The male homosexual identifies with his partner in the sexual act, thus gaining a transient sense of pseudo-masculinity and masculine identity. Repeated homosexual experiences are constantly necessary to reinforce this sense of masculinity which is often felt to be necessary to avoid more serious decompensation. The understanding and realization that what is sought in the homosexual behavior is essentially masculine rather than feminine is a potent source of reassurance and motivation for change in the direction of heterosexual functioning. The need for seeking such homosexual reinforcement occurs under conditions of mounting anxiety, depression, and paranoid fears. The penis of the male partner is often found to be a substitute for the long-sought but denied breast of the “good” mother and allows the homosexual to compensate for the oral deprivation that may have been suffered at the hands of the real mother.

In the family of such patients there characteristically is found a devaluing, demeaning, and degrading of the father who may be quite open and conscious. This degrading often is done by the mother so that the patient identifies with the aggressive, castrating mother. Along with this there is hatred of the father, intensified by oedipal dynamics, which produces considerable guilt and impedes the patient’s ability to feel that he is entitled to be a man. At the same time there is an intense, unsatisfied, and often unconscious yearning for the father’s love and protection. The unavailability or unresponsiveness of the father to the boy child’s need stands in the way of the child’s capacity to gain a masculine identity through identification with the father. The homosexual act thereby becomes an expression of this continually frustrated yearning.

At the same time heterosexual interests or impulses may be continually suppressed or repressed because of unconscious guilt feelings toward the mother created by the intensity of unresolved incestuous and aggressive impulses. In many male homosexual patients, however, the intensity and extent of anger and rage against the mother is strongly repressed and remains unconscious and well defended. Often much therapeutic effort must be expended before a patient can understand the extent of his rage against and fear of women, particularly the mother. A critical part of the therapy of such patients is to overcome such fears, particularly the fear of retaliation by the mother for his attempts to move toward a more consistent and established masculine identity. The mother’s hatred and contempt for men (often covering a deeper and pathological envy) must be put in perspective, together with the patient’s fears that that hatred would be directed against himself.

Consequently, it can be readily appreciated that the treatment of homosexuality is not a treatment of the homosexual behavior itself, or even a direct attempt to alter the homosexual behavior. One can say apodictically that any direct attempts by the analyst to prohibit, change, judge, or modify the homosexual behavior will be anti-therapeutic, will undermine the essential therapeutic alliance, and will more than likely, intensify the patient’s sense of guilt and the need to act out destructively or to utilize the homosexual behavior in the interest of a displaced parental rebellion.

The therapist may at times be forced to take a position or be forced to set limits when behavioral acting-out becomes self-destructive. Homosexual behavior can become self-destructive, and it is often useful to draw the patient’s attention to the consequences of his behavior. Such an intervention, however, is a recognizable parameter which interferes with the analytic work—however necessary it may be at times with some patients. Most patients are quite able to recognize and acknowledge the self-destructive aspects of their homosexual behavior. The point I am making, however, is that the homosexual symptom itself is not targeted as the element to be treated in the therapy. Rather, other important dimensions of the patient’s personality functioning, his conflicts, his developmental impediments, and so forth are the more appropriate object of analytic concern and analytic effort.

Something similar can be said of the full gamut of sexual disorders which we have been considering. Analysis does not and – to my way of thinking should not – direct its efforts to the modification of such sexual disorders. Analysis of such manifestations, whether they be sexual impediments or perversions does not imply change or modification. Rather, it implies an attempt to understand and an attempt to grasp the inner meaning of such symptoms in the fuller context of the patient’s life experience and developmental history. The therapeutic presumption of the analytic approach is that the resolution of underlying conflicts and the opportunity for the patient to rework central developmental issues allows for the better integration of the personality and for an inner growth and development making the impairment of sexual functioning and conflicting sexual expression no longer necessary. One can even push the argument to its extreme and maintain that the direct attempt to change sexually disordered or perverted behavior is essentially a judgment about the patient and an attempt to manipulate the patient, which is entirely foreign to the analytic approach and the analytic understanding of the human personality.

