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 I
THE HYPOTHESIS
 1

BISEXUALITY:
THE ‘BEDROCK’ OF MASCULINITY
AND FEMININITY

Freud’s Writings on Bisexuality

Of the several fundamental biological questions that Freud found crucial,
none played a more central—or fascinating— role for him than that of
biological bisexuality.* It is worth our tracing his thinking in this regard
now, over seventy years later, not only to review his theories but to see
how they accord with recent studies in neurophysiology.
We start back at the origins of psychoanalysis and Freud’s relationship
with Fliess. Impressed by recent findings that the sexual apparatuses start
with undifferentiated fetal anlagen, which, even after adult differentiation
retain vestiges of the other sex, Freud was captivated with his friend’s
speculations. We need not review Fliess’ bizarre notions about 28 (a
periodic number controlling the fate of females) or 23 (that of males). We
can, however, briefly note the position that formed the intellectual basis of
their friendship. Here Fliess speaks: ‘Consideration of these two groups of
biological phenomena points to the conclusion that they have a solid inner
connection with both male and female sexual characteristics. And if both
—only with different emphasis—are present both in man and woman, that
is only consistent with our bisexual constitution.’

* ‘Bisexuality’ is used several ways in the literature: overt homosexuality; pleasure

in both homosexual and heterosexual intercourse; identification with aspects of the
opposite sex; cross-gender non-intercourse behavior, such as effeminacy; friendship;
the capacity of certain cells and tissues to shift appearance and/or function from that
typical of one sex to the other; embryological undifferentiation; vestigial tissues of
the opposite sex in the adult; an innate ‘force’ that can influence behavior toward that
of the opposite sex. In this chapter I shall use the term only with biological
connotations.
8 THE TRANSSEXUAL EXPERIMENT

(1, p. 7; see also Kris’ remarks, pp. 38-43; letters 52, 63, 75, 113).
From the letters to Fliess until the end of his life, Freud repeated his
conviction that bisexuality was a fundamental element in human
psychology, normal and abnormal,* considering it rather as a fracture line
predisposing humans to disorder. In many papers, sensing the absence of
new data from the biologists†, he simply noted its importance‡ (2-4, 6-14,
16, 18, 20, 21, 23, 24). In these papers, he handles the subject with little
more than a phrase: ‘bisexual constitution’, ‘bisexual disposition’,
‘bisexual organisation’, ‘innate bisexual constitution’, ‘cross inheritance’,
indicating the subject is a given almost to be taken for granted. In-other
works, it is considered in more depth (5, 15, 17, 19, 22, 25, 26-28) and
becomes a central conceptual piece.
His most extensive discussion of bisexuality occurs in Three Essays on
Sexuality, even a reading of only the footnote changes of each edition
gives one a historical view of the focal importance of bisexuality in his
theory-making. Above all, what remained constant was his belief that
biological forces, still poorly understood, underlay behavior.
Since I have become acquainted with the notion of bisexuality I regarded
it as the decisive factor, and without taking bisexuality into account I think it
would scarcely be possible to arrive at an understanding of the sexual
manifestations that are actually to be observed in men and women (5, p. 220).
[However, he adds later:] It is not possible to adopt the view that the form to
be taken by sexual life is unambiguously decided, once and for all, with the
inception of the different components of the sexual constitution. On the
contrary, the determining process continues (5, p. 237) . . . The constitutional
factor must await experiences before it can make itself felt; the accidental
factor must have a constitutional basis in order to come into operation. To
cover the majority of cases we can picture what has been described as a
‘complemental series’, in which the

* e.g. ‘bisexuality ... is present, as we believe, in the innate disposition of human

beings’. (25, p. 227)
† e.g. ‘We do not know in what that [bisexual] disposition consists, beyond
anatomical structure’. (5, p. 144)
‡ e.g. ‘Recognition of the organic factor in homosexuality does not relieve us of the
obligation of studying the psychical processes connected with its origin’. (18, p. 230)
 BISEXUALITY 9

