were said to have contained too many data on prominent Nazis, former patients of Hirschfeld, to allow the constant threat of discovery to persist.
Many times in the 1920s, I visited Hirschfeld and his Institute. Among other patients, I also saw transvestites who were there, rarely to be treated, but usually, with Hirschfelds help, to procure permission from the Berlin Police Department to dress in female attire and so appear in public. In the majority of cases, this permission was granted because these patients had no intention of committing a crime through "masquerading" or "impersonating." "Dressing" was considered beneficial to their mental health.
Havelock Ellis proposed the term "eonism" for the same condition, named after the Chevalier dEon de Beaumont, a well-known transvestite at the court of Louis XV. In this way, Ellis wanted to bring the term into accord with sadism and masochism, also named after the most famous exponents of the respective deviations, the French Marquis (later Count) Donatien de Sade, and the Austrian writer, Leopold von Sacher-Masoch.
Because of the much more permissive fashions among women, and for other reasons, the
problem of transvestism almost exclusively concerns men in whom the desire to cross-dress
is often combined with other deviations, particularly with fetishism, narcissism, and the
desire to be tied up (bondage) or somehow humiliated (masochism).
Transvestism (TVism) is a rather frequent occurrence, although it would be impossible to say how many transvestites (TVs) there are, for instance, in the United States. From students of the subject (TVs themselves) I have received estimates ranging from ten thousand to one million. Many transvestites are unknown as such, indulging in their hobby in the privacy of their homes, known perhaps only to their closest relatives, sometimes only to their wives. Others are most attracted to going out "dressed" in order to be accepted as women in public by strangers. They may invite discovery and arrest, but this danger is an additional attraction for some of them. Others may live completely as women, their true status sometimes discovered only after death.
The majority of transvestites are overtly heterosexual, but many may be latent bisexuals. They "feel" as men and know that they are men, marry, and often raise families. A few of them, however, especially when they are "dressed," can as part of their female role react homosexually to the attentions of an unsuspecting normal man. The transvestites marriage is frequently endangered as only relatively few wives can tolerate seeing their husbands in female attire. The average heterosexual woman wants a man for a husband, not someone who looks like a woman; but mutual concessions have often enough preserved such marriages, mostly for the sake of children.
It is not the object of this book to deal in detail with transvestism (TVism) in all its aspects. The object is to deal with transsexualism (TSism) principally. Yet, an extra chapter on TVism with further characterizations will have to be inserted in order to let the picture of transsexualism emerge more clearly. Repetitions will be unavoidable; but the relative unfamiliarity with the subject, even in the medical profession, may make those repetitions permissible, if not desirable.
The transsexual (TS) male or female is deeply unhappy as a member of the sex (or gender) to which he or she was assigned by the anatomical structure of the body, particularly the genitals. To avoid misunderstanding: this has nothing to do with hermaphroditism. The transsexual is physically normal (although occasionally underdeveloped) . These persons can somewhat appease their unhappiness by dressing in the clothes of the opposite sex, that is to say, by cross-dressing, and they are, therefore, transvestites too. But while "dressing" would satisfy the true transvestite (who is content with his morphological sex), it is only incidental and not more than a partial or temporary help to the transsexual. True transsexuals feel that they belong to the other sex, they want to be and function as members of the opposite sex, not only to appear as such. For them, their sex organs, the primary (testes) as well as the secondary (penis and others) are disgusting deformities that must be changed by the surgeons knife. This attitude appears to be the chief differential diagnostic point between the two syndromes (sets of symptoms) - that is, those of transvestism and transsexualism.
The transvestite (TV) usually wants to be left alone. He requests nothing from the medical profession, unless he wants a psychiatrist to try to cure him. The transsexual (TS), however, puts all his faith and future into the hands of the doctor, particularly the surgeon. These patients want to undergo corrective surgery, a so-called "conversion operation," so that their bodies would at least resemble those of the sex to which they feel they belong and to which they ardently want to belong.
