The Etiology of Transsexualism

• Genetic sources
• Endocrine sources
• Psychological causes

The causes of transsexualism and the possible sources from which the desire to change sex may spring are probably the most controversial, puzzling, and obscure parts of this book. There is so far only the very beginning of a type of scientific investigation that takes more than merely psychological aspects into consideration.
The possible origin of transsexualism is not discussed in the medical literature very often or in very much detail. Most frequently, there is the simple statement that the cause is unknown. Almost invariably, it is linked with that of transvestism and sometimes also with homosexuality, both giving rise to confusion.
The two principal theories are concerned either with possible organic, that is, biological (inborn) causes not necessarily inherited, or - much more often - with purely psychological ones.
Biologically minded authors are likely to consider TVism and TSism as "intersexual" phenomena but those are almost exclusively European scientists. American writers, as mentioned previously, reserve the term "intersexuality" exclusively for visible signs of disorders of sexual development, that is to say, for hermaphroditic and pseudo-hermaphroditic abnormalities. The Europeans, especially the Germans, use the term in a much wider sense, including not only transvestism and transsexualism as "intersexual" but also homosexuality. "Zwischenstufen" ("stages in between") was the term employed by Hirschfeld and his school.
Among the more modern writers, Helene Stourzh-Anderle, a Viennese physician, is outstanding with her remarkably erudite book, Sexual Constitution, Psychopathia, Criminality, Genius, published so far only in German.[1] As a clinician, she favors a biological approach without, however, minimizing the great contributions made by Freud and his school.
In her opinion, TVism, TSism, and homosexuality are intersexual manifestations that could be combined with infantile (subsexual) features. All are anchored in an inborn sexual constitution and are caused by a "disturbed chromosomal sex."
Here, mention should also be made of the researches of Schlegel [2] of Germany who found that "intersexual" types of men and women differed from normal types in the measurement of the pelvic outlet and also in the size and shape of their hands. Schlegel claims that in thousands of examinations, he has been able to prove this difference and therefore the existence of a constitutional factor in "intersexuality" to which - naturally - transvestism and transsexualism would belong.
In this country, psychology and psychoanalysis still dominate the field of sexual deviations. Many psychologists, particularly analysts, have little biological background and training. Some seem actually contemptuous of biological facts and persistently overstate psychological data, so much so that a distorted, one-sided picture of the problem under consideration results.
Psychiatrists with biological orientation strongly disagree and even decry the exclusive psychoanalytic interpretations. But their voice is heard too rarely.
Two possible biological sources of transsexualism (and - not to forget - this book occupies itself principally with this phenomenon) are the genetic and the endocrine.
  

Genetic sources

No genetic cause has as yet been proved for any transsexual manifestation. In a few rare cases of the Klinefelter syndrome, being complicated by transsexualism (or vice versa), the usual genetic fault was found, the patients showing 47 chromosomes (instead of the normal 46), with a chromosomal constellation of XXY instead of XY. At the same time, there were the usual clinical findings (see Chapters II and III). All transsexual patients without complicating disorders so far reported showed a normal chromosomal sex.
Let us remember, however, that genetics is still a young science and our investigating methods may still be rather crude, compared to possible future methods. At present we have hardly lifted a corner of the veil that hides the mystery. It would well behoove us, therefore, to keep an open mind, remembering also that negative findings in medicine mean little as compared to the positive. The absence of findings does not negate their possible existence.
A recent valuable article in the British Journal of Psychosomatic Research, [3] "Karyotyping of Transsexualists," by J. Hoenig and J. B. B. Torr, reports genetic studies on thirteen patients with transsexualism. The authors came to these conclusions: "None of the patients showed any signs of hermaphroditism or other physical abnormality. No chromosome abnormalities were found. These negative results do not exclude the possibility that chromosome abnormalities are associated with this condition."
Future investigations dealing with transvestism and transsexualism may incidentally supply valuable research data for the understanding of the nature of sex in general and may well clarify its riddle, correcting some of our present concepts.
We are still used to speaking of a "male" when there are (or were) testicles and a penis, and of a "female" when there are (or were) ovaries and a vagina. As we have seen, the geneticist has now added to our knowledge the "chromosomal sex," which is not always the same as the anatomical. How many unknown factors may still await elucidation, nobody can tell. Even the term "transsexualism" may prove to be inappropriate if it should ever be shown that an anatomically normal male transsexual may actually be a genetic female, or at least not a genetically normal male. In such event, we would be dealing with a transgenital desire instead of a transsexual.
In a recent important and learned treatise, A Periodic Table of Sexual Anomalies, the authors, Drs. M. M. Melicow and A. C. Uson, briefly discuss transsexualism to which, however, they still refer as (the better known) transvestism.[4] Speaking of the possible etiology, they say:

The cause of the sexual aberration is not known. One may postulate that there is a gene in the sex chromosomes which has to do with the identification and feel of maleness or femaleness and that this sex gene is intimately attached to Y chromosomes in males and to one (or both) of the X chromosomes in females. If the bond is broken up, then the sex identification gene, which ordinarily is intimately attached to the isosex differentiation gene, may become transposed and attach itself to the heterosex differentiation gene, resulting in a transvestite. (Iso-equal.)

A theory such as that would indeed explain much better than psychological "conditioning" the astonishing depth and the intensity with which a transsexual identifies with the opposite sex. Incidentally, it would also explain the resistance to treatment.

Per Anchersen, head of the department of psychiatry at the City Hospital of Oslo, Norway, briefly discusses etiology in his paper "Problems of Transvestism." [5]

He has himself examined six transsexuals to whom, however, he refers as "genuine transvestites," using Hamburger's terminology. He found no symptoms of "primary mental disease." He feels that bisexuality, some forms of homosexuality, and transvestism are "different stages along a line of sexual deviation."

Two of the transvestites were a monozygotic pair of twins. "From their early childhood they behaved like girls." After their sixteenth year, they "have been working separated in kitchens." . . . Both "stressed their aversions to homosexual men . . . " one of the twins urgently wished to change his sex, the other preferred to wait and see how his brother was going on . . . . "Intellectually both were retarded with an I.Q. of 74."

This seems so far the only case of identical twins among transsexuals reported in the medical literature. 1 have seen none among my own patients.

Anchersen quotes Kallmann from his studies of homosexual twins as follows: "In 40 monozygotic pairs of twins there was not only a complete concordance concerning the homosexuality as such. Even the development and the performance of the sexual activity were quite identical. . . . In many cases, the twins lived separated from their early childhood." [6]

Albert Ellis, the noted psychologist, disagrees and says:

If homosexuality is a directly inherited human trait, it could reasonably be expected that the fathers of homosexual twins would also, in a very high percentage of cases, have distinct homosexual histories. Since this was not found and since there is no other evidence showing that homosexuals have fathers, uncles, or other male relatives who, in a significantly high percentage of cases, also prove to be homosexual, it seems highly unlikely that true hereditary factors are directly involved in homosexuality. Congenital factors, possibly, but hardly hereditary ones. [7]

Per Anchersen himself concludes: "the homosexuality manifested in the genuine transvestite seems to belong to the constitutional form."
  

A possible endocrine cause of transsexualism has been investigated in a few cases with great thoroughness. Beyond a few suspicious findings, no definite proof has as yet been found. It may or may not have an endocrine significance that among my 152 male transsexuals, nearly 40 per cent were found to have more or less distinct signs of a degree of sexual underdevelopment (hypogonadism), as was mentioned previously. In such a condition, the pituitary as well as the gonads may be at fault with, of course, an inborn reason behind it.

A few years ago the American psychiatrist, Robert J. Stoller, and his collaborators [8] reported the case of an evidently transsexual man who had a typically feminine body build with feminine hair distribution, but with testes and a normal penis and without internal female organs as revealed through laparotomy. Nevertheless, there was "evidence of continuing estrogen influence from a source which has not been determined . . . The microscopic examination of testicular tissue has failed to reveal estrogenproducing cells."

Schwabe and his collaborators,[9] however, reported shortly afterward that in another, probably transsexual male, large amounts of estrogen (more than double the normal) were found in the testes. The hormone-producing Leydig cells were held responsible for this estrogen production.