diminishing intensity of one factor is balanced by the increasing intensity of

the other; there is, however, no reason to deny the existence of extreme cases
at the two ends of the series (5, p. 239-40).
From then on, whenever Freud takes up bisexuality extensively, its
existence as a biological force is accepted as proven, and it is used simply
to fill out an argument. Thus, in ‘A Child is Being Beaten’, he counters
both Fliess’ idea that the repressed (Ucs) is the ‘mental representation of
the subordinate sex’ (15, p. 200) and Adler’s that:
Every individual makes efforts not to remain on the inferior ‘feminine
line’ [of development] and struggles toward the ‘masculine line’ from which
satisfaction can alone be derived (15, p. 201).
He ends his discussion by saying:
In the last resort we can only see that both in male and female individuals
masculine as well as feminine instinctual impulses are found, and that each
can equally well undergo repression and so become unconscious (15, p. 202).
In ‘A Case of Homosexuality in a Woman’, the biological is again
introduced:
It is not for psycho-analysis to solve the problem of homosexuality. It must
rest content with disclosing the psychical mechanisms that resulted in
determining the object-choice, and with tracing back the paths from them to
the instinctual dispositions. There its work ends, and it leaves the rest to
biological research. . . . Psycho-analysis has a common basis with biology, in
that it presupposes an original bisexuality in human beings (as in animals).
But psycho-analysis cannot elucidate the intrinsic nature of what in
conventional or in biological phraseology is termed ‘masculine’ and
‘feminine’: it simply takes over the two concepts and makes them the
foundation of its work (17, p. 171).
Then, in The Ego and the Id, bisexuality enters into an elucidation of the
oedipal conflict:
It would appear, therefore, that in both sexes the relative strength of the
masculine and feminine dispositions is what determines whether the outcome
of the Oedipus situation shall be an identification with the father or with the
mother. This is one of the ways in which bisexuality takes a hand in the
subsequent vicissitudes of the Oedipus complex. The other way is even more
important. For one gets an
10 THE TRANSSEXUAL EXPERIMENT

impression that the simple Oedipus complex is by no means its commonest

form, but rather represents a simplification or schematization which, to be
sure, is often enough justified for practical purposes. Closer study usually
discloses the more complete Oedipus complex, which is twofold, positive and
negative, and is due to the bisexuality originally present in children: that is to
say, a boy has not merely an ambivalent attitude towards his father and an
affectionate object-choice towards his mother, but at the same time he also
behaves like a girl and displays an affectionate feminine attitude to his father
and a corresponding jealousy and hostility towards his mother. It is this
complicating element introduced by bisexuality that makes it so difficult to
obtain a clear view of the facts in connection with the earliest object-choices
and identifications, and still more difficult to describe them intelligibly. It
may even be that the ambivalence displayed in the relations to the parents
should be attributed entirely to bisexuality and that it is not, as I have
represented above, developed out of identification in consequence of rivalry
(19, p. 33).
In several later papers, Freud used the concept of bisexuality at length,
but for only two arguments: (1) to express the belief —a wavering one—
that male and masculine equals active and female and feminine equals
passive (22, 26, 27); and (2) the belief that women are innately inferior, by
which he meant, in part, more bisexual than men (25).
Finally, in ‘Analysis Terminable and Interminable’ Freud summed up
this lifetime of thought on biological forces underlying masculinity and
feminity:
We often have the impression that with the wish for a penis [in females]
and the masculine protest [in males] we have penetrated through all the
psychological strata and have reached bedrock, and that thus our activities are
at an end. This is probably true, since, for the psychical field, the biological
field does in fact play the part of the underlying bedrock (28, p. 252).
Tracing Freud’s thinking regarding this ‘bedrock’ (bisexuality) from the
time of his relationship with Fliess to ‘Analysis Terminable and
Interminable’, one can see the following: (1) from beginning to end
biological bisexuality is an essential building block for theory—fixed and
unchanging in his mind; (2) he recognized that the evidence for this
bisexuality was sparse and that little new was being added in the over 40
years he used this crucial concept; (3) it was not a very
 BISEXUALITY 11

fruitful concept in the sense that it led to great new insights. (This is
decidedly not to say that it was therefore unimportant to him—or to us.)

