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The blurry line

To this day, "The Transsexual Phenomenon" remains one of the most important works dealing with transsexualism.

Harry Benjamin developed his dysphoria scale after seeing hundreds of patients and it was often very difficult for him to identify whether a patient was a transvestite (term used as historical reference) or a transsexual. I include here an excerpt from his book that clearly illustrates this blurring of the lines:

"The relationship between transvestism (TVism) and transsexualism (TSism) deserves further scrutiny and reflection. Both can be considered symptoms or syndromes of the same underlying psychopathological condition, that of a sex or gender role disorientation and indecision. Transvestism is the minor though the more frequent, transsexualism the much more serious although rarer disorder.

Cross-dressing exists (with few exceptions) in practically all transsexuals, while transsexual desires are not evident (although possibly latent) in most transvestites. It seems to depend upon how deeply and for what congenital or acquired reasons the sex and gender orientation is disturbed, whether the clinical picture of transvestism or transsexualism will emerge. The picture of TSism may first appear to be merely TVism, but whether this indicates a progressive character is by no means certain. (See chapter 4, "The Male Transsexual").

Definitions and classifications

In previous medical publications, I have divided all transvestites into three groups according to the clinical picture they presented. First there are those who merely want to "dress," go out "dressed," and to be accepted as women. They want to be allowed to do so. Their clash is with society and the law. Most of them feel, live, and work as men and lead normal, heterosexual lives, often as husbands and fathers.

Group 2 constitutes a more severe stage of an emotional disturbance. It could be interpreted as an intermediate stage between transvestism and transsexualism. These patients may waver in their emotions between the two. They need more than merely "dressing" to appease their psychological sex with its commanding and demanding female component. They want to experience some physical changes, bringing their bodies closer to that of the female, although they do shy away from surgery and the alteration of their genitalia. Such a desire, however, can play a part in their fantasies and daydreams. Like those of Group 1, for them the penis is still an organ of pleasure, in most cases for masturbation only. They crave some degree of gynecomastia (breast development) with the help of hormone medication, which affords them an enormous emotional relief. Psychotherapy is indicated but the patients frequently refuse it or fail to benefit from it. Their clash is not only with society and the law, but also with the medical profession. Relatively few doctors are familiar with their problems; most doctors do not know what to do for them except to reject them as patients or to send them to psychiatrists as "Mental cases."

This clash with society, the law, and the medical profession is still more pronounced and tragic in Group 3, which constitutes fully developed transsexualism. The transsexual shows a much greater degree of sex [9] and gender role disorientation and a much deeper emotional disturbance. To him, his sex organs are sources of disgust and hate. So are his male body forms, hair distribution, masculine habits, male dress, and male sexuality. He lives only for the day when his "female soul" is no longer being outraged by his male body, when he can function as a female - socially, legally, and sexually. In the meantime, he is often asexual or masturbates on occasion, imagining himself to be female.

This, very briefly, is the clinical picture of the three groups as they appeared to me originally during the observation of over two hundred such patients. More than half of them were diagnosed as transsexuals (TSs). The above interpretation, that is to say, transvestism as the mildest and transsexualism as the most severe
disturbance of sex and gender orientation, seems to be practical and to fit the facts. Lukianowicz [10] and Burchard,[11] an English and a German psychiatrist, respectively, are in general agreement with this view. But there are other concepts that deserve consideration and should be outlined.

Sex object choice

Some investigators believe that the two conditions, TVism and TSism, should be sharply separated, principally on the basis of their "sex feel" and their chosen sex partners (object choices). The transvestite - they say - is a man, feels himself to be one, is heterosexual, and merely wants to dress as a woman. The transsexual feels himself to be a woman ("trapped in a man’s body") and is attracted to men. This makes him a homosexual provided his sex is diagnosed from the state of his body. But he, diagnosing himself in accordance with his female psychological sex, considers his sexual desire for a man to be heterosexual, that is, normal.

The choice of a sex partner is changeable. A number of transvestites are bisexual. As men, they can be attracted by women. When "dressed," they could be aroused by men. Chance meetings can be decisive. The statements of these patients cannot always be relied upon. They want to act within the conventions, or at least
want to appear to do so. They may claim heterosexuality when actually they have more homosexual tendencies, which they suppress or simply do not admit. Some feel sufficiently guilty as TVs without wanting to confess to homosexual tendencies besides. Some do admit that heterosexual relations are possible with recourse to fantasies only. (In this way, transsexuals explain their marriages and parenthood and this explanation is most likely correct).

When first interviewed, the patient may appear to be a TV of the first or second group. He often hesitates to reveal his wish for a sex change right away. Only after closer contact has been established and confidence gained does the true nature of his deviation gradually emerge. Such seeming "progression" was observed in five or six out of my 152 transsexual patients, on whom I am reporting in this volume.

The opposite is rare but I have seen it happen. The apparent transvestite, or even transsexual, under treatment or - more likely - through outside influence (meeting the right girl) - turns toward heterosexuality and "normal" life.

For how long is always the question.

Are all transvestites transsexuals?

Coming back to the differences between transvestism and transsexualism., another simpler and more unifying concept and a corresponding definition may have to be considered. That is, that transvestites with their more or less pronounced sex and gender indecision may actually all be transsexuals, but in varying degrees of intensity.

A low degree of largely unconscious transsexualism can be appeased through cross-dressing and demands no other therapy for emotional comfort. These are transvestites (Group 1).

A medium degree of transsexualism makes greater demands in order to restore or maintain an emotional balance. The identification with the female cannot be satisfied by wearing her clothes alone. Some physical changes, especially breast development, are requirements for easing the emotional tension. Some of these
patients waver between transvestitic indulgences and transsexual demands for transformation (Group 2).

For patients of a high degree of transsexualism (the "true and full-fledged transsexual"), a conversion operation is the all-consuming urge, as mentioned earlier and as a later chapter will show still more fully. Cross-dressing is an insufficient help, as aspirin for a brain tumor headache would be (Group 3).

It must be left to further observations and investigations in greater depth to decide whether or not transvestitic desires may really be transsexual in nature and origin. Many probably are, but the frequent fetishistic transvestites may have to be excluded.

If these attempts to define and classify the transvestite and the transsexual appear vague and unsatisfactory, it is because a sharp and scientific separation of the two syndromes is not possible. We have as yet no objective diagnostic methods at our disposal to differentiate between the two. We - often - have to take the statement of an emotionally disturbed individual, whose attitude may change like a mood or who is inclined to tell the doctor what he believes the doctor wants to hear. Furthermore, nature does not abide by rigid systems. The vicissitudes of life and love cause ebbs and flows in the emotions so that fixed boundaries cannot be drawn.

It is true that the request for a conversion operation is typical only for the transsexual and can actually serve as definition. It is also true that the transvestite looks at his sex organ as an organ of pleasure, while the transsexual turns from it in disgust. Yet, even this is not clearly defined in every instance and no two cases are ever alike. An overlapping and blurring of types or groups is certainly frequent"


Harry Benjamin

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