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classifying gender dysphoria

Since the beginning of the twentieth century we have made attempts at categorizing gender dysphoric individuals. First we had the Harry Benjamin gender disorientation scale, then the primary and secondary transsexual typologies followed by Ray Blanchard’s homosexual and autogynephilic typologies.

For some context and brief history of these terminologies, I will simply post Anne Vitale’s excellent essay written in January of 2000:

“It is with dismay that I continue to encounter individuals with gender identity issues using the terms Primary and Secondary Transsexualism as diagnostic indicators.

The terms show up repeatedly in Internet chat rooms, in the Internet news groups, in my email, and by individuals presenting to me in my private practice. The individuals who self-identify as Primary Transsexuals are usually using the term to mean that they are "Benjamin Type VI, true transsexuals." Those who self-identify as Secondary Transsexuals are usually trying to diminish their condition and to find some way to deal with their gender dysphoria without having to face the possibility of transitioning. As we shall soon see, neither term has ever had anything to do with severity or prognosis. There is no hierarchy of transsexualism. There are no Primary Transsexuals or Secondary Transsexuals. There are only gender dysphoric individuals who need help.

Nevertheless, important information about the variations of behaviour within transsexualism has come to light from the efforts of those authors who thought the severity of gender dysphoria was quantifiable. But before we get to that, here is a short history of these classification attempts.

Sex researchers have been trying to classify people who display gender-variant behaviour since the early part of the Twentieth Century. They started by naming the more obvious subgroups such as male cross-dressers and effeminate homosexuals. Later as more individuals came forward seeking help regarding gender rather than sexual orientation issues, a host of authors tried to come up with umbrella terms to distinguish those male individuals seeking sex reassignment who display, what is referred to as "innate" or "core" feminine behavior from those who display behavior that is indistinguishable from non-gender-dysphoric males. As a result, we are left with an array of awkward terms ranging from automonosexualism (Rohleder 1901), homosexual and non-homosexual transvestism (Money and Gaskin,1970-1971 ), primary and secondary transsexualism (Person and Ovesey 1974a and 1074b; Stoller, 1980; Levine and Lothstein, 1981) and now androphilic transsexualism and autogynephilic transsexualism (Blanchard, 1989a).

The terms Primary and Secondary transsexualism came to be the most commonly used. Meanings for those terms were those described by Ethel Person M.D. and Lionel Ovesey M.D. in two papers published in the 1970s (1974a, 1974b).

What has interested clinicians most about Person and Ovesey's study was that they clearly showed that, along with what everyone considered to be the "classic" effeminate homosexual transsexual model, there existed an even more prominent group of non-homosexual genetic males seeking sex reassignment. Although for some it seems counter-intuitive, Person and Ovesey designated the non-homosexual group Primary Transsexuals and the homosexual transsexuals, Secondary Transsexuals. Looking beyond the terminology, here is what they came up with.

Essentially, Person and Ovesey define a Primary Transsexual as one who is functionally asexual and who progresses resolutely toward a surgical resolution without significant deviation toward either homosexuality or heterosexuality. They define a Secondary Transsexual as one who is a homosexual and effeminate from early childhood into adulthood. Within the Secondary classification they identified two sub-classes: Homosexual transsexualism and Transvestitic transsexualism.

In discussing Primary transsexualism, Person and Ovesey note that of the 10 non-homosexual transsexuals in their study sample, 9 showed no evidence of effeminacy in childhood. Each member of the sample was clearly identified by both male and female peers as a boy and was never referred to as being a sissy. They participated in rough-and-tumble behavior as required and did not engage in girls' activities any more than the other boys in their peer group. All 10 of the sample were socially withdrawn in childhood, loners who read a great deal, watched television or occupied themselves with private hobbies. Each of the sample admitted to being envious of girls and fantasized being a girl, but the authors note that none of the sample actually believed he was a girl.

In the second part of the study (1974b) the authors report that the homosexual transsexuals they studied resembled the clinical and then-perceived stereotypical transsexuals. These genetic males were effeminate from earliest childhood. As children they preferred girls as playmates, avoided boyish pursuits and were "mother's helpers." Crossdressing began in childhood, initially for narcissistic satisfaction, but later at puberty to attract male sexual partners. Cross-gender fantasies were frequently tied to identification with movie actresses and drag queens. The authors note that the homosexual cross-dresser wants to be noticed and to this end often wears flamboyant and colorful clothing and engages in theatrical endeavors.

Also included in the Secondary classification, were those cross-dressing transsexuals who were characterized as never being effeminate in childhood but instead were appropriately masculine, and occasionally exceedingly hyper-aggressive and hyper-competitive. They neither played with girls nor engaged in female pursuits. They fantasized about being girls when cross-dressed, but valued their assertiveness and maleness.

Given the number of later authors who attempted to classify transsexuals as either primary or secondary, it is obvious that they also believed that one form of gender dysphoria was more significant than the other. However, these authors differ radically from Person and Ovesey over which sub-type should qualify for which classification. For example, Stoller's primary transsexuals fit the description of Person and Ovesey's secondary transsexuals. Stoller further asserted that Person and Ovesey's primary transsexual should be referred to as secondary transsexuals. The following year, Levine and Lothstein (1981) described a condition they called "primary gender dysphoria" in genetic females. Neither Person, Ovesey nor Stoller agreed with Levine and Lothstein.

Given these important differences of opinion, Primary/Secondary terminology has largely been dropped from the literature. It has instead been replaced with sex researcher Ray Blanchard's more descriptive and non-hierarchical Autogynephilic and Androphilic transsexualism. (More on these classifications in a future work.)


Despite efforts to classify transsexualism hierarchically, neither sexual preference nor a history of feminine behavior have been shown to have any bearing on whether or not an individual will or will not profit from treatment. The work of Person and Ovesey was helpful in describing the range of behaviors and orientations to life that transsexuals may experience. From this we have learned that transsexuals can be widely different from one another, yet show a common need for their condition to be understood and helped. There are no primary transsexuals or secondary transsexuals. There are no true transsexuals or "wannabe" transsexuals. Being gender dysphoric in a society that barely acknowledges the existence of such a condition requires the development of coping mechanisms. Some coping mechanisms are more overt and obvious than others. But no matter what the individual does to survive, one thing is certain, everyone who suffers from gender dysphoria must eventually come to terms with his or her situation”


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