Freud, then, always believed in a constitutional bisexuality that influenced

object choice and the degree of a person’s masculinity and femininity; this
bisexuality produced a resistance in each sex that was ultimately beyond
the reach of analysis because of its biological origin.
Now let us consider this possibility: What Freud thought was an
elemental quality, ‘masculine protest’ or ‘repudiation of femininity’ in
men, rather than reflecting a biological force, is a quite non-biological
defensive maneuver against an earlier stage: closeness and primitive
identification with mother. Comparably in females, earlier than penis envy
in little girls is a stage of primary femininity. The biological lies deeper
still.
Actually, Freud gives us no evidence that repudiation of femininity in
males or the wish for a penis in females has a biological origin. It is rather
a belief based on his finding these conditions ubiquitous and on his
difficulty in removing them by analysis. (Often, when confronted with a
ubiquitous or unanalysable quality in humans, he fell back on the
‘metabiological’, e.g. Lamarckian genetic residues of the ice age as a cause
of the ‘biphasic’ nature of sexual development; entropy and death instinct
to explain negative therapeutic reaction or masochism; masculine equals
active and feminine equals passive because sperm are active and ova wait.)
By now, we may suspect that important aspects of character structure are
permanently fixed very early in life, not by innate factors but by the
impingements of the care-taking human environment, as Freud showed in
his psychological work in contrast to his ‘biological’ theories. The
evidence for this is overwhelming in lower animals: remember Harlow’s
monkeys, the work of ethologists, or the multitude of conditioning
experiments. But more specifically, it is likely that in humans, masculinity
and femininity can be permanently established in earliest life by
psychological forces in opposition to biological state. The following
findings suggest this:

(1) Infants noted at birth to be hermaphroditic go on to

12 THE TRANSSEXUAL EXPERIMENT

develop a ‘hermaphroditic identity’ (believing throughout their lives that

they are neither male nor female or that they are both), whenever their
parents are uncertain about the sex to which the child should be assigned.
However, when the parents do not have this doubt, even in the face of
ambiguous genitals, the child has no question he is a male, if the
assignment was to the male sex, or a female, if the assignment was to the
female sex. This occurs regardless of the biological abnormalities present,
even hidden chromosomal, gonadal, or hormonal defects (29-31).*
(2) Transsexual males, as the result of post-natal events—a specific
family constellation—have an almost complete reversal of masculinity and
femininity, acting like normal women and requesting that their bodies be
changed to female; yet they are without biological abnormality (31).
(3) Fetishistic cross-dressers (31) and certain effeminate homosexuals
(32, 33) as a result of specific attitudes and behavior in their mothers and
fathers, develop mixtures of masculine and feminine or effeminate
behavior as defensive maneuvers to protect their threatened masculinity
(castration anxiety).
These cases are all examples of what Freud called ‘the accidental
factor’ (5). Regression based on futility, it seems to me, made him decide
accidental factors could not sufficiently account for those almost universal
conditions: repudiation of femininity and the wish for a penis. Might not
the former also result from, for instance, the need to escape from primal
identification with mother’s body and feminine behavior (31) and the latter
from lessons in inadequacy taught by mother (adopting her sense of
feeling inferior) and society† ? If boys, in the intimacy of the normal
infant-mother symbiosis, identify with their mothers, and if excessive and
prolonged blissful closeness produces extreme femininity in boys (31), the
boy who is to become masculine will have to repudiate that femininity. But
then the femininity (feminine identification) is there not because it is part
of mankind’s biological inheritance but rather because all boys have
females for mothers.

* An exception to this finding is noted briefly below, and more extensively in

Chapter 10: certain congenitally hypogonadal males.
† See Millet (35) for a recent and extensive criticism of Freud’s views on
femininity.
 BISEXUALITY 13

In addition, observation of children just does not reveal that ‘both sexes
seem to pass through the early phases of libidinal development in the same
manner. . . . We are now obliged to recognize that the little girl is a little
man’ (26, pp. 117-18). Instead, we all have seen girls already feminine
between 1-2 years (e.g. 34).
The New Physiology of
Masculine and Feminine Behavior
Few new physiological data have been incorporated into analytic writings
since Freud’s death, only agreements or disagreements with or
permutations on theory (e.g. 32, 33, 36-40). Especially in the last decade,
however, controlled experiments on animals and ‘natural experiments’ in
humans have suggested that we shall soon know more about biological
influences on masculinity and femininity.*
(a) Controlled Experiments on Laboratory Animals
Brain physiologists are beginning to find the central mechanisms of
behavior in animals, including those of masculinity and femininity. This, it
seems, is the breakthrough; formerly mysterious forces are found to be
made up of hierarchies from components in the brain, influenced by
hormones, internal and external perceptual inputs, other brain centers,
chains of releasing mechanisms, ‘engrams’ of previous experience, and
new—psychological—experience. Interestingly, it appears that, as with the
anlagen for the sexual organs and their related apparatuses (47)†, the
resting state for the central mechanisms of gender‡ is female. Only if the
fetal brain (hypothalamus) is organized