The desire to change sex has been known to psychologists for a long time. Such
patients were rare. Their abnormality has been described in scientific journals in the
past in various ways; for instance, as "total sexual inversion," or "sex
role inversion." Beyond some attempts with psychotherapy in a (futile) effort to cure
them of their strange desires, nothing was or could be done for them medically. Some of
them probably languished in mental institutions, some in prisons, and the majority as
miserable, unhappy members of the community, unless they committed suicide. Only because
of the recent great advances in endocrinology and surgical techniques has the picture
One of the first to take advantage of these advances was a very unhappy young American photographer and ex-G.I. by the name of George Jorgensen. He pursued his desire for a "sex change" with remarkable perseverance and was fortunate enough to find in his familys homeland, Denmark, physicians of compassion, scientific objectivity, and courage to help him. And so, an unknown George Jorgensen became the world-famous Christine Jorgensen, not the first to undergo such surgery, but the first whose transformation was publicized so widely that the news of this therapeutic possibility spread to the farthest corners of the earth.
The facts of her case, which she herself related with good insight and restraint - unfortunately only in a magazine article - caused emotions to run high among those similarly affected. Suddenly they understood and "found" themselves and saw hope for a release from an unhappy existence. Among the public, there was praise for Christine for the courage of her convictions; also there was disbelief with criticism of her physicians, as well as outright condemnation on moral grounds. Such emotional reactions in lay circles reached the height of absurdity and bigotry when Christine was once barred from a New York restaurant and night club as a guest.
Physicians, including psychiatrists, were divided in their opinions, but the conservative Journal of the American Medical Association published an article written by Christine Jorgensens group of Danish physicians, headed by the noted scientist and endocrinologist, Christian Hamburger, in which the Jorgensen case (or a parallel one) was fully described as to history, nature, and treatment, including surgery. Nevertheless, many physicians were critical of the use of any treatment other than psychotherapy in a condition apparently of a psychopathological nature. This was especially true of psychoanalysts. Other physicians, not too well versed in sex problems, confused transsexualism with homosexuality. "Oh, just another fairy," one commented to me when speaking of the Jorgensen case.
For a reasonably normal man or woman, it is almost inconceivable that anyone should
want to change the sex or gender into which he or she was born, especially by such radical
means as major surgery. Therefore, it is extremely difficult for a transsexual to find
understanding, sympathy and, most of all, empathy. Yet, so strong is the desire that
self-mutilations are no rarity, and how often a mysterious suicide is due to the utter
misery of a transsexual is anybodys guess.
Following the sensational Jorgensen publicity in 1952, I was asked to write an article on the subject for the now no longer existing International Journal of Sexology. In this article, which appeared in August 1953, 1 chose the term transsexualism for this almost unknown syndrome. I did the same in a lecture (as part of a symposium) at the New York Academy of Medicine, before the Association for the Advancement of Psychotherapy in December, 1953, discussing male transsexualism only. (The person so afflicted is best referred to as a "transsexual," a simpler term than "transsexualist," which is also used and which, unfortunately, I myself used in the beginning). Dr. Van Emde Boas of Amsterdam prefers to call such patients "transexists," which is shorter but a bit of a twister for the American tongue; and Dr. John Money of Johns Hopkins University has written aptly of "contra-sexism" which, however, ignores the transformation urge. Hamburger and his associates spoke of the transsexual urge as "genuine transvestism" or "eonism." The late Dr. David O. Cauldwell had, in 1949, described in Sexology Magazine  the strange case of a girl who wanted to be a man and called the condition "Psychopathia transsexualis." Dr. Daniel C. Brown speaks of transsexualism as a term related to "Sex role inversion," specifically meaning that this type of invert wants or receives surgical alteration of his genitals. He uses "inversion" as the widest term with transvestism, transsexualism, and homosexuality "expected to accompany most cases of inversion." So much for the terms and its synonyms.
The use of "transsexualism" (sometimes called "transsexuality")
seems to have caught on in the international medical literature of recent years. It is
applied to both sexes but until the much rarer female transsexual receives attention in a
separate chapter, the following will from now on deal with the male almost exclusively.
The relationship between transvestism (TVism) and transsexualism (TSism) deserves further scrutiny and reflection. Both can be considered symptoms or syndromes of the same underlying psychopathological condition, that of a sex or gender role disorientation and indecision. Transvestism is the minor though the more frequent, transsexualism the much more serious although rarer disorder.