More investigations have been made along these lines with negative or doubtful results and still more are in progress. It must not be forgotten that transsexual patients are not too frequent and that reliable scientific studies can be made only where the necessary facilities exist, that is to say, through hospitals, laboratories, and research institutes.

In recent years, evidence has accumulated that hormone medication during pregnancy can have serious consequences for the newborn. If the mother was given testosterone or progesterone for any length of time during her pregnancy (usually to prevent abortion), genital deformities of the newborn may result and have resulted if the genetic sex of the baby was female. Pseudohermaphroditism was the consequence.

Here, a thought is bound to occur: What if the fetus is a male? It is normally under the influence of the mother's female hormone (her estrogen) for nine months. Could that, under certain circumstances, interfere with the development so that the maleness of the newborn is repressed and a too feminine or underdeveloped infant is born? [10] Maybe the mother's progesterone and her small amounts of testosterone could, and probably normally do, act as a "brake," neutralizing the estrogen, or a metabolic conversion takes place automatically somewhere in the body. (Liver?) But maybe this does not always happen. Maybe an especially sensitive "sex center" in that small brain somehow becomes impaired in its development, either in its structure or in its chemistry, by the maternal estrogen. Could that explain why there are so many more male transsexuals, transvestites, and homosexuals than female?

A child's brain is different from an adult's. The brain waves of an encephalogram do not begin to show an adult pattern until the child is four years old or even older.[11] What may be harmless to an adult may be detrimental to the young child. For instance, estrogen.

The female transsexual naturally would need a different explanation, if the mother's endocrine status during pregnancy is being considered. Could an abnormal conversion of estrogen into testosterone take place so that a disturbed chemical mechanism underlies the biological one? Speculation may be allowed in an area that is still as obscure as that of gender disorientation from earliest childhood on. A new line of observation and investigation may have to be opened up.

Another interesting observation, neither genetic nor endocrine, but nevertheless organic, was made some years ago by three American public health physicians, Drs. E. G. Williams, J. D. Reichard, and M. Pescor.[12] It concerned the reaction of the nervous system to Prostigmin, a rather powerful drug that acts directly on the nerves.

Normal males and females react alike. So do homosexual males. The drug, however, had no affect at all on the nerves of "feminine men." According to the authors, this may indicate a possible inborn physical trait having to do with an enzyme that takes part in the chemical reaction through which nerves stimulate muscular action.

To the best of my knowledge, these experiments have not been repeated as yet and therefore no confirmation or elaboration of the observation is available. In the light of the following paragraphs, however, they seem to gain particular significance.

Related to the genetic as well as the endocrine possibilities of etiology is a most recent one, coming from Williarn C. Young [13] and his group at the Oregon Regional Primate Research Center. It may be termed the neural or cerebroneural one. The neural structures and brain centers are the "target," that is to say, receiving organs for hormonal influences. Their genetic quality can decide how these hormones may affect them.

The Oregon group, working largely with monkeys, point to the "mechanism of hormonal action in organizing the tissues of the central nervous system." They say, "Evidence has accumulated indicating that the gonadal hormones have a broad role in the determination of (sex) behavior" through their "differentiation or organization of neural tissues."

And so, after fifty years and more, the fundamental experiments of Eugen Steinach [14] of Vienna, who masculinized castrated females by implanting testicles and feminized castrated males through ovarian implants (and later female hormone injections) have found a modern substantiation, explanation, and elaboration.

Recent brain research has likewise revealed possible pertinent facts. A frontal lobotomy, for instance, severing connections between the cerebral cortex and certain parts of deeper, more primitive centers (of the limbic system) sometimes results in bizarre and uninhibited sexual behavior. On other occasions, in clinical work, for instance, the lobotomy eliminated such behavior.

With the help of exceedingly fine electrodes inserted into the brain structure, response to stimulation could be tested. Moving these electrodes only a fraction of a millimeter, either fear or anger or sexual excitation would be elicited.

The possibility of other organic causes may be thought of, such as early encephalitic infections or brain injuries at birth, but no evidence along such lines has as yet been found.

However, a report recently came from Dr. Roger A. Gorsky of the Brain Research Institute of the University of California at Los Angeles that may prove to be of greatest importance. Dr. Gorsky, as reported in Science Newsletter [15] found that at least a portion of the brain, known as the hypothalamus, is inherently feminine.

