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Psychopathia Transsexualis: Early Psychological Theories of Transsexualism

“The adult who wants to change sex can be exasperating, intriguing, and pathetic.” Richard Green, Sexual Identity Conflict in Children and Adults, 1974.

Kraft-Ebbing’s identification of “psychopathia transsexualis” in the 1930s set the stage for how transness was to be understood for decades to come. Gaining momentum with the work of researchers such as Harry Benjamin, John Money, and Richard Green in the 1960s and 1970s, explanatory theories of transness proliferated, and encompassed a variety of approaches.

For the current reader of the psychological literature on trans, the first difficulty is deciphering the inconsistent language which continues to be used. For example, the term “male transsexual” could be used to mean “female to male transsexual” or “male to female transsexual”, depending on who was writing. In the same fashion, “homosexual transsexual” could mean either attraction to same or “opposite” sex depending on how the “real” identity of the trans subject in question was understood [1]. Language and the generation of meaning remains a significant problem for trans people today, with even recent studies proving inconsistent in their terminology. Who was doing the naming of whom, and on what basis, mark asymmetrical relationships of power which continue to operate. In other words, trans people still struggle to have the power and choice to name themselves and speak about themselves in ways which are not defined or controlled by others.

One of the central questions in early psychological literature concerned the cause or source of transness, presumably so that the offending factor(s) could be identified and routed out in a timely fashion. Researchers were perplexed by findings which showed that while trans people were often deemed “neurotic” (and who wouldn’t be neurotic as a trans person in the 1960s?), they were in every other respect “normal,” “functional” people. However, a couple of researchers produced “evidence” showing that there were two types of trans people: criminal, deviant, antisocial ones who were described as something like a combination of a drag queen and Jack the Ripper, and nice, respectable, well-adjusted ones who just wanted to live their lives in peace.[2] The second group was deemed sufficiently un-psychotic to be allowed to receive treatment. Given clear evidence that adult trans people were entirely, unanimously resistant to all forms of psychotherapy (including aversion therapy with electric shocks[3]) aimed at changing their gender identity, researchers turned to the investigation of early childhood or biological factors.

Early work was characterized by a focus on male-to-female transsexuals to the near-complete invisibility of female-to-males, assumptions about appropriate gender behaviour, and messy conflation of gender and sexuality. Appropriate gender behaviour, both of the trans people themselves, and their family and peers, was used as a clinical tool to assess the trans subjects. While some researchers did note that MTF trans subjects were more likely to display stereotypical gendered behaviour, they also suggested that perhaps this behaviour and stated gender role preferences represented a strategy on the part of the trans subject.[4] In other words, both as a result of clinical expectations and of the trans subjects’ own ideas about how “proper” women behaved, MTFs presented themselves so as to get the best “fit” in accordance with social norms, as well as to increase their likelihood of securing the treatment they wanted. Support for this notion is provided by later standards of care for trans people wanting surgery. If the patient did not behave “in a gender role in line with his or her gender identity,” surgery might be refused. Clinicians argued that too great a degree of “gender discrepancy” would make it impossible for the subject to pass, and thus surgery would be of no use.[5] Reports that trans people were inclined to commit suicide or lapse into deep depression when surgery was refused did not seem to trouble researchers who were committed to making sure gender categories remained orderly. Knowledge of this state of affairs no doubt affected the behaviour and stated preferences of trans people who wanted full surgical treatment.

Researchers often tried to quantify, using the Guilford-Zimmerman Temperament Scale developed in 1948, each subject’s degree of “masculinity” and “femininity.” Masculine behaviour in females, for example, was demonstrated by such things as “giving priority to career over marriage or at least combining the two in future expectancies, and of preferring casual, masculine-derived clothing styles over ruffles and frills”.[6] However, cross-cultural data provided by anthropologists[7] suggested that gender identity involved some degree of social assimilation and knowledge of what elements in each culture were considered masculine or feminine. Thus, the G-Z scale was more of an indicator of how well each person had absorbed the central cultural messages about what constituted masculinity or femininity, as well as a guide to clinicians’ own stereotyped gender categorizations, rather than an empirical assessment of a deeply felt identity. Writing in 2002, it seems largely absurd that combining career and marriage would be a flashing red light for gender deviance.