Cross-dressing exists (with few exceptions) in practically all transsexuals, while
transsexual desires are not evident (although possibly latent) in most transvestites. It
seems to depend upon how deeply and for what congenital or acquired reasons the sex and
gender orientation is disturbed, whether the clinical picture of transvestism or
transsexualism will emerge. The picture of TSism may first appear to be merely TVism, but
whether this indicates a progressive character is by no means certain. (See chapter 4,
"The Male Transsexual").
In previous medical publications, I have divided all transvestites into three groups according to the clinical picture they presented. First there are those who merely want to "dress," go out "dressed," and to be accepted as women. They want to be allowed to do so. Their clash is with society and the law. Most of them feel, live, and work as men and lead normal, heterosexual lives, often as husbands and fathers.
Group 2 constitutes a more severe stage of an emotional disturbance. It could be interpreted as an intermediate stage between transvestism and transsexualism. These patients may waver in their emotions between the two. They need more than merely "dressing" to appease their psychological sex with its commanding and demanding female component. They want to experience some physical changes, bringing their bodies closer to that of the female, although they do shy away from surgery and the alteration of their genitalia. Such a desire, however, can play a part in their fantasies and daydreams. Like those of Group 1, for them the penis is still an organ of pleasure, in most cases for masturbation only. They crave some degree of gynecomastia (breast development) with the help of hormone medication, which affords them an enormous emotional relief. Psychotherapy is indicated but the patients frequently refuse it or fail to benefit from it. Their clash is not only with society and the law, but also with the medical profession. Relatively few doctors are familiar with their problems; most doctors do not know what to do for them except to reject them as patients or to send them to psychiatrists as "Mental cases."
This clash with society, the law, and the medical profession is still more pronounced and tragic in Group 3, which constitutes fully developed transsexualism. The transsexual shows a much greater degree of sex  and gender role disorientation and a much deeper emotional disturbance. To him, his sex organs are sources of disgust and hate. So are his male body forms, hair distribution, masculine habits, male dress, and male sexuality. He lives only for the day when his "female soul" is no longer being outraged by his male body, when he can function as a female - socially, legally, and sexually. In the meantime, he is often asexual or masturbates on occasion, imagining himself to be female.
This, very briefly, is the clinical picture of the three groups as they appeared to me originally during the observation of over two hundred such patients. More than half of them were diagnosed as transsexuals (TSs).
The above interpretation, that is to say, transvestism as the mildest and transsexualism as the most severe disturbance of sex and gender orientation, seems to be practical and to fit the facts. Lukianowicz  and Burchard, an English and a German psychiatrist, respectively, are in general agreement with this view. But there are other concepts that deserve consideration and should be outlined.
Some investigators believe that the two conditions, TVism and TSism, should be sharply separated, principally on the basis of their "sex feel" and their chosen sex partners (object choices). The transvestite - they say - is a man, feels himself to be one, is heterosexual, and merely wants to dress as a woman. The transsexual feels himself to be a woman ("trapped in a mans body") and is attracted to men. This makes him a homosexual provided his sex is diagnosed from the state of his body. But he, diagnosing himself in accordance with his female psychological sex, considers his sexual desire for a man to be heterosexual, that is, normal.
The choice of a sex partner is changeable. A number of transvestites are bisexual. As men, they can be attracted by women. When "dressed," they could be aroused by men. Chance meetings can be decisive. The statements of these patients cannot always be relied upon. They want to act within the conventions, or at least want to appear to do so. They may claim heterosexuality when actually they have more homosexual tendencies, which they suppress or simply do not admit. Some feel sufficiently guilty as TVs without wanting to confess to homosexual tendencies besides. Some do admit that heterosexual relations are possible with recourse to fantasies only. (In this way, transsexuals explain their marriages and parenthood and this explanation is most likely correct. )
When first interviewed, the patient may appear to be a TV of the first or second group. He often hesitates to reveal his wish for a sex change right away. Only after closer contact has been establisbed and confidence gained does the true nature of his deviation gradually emerge. Such seeming "progression" was observed in five or six out of my 152 transsexual patients, on whom I am reporting in this volume.