"Unless there is testicular tissue secreting testosterone during this period of development to organize this portion of the brain along masculine lines, it remains forever feminine."

Since the hypothalamus has much to do with the regulation of the pituitary function, secondary endocrine anomalies could well occur.

A psychic trauma, too, seems to have produced a period of transvestism. A case has been reported to me of a man who had never previously been a transvestite; but after the sudden death of his father, he turned to cross-dressing. After a few months, the desire disappeared as suddenly as it had started. It seems likely, however, that the tendency toward TVism existed as a latent or suppressed condition and the psychic shock merely "triggered" it into reality. Such a psychic mechanism may be operative to explain occasional actions of the "pseudo-transvestite" (Type I in S.O.S.).
  

Psychological causes

The possible psychological causes of transsexualism have received much more attention and also more endorsement than those that could be called "organic" (at least in the American literature). Among those causes, the phenomenon of imprinting should be mentioned first.

I M P R I N T I N G
This is a form of learning in earliest childhood, at a critical period of development, roughly between eighteen months and two and a half years. This theory is based on convincing experiments originally conducted and described by the Austrian zoologist, K. Z. Lorenz.[16] They may accidentally have a parallel in humans.

Green and Money [17] of Johns Hopkins School of Medicine have this to say:

Imprinting is triggered by a specific perceptual stimulus which can be varied within certain limits. Lorenz' classic experiment demonstrated that the mother-following reaction in newly-hatched mallard ducklings can be manipulated experimentally to become imprinted to any substitute object that has the correct height-width ratio and moves. When he squatted and substituted himself for the duckling's mother, the birds followed him, and only him, around with the same devotion they would otherwise exhibit for their own mother. Lorenz similarly imprinted newly hatched jackdaws and found that when these birds reached sexual maturity, they imprinted not another jackdaw but a human being as sexual partner, courting either Lorenz or some other person.

Green and Money then continue to draw these conclusions:

Aberrations of gender role may represent misprinting, so to speak, in which a more or less normal response, that of identifying with and impersonating a specific human being, becomes associated with the wrong perceptual stimulus. Among animals, good and poor imprinters can be bred. Perhaps, therefore, those human cases of gender role disorder which come to our attention are examples of people especially prone to fall victims of their particular environment.

The authors very clearly indicate here the possibility of an inherited predisposition for imprinting and naturally for its consequences. They found among their patients an "infrequency of forceful parental dominance in the household" and also "the relatively fragile body build of many of these boys."

This again combines imprinting, a psychological factor, with body build, a physical attribute.

The difficulty of proving (not only assuming), imprinting lies in the fact that parents may not remember the details in their households during the very early lives of their children and the patients themselves can hardly help. But their incongruous gender role is already recognizable when they are still very small.[18]

C H I L D H O O D C O N D I T I O N I N G
In the scientific literature, the psychologically harmful influences in childhood, so-called "conditioning," are the most frequently mentioned and most widely accepted causes of transvestism, transsexualism, as well as homosexuality.

Literally, or in substance, here are statements that were made to me by transsexual patients:

I know my parents were disappointed when I was born a boy. They were so much hoping for a girl.
My mother wanted me to be a girl and secretly dressed me as a girl and brought me up that way till I was old enough to go to school.

I am an only child and I was pampered by my parents. They let me play with the toys I wanted and they were the ones that girls prefer, like dolls, etc.

I was raised the only boy among five sisters and I was always envious of their nice dresses and wanted to be like them.

My parents were divorced when I was very young and I hardly knew my father. My mother raised me. . . .

My parents died when I was very young and my grandparents raised me and let me have my own way.

I remember, my mother occasionally punished me for something I had done by making me wear my sister's dress to humiliate me.

I was never a "real boy" and my father wanted to make me one. He hated me for my lack of masculinity and showed me his dislike. He always preferred my sister and gave her all she wanted. I envied her. I hated my father and I still hate him.

Many similar early histories of transsexuals as well as of transvestites could be gleaned from the literature and certainly from my private correspondence. (See also the case histories in R. E. L. Masters' chapter). Lukianowicz [19] in his comprehensive survey not only relates some of his own observations, but quotes at length those of other authors. The possibility should, however, not be overlooked, that some of these patients may prefer such explanation to an inborn one and therefore allow a wish to be the father of their thought.

