"Homosexual Gender Dysphoria
Homosexual gender dysphorics are those who, from the time of earliest sexual awareness in childhood or puberty, feel attracted only to men. The individual's masturbatory fantasies and romantic daydreams are of males; if he also has sexual encounters or love relationships in real life, these are exclusively or almost exclusively with men.
The natural history of homosexual gender dysphoria is strikingly different from any of the syndromes examined so far. This difference, which has led many theorists to conclude that homosexual gender dysphoria must have a separate etiology, is already apparent in the individual's earliest gender role behavior. The childhood behavior of homosexual gender dysphorics, unlike that of heterosexual, analloerotic, or bisexual gender dysphorics, closely resembles the DSM-III-R diagnosis of gender identity disorder of childhood, described in Chapter I. As boys, they are unusually deficient in, or afraid of, physical competitiveness: They avoid rough-and-tumble play, are frightened of fistfIghts, and strongly dislike team sports. They prefer to play with girls, to play girls' games, and to play with girls' toys, in particular, Barbie-type dolls.
They also prefer the company of adult women to that of adult men, and they like to take part in women's conversations. They often become mothers' helpers, and they take an unusual interest in domestic pursuits such as cooking, sewing, and decorating. They are keenly interested in women's clothes, hairstyles, and makeup. Many entertain themselves by drawing pictures of glamorous women; those whose mothers will allow it like to pick out their mothers' dresses, brush their hair, and make up their faces.
Some of these boys also dress themselves up as women, although this might not occur as regularly in the childhood of homosexual gender dysphoncs as in that of transvestites. Cross-dressing, when it does occur, is often accompanied by playacting various romantic roles such as princess or ballerina. Cross-dressing in homosexual gender dysphorics is not sexually arousing, either in childhood or later.
It is not clear whether, or at what age, these children explicitly formulate the wish to be female. Adult homosexual gender dysphorics frequently date such wishes to earliest conscious awareness, but such retrospective reports cannot be assumed to be valid. Even when they are not engaging in any obvious cross-gender behavior, these boys are observably effeminate. This may manifest itself in feminine speech patterns, gestures, or gait. As these children reach middle or late childhood, their schoolmates begin to notice the subtle as well as the obvious signs of effeminacy and respond by labelling them " sissies. " When they reach puberty, the taunts of "sissy" tum to "queer," "fruit," and "faggot," and these children begin to be ostracized by their peers.
Although it is true that the great majority of adult homosexual gender dysphorics were feminine boys, it is not conversely true that the majority of feminine boys will end up as homosexual gender dysphorics. The majority of feminine boys do, in fact, end up in adulthood as homosexuals, but they are fully content with their male sex and have few, if any, gross
cross-gender behaviors (Green 1987; Zuger 1984). It appears that, in this majority of cases, the boy's femininity spontaneously' 'bums out" around puberty (Harry 1983; Whitam 1977; Zuger 1978). Puberty, then, may be a kind of developmental crossroads, separating gender dysphoric from ordinary homosexuals. It is unknown, however, whether environmental factors at puberty determine which course the individuai will follow, or whether the degree of a boy's femininity determines whether he will defeminize at puberty, or whether boys who defeminise and boys who do not are qualitatively different from the beginning.
Homosexual gender dysphorics are not as variable in adulthood as non-homosexual (heterosexual, bisexual, or analloerotic) patients, but they do differ in degree of cross-gender identity and intensity of gender dysphoria. Some individuals with milder cases might feel feminine without ever acting this out; others engage in episodic cross-gender behaviour as "drag queens," a group cited by DSM-III-R as examples of homosexual GIDAANT. Many, perhaps most, of those with milder cases never seriously entertain the thought of seeking sex-reassignment surgery; some do so in a halfhearted way and soon give up the idea. The most strongly gender dysphoric individuals-the homosexual transsexuals~eventually attempt to establish themselves in society as females, if this is at all practical, and begin to explore the available routes to surgical sex reassignment. It should be noted that, in contrast to the heterosexual type, homosexual gender dysphoria does not tend to be progressive. The homosexual individual's transsexual wishes are probably as strong as they are going to be by age 20 or 25; in some cases they may even decline in postadolescence.
One of the most striking features of full-blown homosexual transsexualism is the effect of gender dysphoria on the individual's sexual behavior. The majority of preoperative homosexual transsexuals do have intercourse with male partners from time to time, but these encounters are regulated by various constraints. They generally avoid letting their partners see them naked, and they often wear panties or some other type of undergarment to hide the penis and scrotum. The transsexual strictly functions as the insertee in anal or oral intercourse; the partner is not even allowed to touch the transsexual's genitals. Indeed, a sexual partner who showed any interest in the transsexual's penis would be regarded as undesirable, for reasons explained below.
Homosexual gender dysphorics maintain that their sexual interest in other men is actually heterosexual, because "inside" they really are women. They also prefer partners who are heterosexual or who claim to be so and who concur with the transsexual's self-evaluation that he is "really" a woman. Transsexuals, therefore, reject lovers who show an interest in their male genitals, not only because they hate their genitals to be touched in the first place, but also because they conclude (probably correctly) that these men are homosexual.
Some homosexual transsexuals simply prefer to avoid the emotional conflict and practical difficulties involved in sexual intercourse altogether. As one preoperative patient stated, with unintentional humor, "I guess I'm just an old-fashioned girl-I don't believe in sex before surgery." As I have previously stated, the reluctance of such individuals to engage in intercourse preoperatively should not be interpreted as "asexuality.'
After vaginoplasty, of course, homosexual transsexuals are better equipped both to copulate as they wish and to attract heterosexual men. It is therefore not surprising that they are then more likely to become involved in love relationships (Blanchard 1985a; Blanchard et al. 1983)."