Cross-Gender Identity in a Broader Context. In: Steiner BW, editor. Gender Dysphoria. Boston: Springer US; 1985. pp. 259-324. [DOI: 10.1007/978-1-4684-4784-2_9]

Societal individualism predicts prevalence of nonhomosexual orientation in male-to-female transsexualism

There are two distinct subtypes of male-to-female (MtF) transsexuals: homosexual and nonhomosexual. The relative prevalence of these two subtypes varies dramatically between countries, but no explanation of this variability has yet been proposed. This study examined the hypothesis that the prevalence of nonhomosexual MtF transsexualism, relative to homosexual MtF transsexualism, would be higher in individualistic countries than in collectivistic countries. I analyzed data from 22 studies of MtF transsexualism, conducted in 16 countries, examining the association between percentage of nonhomosexual participants and Hofstede's (Culture's consequences: Comparing values, behaviors, institutions, and organizations across nations, 2001) Individualism Index (IDV). IDV accounted for 77% of observed variance in the percentage of nonhomosexual MtF participants (r = 0.88, p < .0001). Controlling for differences in national wealth and in Hofstede's other indices of societal values (Power Distance, Uncertainty Avoidance, and Masculinity) did not significantly change the ability of IDV to account for variance in the percentage of nonhomosexual participants. The factors that contribute to the observed association between societal individualism and the relative prevalence of nonhomosexual MtF transsexualism remain to be determined, but a greater tolerance within individualistic countries for socially disruptive gender transitions by nonhomosexual gender dysphoric men, and the availability within many collectivistic countries of socially approved transgender roles for pervasively feminine homosexual gender dysphoric men, are plausible contributors.

Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults

The most widely used and influential typologies for transsexualism and gender identity disorder (GID) in adolescents and adults employ either sexual orientation or age of onset of GID-related symptoms as bases for categorization. This review compares these two typological approaches, with the goal of determining which one should be employed for the diagnosis of GID in Adolescents or Adults (or its successor diagnosis) in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Typologies based on sexual orientation and age of onset of GID-related symptoms are roughly comparable in ease and reliability of subtype assignment. Typologies based on sexual orientation, however, employ subtypes that are less ambiguous and better suited to objective confirmation and that offer more concise, comprehensive clinical description. Typologies based on sexual orientation are also superior in their ability to predict treatment-related outcomes and comorbid psychopathology and to facilitate research. Commonly expressed objections to typologies based on sexual orientation are unpersuasive when examined closely. The DSM should continue to employ subtypes based on sexual orientation for the diagnosis of GID in Adolescents or Adults or its successor diagnosis.

Erotic target location errors: an underappreciated paraphilic dimension

Based on studies of heterosexual male fetishists, transvestites, and transsexuals, Blanchard (1991) proposed the existence of a hitherto unrecognized paraphilic dimension, erotic target location errors (ETLEs), involving the erroneous location of erotic targets in the environment. ETLEs can involve preferential attention to a peripheral or inessential part of an erotic target, manifesting as fetishism, or mislocation of an erotic target in one's own body, manifesting as the desire to impersonate or become a facsimile of the erotic target (e.g., transvestism or transsexualism). Despite its potential clinical and heuristic value, the concept that ETLEs define a paraphilic dimension is underappreciated. This review summarizes the studies leading to the concept of ETLEs and describes how ETLEs are believed to manifest in men whose preferred erotic targets are women, children, men, amputees, plush animals, and real animals. This review also describes ETLEs in women; discusses possible etiologies of ETLEs; considers the implications of the ETLE concept for psychoanalytic theories of transvestism and male-to-female transsexualism, as well as for the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; suggests reasons why the concept of ETLEs has been underappreciated; and describes what might result if the concept were more widely appreciated.