* The upsurge had its precursors among brain researchers (e.g. 41-43), observers of
bisexual manifestations in natural behavior (e.g. 44, 45, for review), discovery of the
chemical similarities between male and female hormones (e.g. 46), and the
endocrinologists’ knowledge that many male tissues respond to female hormones
(e.g. breasts, skin, hair, fat) and vice versa with female tissue and male hormones.
† And possibly even the chromosomes. Some suggest that the Y chromosome, the
so-called male chromosome, is simply a defective X chromosome, a late mutant in
evolutionary history (48).
‡ ‘Gender’, i.e. masculine and feminine behavior as contrasted with ‘sex’, i.e. male
and female (31).
14 THE TRANSSEXUAL EXPERIMENT

by androgen does masculine behavior result (e.g. 49-62). And, if normally

occurring androgens are blocked in the male, then once again femininity
appears. Apparently the brain makes do with one type of anatomic system:
if it is activated with androgens, it is the ‘bedrock’ of masculinity; without
activation, it will subserve femininity.
The genital anatomic fact is that, embryologically speaking, the penis is
a masculinized clitoris; the neurophysiological fact is that the male brain is
an androgenized female brain.*
There are critical (sensitive) periods when the brain is most susceptible
to the influences of fetal sex hormones that organize subsequent tendencies
toward masculine or feminine (not just reproductive) behavior. The period
of greatest sensitivity to such hormones varies from species to species,
some just after and some just before birth, but is rather invariant for
individuals of both sexes within the species. The power of the critical
period is so great that a single pulse of hormone in the laboratory may set
for life the gender behavior as masculine or feminine (without there being
any anatomic change in the body, for by this time the development of the
reproductive anatomy is complete [e.g. 43, 53, 56, 59-61]
(b) ‘Natural Experiments’ in Humans
I have used the vague term ‘biological force’ to indicate a belief in
biological mechanisms that might influence the development and control
of masculinity and femininity (31). Such an influence has its final common
pathway, at least in lower animals, in the brain, where electrochemical
impulses become drive and action. But what of humans?
The following categories, for which we are indebted to Money and his
colleagues in particular, are ‘natural experiments’ which suggest that
similar forces are at work in humans.

* Women’s liberation activists and other metapsychological romantics can make of

this what they like, but what they make is, as I believe was true of Freud when he
came to the opposite conclusion that women are innately inferior to men, related to
science as daydreams are to reality.
 BISEXUALITY 15

(a) Feminization
i. Chromosomal abnormality: XO (Turner's Syndrome)*
Although these individuals are missing a second chromosome and have
no gonads to produce sex hormones, anatomic development is nonetheless
in the female direction. In addition, such patients grow up feminine in
behavior and heterosexual in object choice (63, 64, 31).
ii. Androgen insensitivity (testicular feminization) syndrome*
With male (XY) chromosomes, the subject nonetheless develops to
adulthood as a normal-appearing female. It is probable that the hormonal
defect is in the target organs (the gonads and extra-gonadal tissues) which,
abnormally, fail to respond to circulating andogens (46). Subjects are
feminine and heterosexual (65).

iii. Constitutional male hypogonadism

These males, who appeared physically normal at birth, are discovered in
adolescence or later to have testes markedly deficient in androgen
production since fetal life. An unusually large number from early
childhood on are feminine and state in words and behavior that they
believe they really should be girls (66, 31).

iv. Temporal lobe disorder

A number of reports (reviewed in 67) implicate paroxysmal temporal
lobe disorder with cross-gender behavior, oddly enough, only in males.
The behavior (usually, dressing in clothes of the opposite sex) comes on
with the paroxysmal electrical burst; remission of the disorder with
treatment leads to immediate loss of the bisexual behavior.

* These two categories are not as yet highly suggestive. We need more information
before we can decide if the adult femininity in these patients is related to their
unandrogenized brains or simply to their having been raised from birth unequivocally
as girls (see p. 12 above, ‘hermaphroditic identity’).
16 THE TRANSSEXUAL EXPERIMENT

(b) Masculinization
i. Progesterone effects
Otherwise normal human females were masculinized in utero by large
doses of progesterone given to their mothers to prevent spontaneous
abortion. In addition to masculinized genitals (hermaphroditism) these
little girls have developed into tomboys (masculine in behavior but
heterosexual in object choice) more than a control series (68, 69).
ii. Adrenogenital syndrome
Fetal hyperadrenalism causes masculinization of the external genitals in
females. Money, who has always reported these girls to be normally
feminine if properly diagnosed and raised as females (29, 30) now thinks
they are ‘tomboyish’, though heterosexual (69).
These human ‘experiments’ are much less indicative of a biological
bisexuality that can guide behavior than is the animal work. They are
suggestive, but they do not yet refute the evidence that post-natal effects in
humans can quite overturn the biological (except, again, with hypogonadal
males). Similarly, a body of work on genetics has tried to link overt
homosexuality with inherited factors (e.g. 70-72). These studies cannot be
adequately evaluated (38, 73).