The gendered behaviour of family members was also suggested as a contributing factor to transness. Clinicians such as Robert Stoller, who were grounded in a psychoanalytic tradition, argued that an “overbearing,” “aggressive” mother, or a mother with “bisexual tendencies,” plus an absent or “passive” father, living in an unhappy marriage, would, through a complex and quasi-Freudian process, contribute to transness, perhaps even more than any other factor.[8] In case histories, mothers confessed guiltily to having preferred pants over dresses, engaging in athletic activities as youngsters, giving their biologically male children too much love and/or allowing the children to see them naked. According to many researchers, the mother thus transmitted her own fundamental (and by clinical standards, dysfunctional) attitudes about gender to the child. Other 1970s researchers, such as Richard Green, implicated parental sexual expectations and discipline styles: “A father with considerable sex anxiety tended to have more feminine sons (and daughters). Similarly, mother’s insistence on good table manners, severity in toilet training, and punishment of aggression towards parents was associated with femininity in both boys and girls.”[9] To put this as a very simplistic equation, “too much mother” equalled “feminine boys” and “too much father” equalled “masculine girls”.[10] It does not seem entirely clear in these theories whether the mother created a femmy son through her overbearing authoritarian aggression or overindulgent affection, latent masculinity and/or bisexuality or smothering feminine heterosexuality. For budding FTM children, the responsibility lay with the mother whose own psychological conflicts about femininity left her unable to nurture the “developing female gender-self.” “This failure to provide age-appropriate mirroring to sustain and promote this aspect of the developing self can give rise to devastating disintegration anxiety.”[11] The girl child thus turned to a nearby male role model. Psychoanalytic theories, then, positioned the potentially trans child within a nexus of familial relationships to attempt to pinpoint some type of relational identity dysfunction. Identity was, in this schema, derived from one’s interaction with others, and if those others could be persuaded to act gender-appropriately, then perhaps the child would too.

But most significantly for current research into transness, and for trans people’s lived experience, was the conflation of gender and sexuality. Building on the “gender inversion” theory of homosexuality which originated in the 19th century, and which held that lesbians were “mannish” women who either identified with or wanted to be men, and that gay men were “effeminate” and female-identified, many theories about “gender dysfunction” incorporated assumptions about sexual orientation. Much care was taken to show that “normal” transsexuals (the ones who fit the proper profile, anyway) prefered partners who were heterosexual, and in fact actively rejected any whiff of homosexuality.[12]

Nevertheless, the link between transness and homosexuality was a hard one to shake. Betty Steiner, for example, reported in 1985 that MTFs who preferred biological male partners were labeled “homosexual subtypes,” although the authors of the DSM-III indicated that “homosexual transsexuals often will deny that their behavior is homosexual because of their conviction that they are ‘really’ of the other sex.”[13] We can see here that labelling of who is what is based on what clinicians feel is the “true” identity of the subject, despite the subject’s assertions to the contrary. In assessment of potential FTMs, “male” behaviour in biological women, such as the aforementioned enjoyment of sports, was also examined for its potential correlation with “actual or incipient lesbianism.”[14] Some researchers even suggested that unlike male-to-females, there were no “true” female transsexuals, and that “masculine females are the far end of a continuum of butch homosexuality.”[15] It is not entirely clear from the limited clinical material available from this time whether FTM invisibility was due to researcher androcentrism and unwillingness to “see” FTM as a viable identity, to FTMs’ more limited choices in accessing care (or use of private clinics), or indeed, concealment/erasure of FTMs within particular communities by “reading” them as simply very butch lesbians.