Clinical and theoretical parallels between desire for limb amputation and gender identity disorder

Desire for amputation of a healthy limb has usually been regarded as a paraphilia (apotemnophilia), but some researchers propose that it may be a disorder of identity, similar to Gender Identity Disorder (GID) or transsexualism. Similarities between the desire for limb amputation and nonhomosexual male-to-female (MtF) transsexualism include profound dissatisfaction with embodiment, related paraphilias from which the conditions plausibly derive (apotemnophilia and autogynephilia), sexual arousal from simulation of the sought-after status (pretending to be an amputee and transvestism), attraction to persons with the same body type one wants to acquire, and an elevated prevalence of other paraphilic interests. K. Freund and R. Blanchard (1993) proposed that nonhomosexual MtF transsexualism represents an erotic target location error, in which men whose preferred erotic targets are women also eroticize their own feminized bodies. Desire for limb amputation may also reflect an erotic target location error, occurring in combination with an unusual erotic target preference for amputees. This model predicts that persons who desire limb amputation would almost always be attracted to amputees and would display an increased prevalence of gender identity problems, both of which have been observed. Persons who desire limb amputation and nonhomosexual MtF transsexuals often assert that their motives for wanting to change their bodies reflect issues of identity rather than sexuality, but because erotic/romantic orientations contribute significantly to identity, such distinctions may not be meaningful. Experience with nonhomosexual MtF transsexualism suggests possible directions for research and treatment for persons who desire limb amputation.

Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography

Men's sexual arousal patterns are category-specific: Men typically display significantly greater physiological responses to sexual stimuli depicting members of their preferred gender category. Category-specific patterns of sexual arousal have not been consistently reported in natal women. We used vaginal photoplethysmography to examine patterns of sexual arousal in 11 male-to-female (MtF) transsexuals following sex reassignment surgery (SRS) and in 72 natal women. Subjective arousal was measured with a continuous response lever. Video clips depicting sexual activity between two males, two females, or one male and one female were used as erotic stimuli. All transsexual participants displayed category-specific sexual arousal. Five homosexual transsexual participants (attracted exclusively to males before sex reassignment) showed greater genital and subjective responses to male than to female stimuli, while six nonhomosexual transsexual participants showed the opposite pattern. Vaginal pulse amplitude (VPA) was lower in transsexual participants than in natal women. The mean correlation between VPA and subjective responses was high in nonhomosexual transsexuals, but was significantly lower in homosexual transsexuals and in natal women. One transsexual participant who reported a change in sexual orientation following sex reassignment displayed VPA and subjective responses consistent with her pre-reassignment sexual orientation. We conclude that male-to-female transsexuals display male-typical category-specific sexual arousal following SRS, and that vaginal photoplethysmography is a promising methodology for studying patterns of sexual arousal in postoperative transsexuals.

Sexuality before and after male-to-female sex reassignment surgery

The sexual behaviors and attitudes of male-to-female (MtF) transsexuals have not been investigated systematically. This study presents information about sexuality before and after sex reassignment surgery (SRS), as reported by 232 MtF patients of one surgeon. Data were collected using self-administered questionnaires. The mean age of participants at time of SRS was 44 years (range, 18-70 years). Before SRS, 54% of participants had been predominantly attracted to women and 9% had been predominantly attracted to men. After SRS, these figures were 25% and 34%, respectively.Participants' median numbers of sexual partners before SRS and in the last 12 months after SRS were 6 and 1, respectively. Participants' reported number of sexual partners before SRS was similar to the number of partners reported by male participants in the National Health and Social Life Survey (NHSLS). After SRS, 32% of participants reported no sexual partners in the last 12 months, higher than reported by male or female participants in the NHSLS. Bisexual participants reported more partners before and after SRS than did other participants. 49% of participants reported hundreds of episodes or more of sexual arousal to cross-dressing or cross-gender fantasy (autogynephilia) before SRS; after SRS, only 3% so reported. More frequent autogynephilic arousal after SRS was correlated with more frequent masturbation, a larger number of sexual partners, and more frequent partnered sexual activity. 85% of participants experienced orgasm at least occasionally after SRS and 55% ejaculated with orgasm.

Clinical characteristics of a total cohort of female and male applicants for sex reassignment: a descriptive study

The objective of this study was to compare the features of female-to-male transsexuals (F-M) with those of male-to-female transsexuals (M-F) in the cohort of all applicants for sex reassignment over a 20-year period. In an observational, cross-sectional design the cohort was retrospectively identified, consisting of all 233 subjects who applied for sex reassignment in Sweden during the period 1972-1992. The cohort was subdivided into the groups M-F (n=134) and F-M (n=99), and the two groups were compared. M-F were older when applying for sex reassignment surgery than F-M, and more often had a history of marriage and children than their F-M counterparts. M-F also had more heterosexual experience. F-M, on the other hand, more frequently exhibited cross-gender behaviour in childhood than did M-F transsexuals. The present and previous studies strongly support the view that transsexualism manifests itself differently in males and females. Various models for understanding these differences are discussed.