The opposite is rare but I have seen it happen. The apparent transvestite, or even
transsexual, under treatment or - more likely - through outside influence (meeting the
right girl) - turns toward heterosexuality and "normal" life. For how long is
always the question.
Coming back to the differences between transvestism and transsexualism., another simpler and more unifying concept and a corresponding definition may have to be considered. That is, that transvestites with their more or less pronounced sex and gender indecision may actually all be transsexuals, but in varying degrees of intensity.
A low degree of largely unconscious transsexualism can be appeased through cross-dressing and demands no other therapy for emotional comfort. These are transvestites (Group 1).
A medium degree of transsexualism makes greater demands in order to restore or maintain an emotional balance. The identification with the female cannot be satisfied by wearing her clothes alone. Some physical changes, especially breast development, are requirements for easing the emotional tension. Some of these pa
tients waver between transvestitic indulgences and transsexual demands for transformation (Group 2).
For patients of a high degree of transsexualism (the "true and full-fledged transsexual"), a conversion operation is the all-consuming urge, as mentioned earlier and as a later chapter will show still more fully. Cross-dressing is an insufficient help, as aspirin for a brain tumor headache would be (Group 3).
It must be left to further observations and investigations in greater depth to decide whether or not transvestitic desires may really be transsexual in nature and origin. Many probably are, but the frequent fetishistic transvestites may have to be excluded.
If these attempts to define and classify the transvestite and the transsexual appear vague and unsatisfactory, it is because a sharp and scientific separation of the two syndromes is not possible. We have as yet no objective diagnostic methods at our disposal to differentiate between the two. We - often - have to take the statement of an emotionally disturbed individual, whose attitude may change like a mood or who is inclined to tell the doctor what he believes the doctor wants to hear. Furthermore, nature does not abide by rigid systems. The vicissitudes of life and love cause ebbs and flows in the emotions so that fixed boundaries cannot be drawn.
It is true that the request for a conversion operation is typical only for the
transsexual and can actually serve as definition. It is also true that the transvestite
looks at his sex organ as an organ of pleasure, while the transsexual turns from it in
disgust. Yet, even this is not clearly defined in every instance and no two cases are ever
alike. An overlapping and blurring of types or groups is certainly frequent.
As a working hypothesis, but with good practical uses, the accompanying Table 1. should illustrate six different types of the transvestism-transsexualism syndrome as clinical observations seem to reveal them. While there are six types, there are seven categories listed on the scale, the first one describing the average, normal person. The seven categories were suggested by the Kinsey Scale (K.S.) and could be described as the Sex Orientation Scale (S.O.S.).
To remind the reader, the Kinsey Scale was introduced in Kinsey, Pomeroy, and Martins monumental Sexual Behavior in the Human Male  as an ingenious rating scale between hetero- and homosexuality, a continuum of human sexual behavior, allowing any number of intermediate stages between complete hetero- and complete homosexuality. The Kinsey Scale reduces them to seven, from zero to six. A zero would be an exclusively heterosexual man or woman, a six an equally exclusive homosexual. A three would be a bisexual person who can be sexually aroused, equally, by members of either sex. The other figures (one, two, four, and five) indicate and diagnose the respective intermediate stages.
The Sex Orientation Scale (S.O.S.) likewise lists seven categories or types (not necessarily stages), the zero, however, separately, as it would apply to any person of normal sex and gender orientation for whom ideas of "dressing" or sex change are completely foreign and definitely unpleasant, whether that person is hetero-, bi-, or homosexual. It must be emphasized again that the remaining six types are not and never can be sharply separated. The clinical pictures are approximations, schematized and idealized, so that the TV and TS who may look for himself among the types will find his own picture usually in between two recorded categories, his principal characteristics listed in both adjoining columns. Type I, Type II, and Type III would belong to the original Group 1. Type IV would be Group 2 and Types V and VI would equal Group 3, as the accompanying Table 2 shows.