Buchner found among his 262 TVs (with a small but unknown percentage of TSs) the following:

These figures are based on the first eighteen years of life. Taking a more vital earlier period, conditioning may be much more important. "Janet Thompson" says: "It seems evident to me that the inception of TVism falls in the one- to five-year-old period of the child' s life as a result of faulty, incomplete, or distorted sex identification."

There can be no doubt that unfavorable early childhood experiences can constitute truly corrosive emotional traumata. That can neither be denied nor minimized. Yet, for the sake of scientific objectivity, it should be repeated here that many similar histories from the first few years of life can be elicited from persons who grew into perfectly normal adulthood later on. Those histories rarely become known, simply because "normal," well-adjusted men and women do not go to psychologists as a rule and one would have to look among one's friends and acquaintances for examples. With a little effort, they would be readily available.

We all know men who lost their fathers at an early age, devoted their lives for years and years to their mothers, and by all psychoanalytic theories should have become homosexuals, transvestites, or transsexuals. But they did not. They had girl friends off and on and married as soon as the mother had passed away. It seems to me that conditioning cannot be the whole story. Unless there is a constitutional weakness, conditioning won't "take."

Around the turn of the century, it was widely customary to raise boys almost the same as girls. They kept their long curls and wore dresses till they were five or six, that is to say, during rather critical years. Winston Churchill was one of those children, according to early pictures of him. Were there more transvestites, and the like then than there are now? Certainly not.

A question of cause and effect should be raised in this connection. Could it not be that a constitutionally rather feminine-looking boy "conditioned" his parents so that they were inclined to forget about the tiny sex organs and reared him as a girl until it was time to send him to school? Especially if they had hoped for a girl?

" He always looked and behaved more like a girl than a boy," is the explanation that parents gave to me to justify their errors.

Whenever "conditioning" went against a healthy boy's true nature, no harm was done. As soon as he was old enough, he would rebel against the girl's dresses, because he wanted to be like all the other boys. But when the false upbringing harmonized with a constitution of a high feminine component, then it was a different story. Then the ground could have been laid for a future sex and gender disharmony.

In one case that I observed some years ago, a kind of reverse situation actually seemed to exist. The parents were very glad to have the boy that was born to them, but at the age of three or four the child became very unhappy and difficult and wanted to be dressed and treated "like all other girls." The parents and two older sisters fought for a son and a brother, but finally had to give in to keep the peace. They allowed the little boy to wear girl's dresses, but insisted on a regular boy's haircut. These constituted the most distressing moments in the boy's life.

Finally, he had to go to school as a boy and grew up into an extremely feminine-looking transsexual and transvestite. Desperately clamoring to have a conversion operation performed, he was studied by two groups of psychiatrists at the University of ______. One group recommended the operation as the only way to protect the patient's sanity. The other group advised against it, because they considered it unlikely that it would solve the underlying psychological problems. Psychotherapy was attempted for a short time, but failed, perhaps owing to the patient's lack of cooperation. With financial help from the mother who was sympathetic toward a change, the patient at last went abroad and succeeded in realizing his life's ambition. The operation was performed, but only partially so. For unknown reasons, no vagina was constructed at that time.

In spite of that defect, the patient seemed more contented and emotionally better balanced when I saw him several weeks after the operation: better, at least, than on a visit to my office two years prior. He went to work as a woman, but the desire to become more complete never left him. After another two years, he returned to Europe for his vaginal plastic. The last I heard was that the operation was not successful because a fistula formed between the artificial vagina and the rectum. A further operation, however, may in the meantime have corrected this condition.

In any event, this case seems to prove that an unknown constitutional factor was at the bottom of the gender disorientation and that "conditioning" evidently played no part in this instance.

As reported in a lecture at the Albert Einstein College of Medicine (Jacobi Hospital) in April 1964, in 122 cases of male transsexualism among my own patients, conditioning in childhood could be shown in twenty-five cases (20 per cent). To this figure we may possibly add thirty-two doubtful cases (26 per cent). In 64 cases (56 per cent), no evidence of conditioning could be found. (In three cases, the early history was unknown.)