Though MTFs and “effeminate homosexuals” were often linked in the research, post-op MTFs were considered properly assimilated when they sought out heterosexual men as partners, with whom they would play the “passive, receptive role,” seeking only to give pleasure without demanding it themselves.[16] “In no case”, reported the researchers, “was there a regret at playing a receptor role only. On the contrary, there was delight in it as a symbol of femininity.”[17]. Green, writing in 1974, incorporates sexual orientation as a component of gender identity, arguing that gender identity encompassed not only one’s internally felt sense of oneself but also “an individual’s preference for male or female sexual partners.”[18] Sexual identity and roles was thus correlated with gender identity and roles. The sexual “transgression” of queerness was often mixed up with gender “transgression” of varying degrees (and in the 1960s, it didn’t seem to take much effort to step over that boundary; enjoying a simple game of catch in the backyard could turn a normal biological woman into an incipient lesbian).

Sexual deviance was another important theme, and continues to inform assumptions about transness. When I began the research for this project, I discovered that the library arranged books on transsexuality on the same shelf as, and mixed in with, books on child molestation. A few books even went so far as to combine “gender disorders” with so-called “paraphilias” which included foot fetishism, child sexual abuse, and S/M.[19] A subject search of the library catalogue turned up this cross-listing gem: “For ‘transsexualism,’ search also under ‘sexual deviance.'”

In most psychological literature, trans people were not sexual subjects, and this continues to be the case. While their bodies were the stage for dramas of medical intervention and accusations of sexual deviance, they appeared disconnected from their physical incarnations. MTFs experienced “penile dissociation”[20] and “neurophysiologic dysfunction.”[21] Sexuality, if it occurred at all, was depicted as a “mercy fuck” sort of affair in which the trans person’s partner either was unaware of their lover’s trans status, or generously “overlooked” it. Orgasms were unheard of, and the trans person was not permitted to enjoy the sexiness of hir own body or its accoutrements, since that would constitute autogynephilia which indicated sexual dysfunction (and might prevent the trans person from accessing the desired care). In any case, the trans person did not have an active sexuality which was seen as healthy and normative, beyond hir choice of partner. Their success in sexual relations was determined by how closely their relationships mimicked the standard heterosexual model of monogamy, and passive female-active male.

While much of this literature may seem laughable (or tragic) to us now, the themes in early clinical studies continue to inform current practice. The practice of naming, finding the “cause” of trans behaviour (which is defined as a pathology), and expectations for appropriate sexuality and self-presentation remain relevant themes in both clinical literature and trans activism. It is worthwhile to examine these earlier works to see how assumptions about trans people were developed, disseminated, and reiterated, so that clinical practice itself attempted to produce trans subjects whose identities were bounded by these institutional parameters. It is a circular type of logic: we, the psychological institutions, say that trans people should be this way, and that if they are this way then they may receive the care they desire. Lo and behold, we observe that trans people who desire care conform to this model, which must mean the model is working, and so trans people should be this way, and so on. This process of regulation often remains invisible, and thus it is helpful for us to look back and see the origins of it, in order that we may continue to be critical and careful about the assumptions that guide clinical practice and norms.