The following chapters will make use of the types from I to VI in relating case histories and in establishing a diagnosis of the respective patients. Referring to Table i will then enable the reader to get a somewhat clearer picture of the particular individual and his or her problem. It should be noted again, however, that most patients would fall in between two types and may even have this or that symptom of still another type.
It has been the intention here to point out the possibility of several conceptions and classifications of the transvestitic and the transsexual phenomenon. Future studies and observations may decide which one is likely to come closest to the truth and in this way a possible understanding of the etiology may be gained. If this etiology should ever be established through future researches, classifications may have to be modified accordingly. In the meantime, the S.O.S. may serve a pragmatic and diagnostic purpose.
The term "homosexuality" has never impressed me as very fortunate. It indicates an exclusiveness and a finality that exists in only a relatively small group of men, those who are entirely homosexual. According to Kinsey, Pomeroy, and Martin, this group (the 6 on their rating scale) applies to not more than 4 per cent of the total male population.
To quote again from Sexual Behavior in the Human Male (page 652), "since only 50 per cent of the population is exclusively heterosexual throughout its adult life, and since only 4 per cent is exclusively homosexual throughout its life, it appears that nearly one half (46 per cent) of the population engages in both heterosexual and homosexual activities or reacts to persons of both sexes in the course of their adult lives."
If we allow ourselves the use of the term "bisexuality" in this 46 per cent, it is evident that the term homosexuality is applied much too often. The reason is that even one homosexual contact in a man's life, if it becomes known, all too often stamps him forever as a homosexual which, of course, he is not.
If, therefore, we restrict "homosexuality" and "homosexual" to only
the above 4 per cent, and otherwise speak merely of homosexual behavior, inclinations, and
more or less frequent activities, we come a little closer to the truth and are being, in
addition, more fair. In any event, let us remember that the great majority of all
so-called homosexuals are in reality bisexually oriented although they may live
exclusively homo- or heterosexual lives.
Furthermore, homosexual orientation may be a symptom, as are transvestism and transsexualism, with a variety of possible causes and inceptions. These causes and inceptions may be anchored in an inherited or congenital (constitutional) predisposition or they may be an acquired condition.
It is unfortunate in a way that the very descriptive term "intersexuality" is not used in this country except for hermaphroditic deformities, that is to say, for purely physical manifestations. Why it should not be used for psychosexual abnormalities too is not quite clear. But, making concessions to American science, "intersexuality" shall not be applied either to transvestism or transsexualism, nor to homosexuality.
The most evident distinction between these three disorders lies in the sex partner: for the present discussion, a male sex partner, his existence or nonexistence, and his significance. Homosexual activity is not feasible without him. He is a primary factor. The homosexual is a man and wants to be nothing else. He is merely aroused sexually by another man. Even if he is of the effeminate variety, he is still in harmony with his male sex and his masculine gender. The TV and the TS are not in such harmony. Besides, TVism (that is, cross-dressing) is a completely solitary act, requiring no partner at all for its enjoyment. In TSism the chief object is the sex transformation. A male sex partner may afterward be desired more or less urgently, but he is a secondary factor, often enough dispensable and by no means constant.
The sex relations of the male homosexual are those of man with man. The sex relations
of a male transsexual are those of a woman with a man, hindered only by the anatomical
structures that an operation is to alter. The sex relations of a transvestite are (in the
majority) those of heterosexual partners, the male, however, frequently assuming the
female position in coitus.
Transsexualism is a sex and gender problem, the transsexual being primarily concerned with his (or her) self only, a sex partner being of secondary although occasionally vital importance.
Transvestism is a social problem with a sex and gender implication, the transvestite requiring no sex partner (for his cross-dressing).
Neither the homosexual nor the bisexual is disoriented in his sex or gender role. Even those known as "queens," who are the effeminate type of homosexuals, as a rule "dress" for expediency without emotional necessity and have no desire to change their sex.
There are homosexuals who get an emotional satisfaction from cross-dressing. It would be a matter of semantics to consider them "homosexual transvestites" or "transvestitic homosexuals." They simply desire, for their sexual gratification, both cross-dressing and a partner of the same sex.