C. V. Prince, editor of Transvestia, also investigated the probable frequency of conditioning by sending out questionnaires to 166 known transvestites, containing an unknown but small number of transsexuals. Conditioning was reported in "fewer than 20 per cent," according to Prince, who published his findings in Sexology Magazine.[20]

More recently, H. Taylor Buchner, from the Survey Research Center of the University of California, who had sent out a quesionnaire to 262 subscribers of Transvestia (mostly transvestites) reported the following data as far as the problem of conditioning is concerned:

Summarizing my impression, I would like to repeat here what I said in my first lecture on the subject more than ten years ago:

Our genetic and endocrine equipment constitutes either an unresponsive, sterile, or a more or less responsive, that is to say, fertile soil on which the wrong conditioning and a psychic trauma can grow and develop into such a basic conflict that subsequently a deviation like transsexualism can result.

To express it differently, our organic sexual constitution, that is to say, the chromosomal sex, supported and maintained by the endocrine, form the substance and the material that make up our sexuality. Psychological conditioning in early life would determine its final shape and individual function. The substance is largely inaccessible to treatment. The function alone would be the domain of psychotherapy.
  

Footnotes

[1] Stourzh-Anderle, Helene, Sexuelle Konstitution, 1955, Verlag f. Medizinische Wissenschaften, Wien-Bonn.

[2] Schlegel, W. S., Die Sexualinstinkte des Menschen, Ruetten und Loening Verlag, Hamburg, 1962.

[3] 1964, Vol. 8, pp. 157-159. Pergamon Press, Ltd.

[4] J. Urology, Vol. 91, No. 4, April 1964.

[5] Ancherson, Per, "Problems of Transvestism," Acta Psych. et Neurol. Scandin.,Suppl. 106, 1956, p. 249.

[6] Kallmann, F. J., Amer. J. Human Genetics, 1952, IV, pp. 136-146.

[7] Ellis, Albert, Advances in Sex Research, Hoeber Medical Division, Harper and Row, 1963, p. 164.

[8] Stoller, R. J., Garfinkel, H., and Rosen, A. C., "Passing and the Maintenance of Sexual Identification in an Intersexed Patient." A.M.A. Archives General Psychiatry, Vol. 2, April 1960, pp. 379-384.

[9] Schwabe, A. D., et al., Pubertal Feminization in a Genetic Male with Testicular Atrophy and Normal Urinary Gonadotropin," J. Clinical Endocrinology and Metabolism, Vol. 22, August 1962, pp. 839-845.

[10] A feminizing influence of estrogen has been demonstrated when a mother, soon after her confinement, began taking birth control pills (which contain estrogen) and at the same time, breast-fed her baby. Enough estrogen entered her milk to produce enlargement of the baby's breasts.

[11] Rudolf Engel, J. Lancet, Vol. 81, 1961, p. 523.

[12] "Homosexuality: A Biological Anomaly," J. Nervous & Mental Diseases, Vol. 99, No. 65, January 1944.

[13] Young, William C., Goy, Robert W., Phoenix, Charles H., "Hormones and Sexual Behavior," Science, Vol. 143, No. 3603, January 17, 1964.

[14] Steinach, Eugen, Sex and Life, Viking Press, New York, 1940.

[15] Science Newsletter, August 28, 1965.

[16] Lorenz, K. Z., King Solomon’s Ring. New Light on Animal Ways. The Thomas Y. Crowell Co., New York, 1952.

[17] Green, R., and Money, J., "Effeminacy in Prepubertal Boys. Summary of 11 Cases," Pediatrics, Vol. 27, No. 2, February 1961.

[18] Money, J., Hampson, J. G., and Hampson, J. L., "Imprinting and the Establishment of Gender Role," Archives Neurology and Psychiatry, Vol. 77,1957, p. 333.

[19] Lukianowicz, D. P. M., "Survey of Various Aspects of Transvestism," J. Nervous & Mental Diseases, Vol. 128, No. 1, January 1959.

[20] Prince, C. V., "166 Men in Dresses," Sexology Magazine, March 1962, pp. 520-525.