I believe Freud was wrong in saying that the etiology of both repudiation
of femininity and the wish for a penis was biological. But his conviction
that there were physiological mechanisms that could influence either
masculine and feminine behavior in the same person (bisexuality) has
support in hundreds of studies of animals, though the necessary studies of
humans are as yet only weakly supportive.
The details of physiology certainly make for more sophisticated
discussion now than in Freud’s time. They also suggest errors by Freud.
His insistence on taking the biological into account, has not, however, been
proven wrong. In the case of bisexuality, we can see that the brain is not
the tabula rasa that some allege it to be. While the newborn presents a
most malleable CNS upon which the environment writes, we cannot say
 BISEXUALITY 17

that the CNS is neutral or neuter. Rather, we can say that the effects of
these biological systems, organized prenatally in a masculine or feminine
direction, are almost always* too gentle in humans to withstand the more
powerful forces of environment in human development, the first and most
profound of which is mothering.
Freud recognized the dangers of biologizing and his own propensities
therein: ‘I regard it as a methodological error to seize upon a phylogenetic
explanation before the ontogenetic possibilities have been exhausted.’†
Even Fliess’ excesses, however, could not quite cool his own similar
tendency (as we see in the just-quoted footnote paragraph), probably just
as much a contribution to their friendship early as to their breaking off
later. It is so often around biological words that battles in psychoanalysis
have been fought: e.g. the stages of libidinal development as the origins of
specific neuroses; the death instinct; Lamarckian inheritance; libido versus
a neutral psychic energy.
But each example is only a particular case, as is bisexuality, of one of
Freud’s main philosophic concerns: the relation between the biological and
psychological. A great pitfall, so seductive for many of us, is the premature
linkage of the two.

* See footnote page 12.

† The full paragraph is worth noting; it biologizes: ‘All that we find in the

prehistory of neuroses is that a child catches hold of this phylogenetic experience

where his own experience fails him. He fills in the gaps in individual truth with
prehistoric truth; he replaces occurrences in his own life by occurrences in the life of
his ancestors. I fully agree with Jung in recognizing the existence of this phylogenetic
heritage; but I regard it as a methodological error to seize upon a phylogenetic
explanation before the ontogenetic possibilities have been exhausted. I cannot see any
reason for obstinately disputing the importance of infantile prehistory while at the
same time freely acknowledging the importance of ancestral prehistory. Nor can I
overlook the fact that phylogenetic motives and productions themselves stand in need
of elucidation, and that in quite a number of instances this is afforded by factors in
the childhood of the individual. And, finally, I cannot feel surprised that what was
originally produced by certain circumstances in prehistoric times and was then
transmitted in the shape of a predisposition to its re-acquirement should, since the
same circumstances persist, emerge once more as a concrete event in the experience
of the individual.’ (14, p. 97) Anyone who can set up the experiments that
demonstrate scientifically what Freud and Jung take for granted—phylogenetic
memory of psychological events—will be a quite sensational genius.
18 THE TRANSSEXUAL EXPERIMENT

There not being enough facts yet, one is tempted to bridge the gap with
grand theories or words that concretize concepts into ‘facts’. Freud
recognized this and was constantly struggling against his (repudiated)
enthusiasm to be a philosopher, so as, in Kris’ words, to ‘succeed in
establishing the distance between the physiological and psychological
approaches’ (1, p. 44). Happily, unlike his colleagues-become-enemies, he
never quite succumbed to the seduction of the one grand answer. Always
after the flight, he backed off, expressed his uncertainty, softened his
syntax, and declared the necessary data were still missing. That is why he
contrasts markedly with the pyrotechnicians who have been so attracted to
him.
The last words of the Three Essays on Sexuality, still valid, reveal
Freud’s sense:
The unsatisfactory conclusion, however, that emerges from these
investigations of the disturbances of sexual life is that we know far too little
of the biological processes constituting the essence of sexuality to be able to
construct from our fragmentary information a theory adequate to the
understanding alike of normal and of pathological conditions (5, p. 243).
 Chapter I

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*S.E.—Standard Edition of the Complete Psychological Works of Sigmund Freud

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