  1. And of course the possibility of trans people being bi- or multi-sexual, attracted to other trans people, or having a fluid sexual identity, was inconceivable for researchers.
  2. Norman Knorr, Sanford Wolf, and Eugene Meyer. “Psychiatric Evaluation of Male Transsexuals for Surgery”. In Transsexualism and Sex Reassignment, eds. Green, Richard and John Money (Baltimore, Johns Hopkins University Press, 1969).
  3. Michael Gelder and Isaac Marks, “Aversion Treatment in Transvestism and Transsexualism”. In Transsexualism and Sex Reassignment. Electroshock aversion therapy was tried on people displaying a variety of cross gender behaviour. “True” transsexuals were deemed unshakable in their gender identity, although “transvestites” produced some “better” results, although considering that these “improvements” consisted of increased anxiety and neuroses over sexuality and self-presentation, it’s not clear how this was seen as progress.
  4. John Money and Clay Primrose, “Sexual Dimorphism and Dissociation in the Psychology of Male Transsexuals”. In Transsexualism and Sex Reassignment.
  5. John Hoenig, “Etiology of Transsexualism”. In Gender Dysphoria: Development, Research, Management, ed. Betty Steiner (New York: Plenum Press, 1985), 37.
  6. John Money, “Sex Reassignment as Related to Hermaphroditism and Transsexualism”. In Transsexualism and Sex Reassignment.
  7. Early work provided by Richard Green, “Mythological, Historical, and Cross-Cultural Aspects of Transsexualism” in Transsexualism and Sex Reassignment. See also later work by Leonore Loeb Adler, Jason Cromwell, Leslie Feinberg, Walter Williams.
  8. Robert Stoller, “Parental Influences in Male Transsexualism”. In Transsexualism and Sex Reassignment. Also Richard Green, “Childhood Cross-Gender Identification” in same.
  9. Richard Green, Sexual Identity Conflict in Children and Adults (New York: Basic Books, 1974), 24. One supposes that such trans people would at least have good table manners and be expected not to relieve themselves on the fancy carpets.
  10. Robert Stoller, Presentations of Gender. New Haven and London: Yale University Press, 1985, 8.
  11. Foreword by Milton Eber in Female-to-Male Transsexualism: Historical, Clinical, and Theoretical Issues, ed. Leslie Martin Lothstein (Boston: Routledge,1983), x.
  12. Ira Pauly, “Adult Manifestations of Female Transsexualism”. In Transsexualism and Sex Reassignment. MTFs apparently considered it “unnatural” to have relationships with women. Richard Green (1974) distinguishes between MTF TS, TV, and male homosexuals.
  13. Betty Steiner, Ray Blanchard, and Kenneth Zucker, “Introduction”. In Gender Dysphoria: Development, Research, Management, 3. Steiner et al also report that this group composes “almost 100% of male-to-female transsexuals”.
  14. John Money and Clay Primrose, “Sexual Dimporphism and Dissociation in the Psychology of Male Transsexuals.” In Transsexualism and Sex Reassignment. Also Green, Richard, “Childhood Cross-Gender Identification.”
  15. Stoller, Presentations of Gender, 21. Luckily for the “butch homosexual” women, “butch homosexuality in women differs from effeminate homosexuality in males in that these masculine women do not have the element of caricature that defines effeminacy.” Stoller, 22.
  16. Money and Primrose, “Sexual Dimporphism and Dissociation in the Psychology of Male Transsexuals.” In Transsexualism and Sex Reassignment.
  17. Ibid., 121.
  18. Green, Sexual Identity Conflict in Children and Adults, xv.
  19. William B. Arndt, Gender Disorders and the Paraphilias (Madison, CT: International Universities Press, 1991). Discouragingly, this book was published relatively recently.
  20. Guze, Henry. “Psychosocial Adjustment of Transsexuals: An Evaluation and Theoretical Formulation.” Transsexualism and Sex Reassignment.
  21. Money and Primrose.

1 thought on “Psychopathia Transsexualis: Early Psychological Theories of Transsexualism”

  1. Corrections:

    Richard von Krafft-Ebing wrote the first edition of “Psychopathia Sexualis: eine Klinisch-Forensische Studie” in 1886.

    The title was later adapted to “Psychopathia Transexualis” by a popular and influential, but non-scientific author, David O. Cauldwell, in 1949 (Sexology, vol. 16, 1949, pp. 274-280)

    Green (1974) regards gender identity as one component of sexuality, not the other way around.

    Take this article with a grain of salt, do your own research, and seek out more authoritative sources. This is the kind of internet resource that gives the web a bad name as a source of information for a good reason.


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