Daniel Brown  says "The criterion of homosexuality is simply sexual behavior involving individuals of the same sex, while the criterion of inversion [see previous explanation on page 14] is a personality in which the persons thinking, feeling, and acting are typical of the opposite sex."
Charles Prince, whom we will meet again in a later chapter, formed a theory as to the psychological inception of all three deviations. It concerns the childs identification with the wrong parent, particularly the boy with his mother or with another female. He says:
Those impressed with the sexual women are likely to express their feminity in sexual behavior and become homosexual; those fixed on the psychological aspect maintain that they are women in a male body and that they feel as women. They seek emasculatory surgery to bring the body in conformity with the psyche. They are the transsexuals. Finally, those who were set on the social aspects of women seek to emulate her in expressing their feminity, which means their clothing, adomment, hair-do, mannerisms, etc. This type becomes a transvestite.
From all that has been said, it seems evident that the question "Is the transsexual homosexual?" must be answered "yes" and " no." "Yes," if his anatomy is considered; "no" if his psyche is given preference.
What would be the situation after corrective surgery has been performed and the sex anatomy now resembles that of a woman? Is the "new woman" still a homosexual man? "Yes," if pedantry and technicalities prevail. "No" if reason and common sense are applied and if the respective patient is treated as an individual and not as a rubber stamp.
Again the thought clearly emerges that what we call "sex" is of a very dubious nature and has no accurate scientific meaning. Between "male" and "female," "sex" is a continuum with many "in betweens."
To bring the discussion regarding the three deviations of the title of this chapter to a close, a nutshell characterization would be this:
Footnotes Die Tranvestiten. Eine Untersuchung über den erotischen Verkleidungstrieb. Ferd. Spohr Verlag. 1925.
 In rare cases a structural abnormality is said to have been found when the abdominal cavity was opened, for instance, ovaries in males. Such a TS would then also be a pseudohermaphrodite.
 A few daring surgeons performed "conversion operations" thirty or forty years ago but with very doubtful if not unfavorable results. In most cases, they castrated or removed the penis only, without attempting to create a vagina (see case of Lilly Elbe, as described in Niels Hoyers Man into Woman, Dutton & Co., 1933).
 J.A.M.A., Vol. 152, May 30, 1953, pp. 391-396.
 Sexology, December 1949.
 "Transvestism and Sex Role Inversion," Chapter in The Encyclopedia of Sexual Behavior, Hawthorne Books, Inc., 1961.
 "Inversion and Homosexuality," Amer. J. Orthopsychiatry, Vol. 28, No. 2, April 1958.
 Published in the Amer. J. Psychotherapy. Vol. 28, No. 3, July 1964.
 Sex is a matter of anatomy and physiology. "Male" and "female" are sexual terms. Gender, however, can be considered a mixture of inborn and acquired, that is, learned characteristics. "Masculine" and "feminine" are therefore expressions belonging to the gender concept.
 Lukianowicz, D. D. P., "Survey of Various Aspects of Transvestism," J. Ner vous & Mental Diseases, Vol. 128, No. 1, January 1959.
 Burchard, J. M., Struktur und Soziologie des Transvestismus und Transsexualismus. F. Enke Verlag, 1961.
 W.B. Saunders Co., 1948.
 After having devised the first S.O.S. chart, it was shown to two of the most earnest students of the transvestitic problem, both transvestites themselves, and they formulated charts of their own. In one, seven types were likewise recognized and recorded as follows:
In the other chart, five groups of transvestites were classified and their prevalence estimated as follows:
An interesting and detailed description of the individual types or groups in these two charts may - it is to be hoped - find a place of publication elsewhere. An estimation such as this "from within" is certainly valuable to compare with my own S.O.S. derived strictly "from without."
 Brown, Daniel. Amer. J. Orthopsychiatry, April 1958.
 Taken from an abstract of "The Expression of Feminity in the Male," a lecture given before the SSSS, November 1963. See also C. V. Prince, "Homosexuality, Transvestism and Transsexualism," Amer. J. Psychotherapy, January 1957.
 See also the striking discussion with philosophical overtones in the chapter "The Complimentarity of Human Sexes," by G. B. Lal.