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Etiology

In the etiology of transexualism, as of other gender identity/role disorders, there is no demonstrable evidence of a hereditary factor, either in the family tree or as a spontaneous mutation. Transexualism has been recorded in some males with the 47, XXY chromosomal condition (Klinefelter’s syndrome), but most XXY individuals are not transexuals.

By inference from experimental animal studies, prenatal hormonal history may be etiologically significant. There is as yet no directly demonstrable human evidence to implicate a prenatal hormonal effect, chiefly because there are no retrospectively retrievable records of the prenatal hormonal history of transexuals. If hormones do play an etiologic role, however, then it is almost certainly in the prenatal period, and not at puberty or later. It is very rare to find a hormonal abnormality in an untreated postpubertal transexual.

In cases of hermaphroditism with a known prenatal history of hormonal abnormality, transexualism is not a subsequent sequel, except in the presence of ambiguity of gender assignment and rearing postnatally. Such cases indicate that prenatal hormonal history alone is not capable of determining the subsequent differentiation of gender identity /role. Postnatal history is proportionally more important. It has not yet proved possible to find a formula from which to predict transexualism on the basis of early childhood history, even among children who overtly wish to change sex. These same children have proved to develop as adolescent homosexuals or bisexuals rather than transexuals. In some families, it is possible to recognize a covert collusion of the parents and the child with respect to the child’s repudiation of his or her anatomic sex.

Diagnosis

The diagnosis of transexualism is based initially on the presenting complaint, namely the need for sex reassignment. It is necessary for legal and ethical reasons to check the anamnesis against other informants and social records. It is in the nature of transexualism to give a revised or edited biography. The best diagnostic test is the “real-life test” for a minimum of two years, during which time social, emotional, and economic rehabilitation in the new sex role is achieved.

Usually the physical examination yields nothing contributing to the diagnosis, but it should not be omitted. In a few cases, other unrelated pathology may limit the therapy for sex reassignment. Very rarely, the EEG may show a temporal lobe epileptic focus requiring neurosurgery after which the sex problem may remit. Hormonal evaluations, useful for the research information they provide, are typically noncontributory.

Differential Diagnosis

The check list for the differential diagnosis includes:

Temporal lobe epilepsy with transexualism or transvestism as a related symptom.

Schizophrenic disorder with transexual gender identity confusion as a symptom.

Transvestism with a strong element of transexualism that emerges, especially in middle life.

Female impersonation in an extremely effeminate male homosexual (drag queen) or male impersonation in a virilistic lesbian.

The above diagnoses do not, in and of themselves alone, rule out the possibility of rehabilitation by means of sex reassignment, but they do require caution and unhurried decisions. Much the same applies also to transexuals who are pathologically depressed, for sex reassignment alone does not reverse depression.

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In America, as in the West more generally, the individual person is considered to be the autonomous agent of action, valuable in and of himself or herself, and the unit through which larger groups are comprehended (c.f., Barnett; Dolgin; Dumont; MacPherson). The significance of this particular construction, which seems perfectly natural to us whose own social order is based on its implications, can be compared to other societies in which alternative constructions pertain. American law is based explicitly on the presumption of the autonomous individual who should, ideally, be treated as equal to all other individuals. For instance, the dictum, basic to Americans, that individuals should receive equal treatment is absent in the world of traditional-caste India, which relies on its own fundamental dictum that people are unequal because created unequally (Barnett). For the sociologist, contemporary efforts in the United States, by both judicial and legislative means, to rectify actual inequalities provide a particularly apt place within which to examine the society’s conception of itself. The contradiction contained in “separate but equal” is now patent and such separation is illegal. Other contradictions remain implicit. Programs such as affirmative action, first effected through executive orders during the Johnson administration and based on legislation in the 1964 Civil Rights Act, entail official recognition of ext inequalities and governmental efforts tow rectification. The inclusion of sex in the legislation, along with race, color, religion, and national origin, may well have been a contingent and not particularly well thought out addition. However, for the legal situation of American women in the past decade, the consequences have been vast.

While the above is intended to illustrate general connection between a society’s not of the person and its substantive law, the examples of discrimination, specifically of sex discrimination, speak more directly to the interrelation between sex and law. Legislation relating to sexual discrimination may seem legally peripheral to laws constraining sex acts. Yet prescribed or prohibited treatment of women as a group (in contrast to men) must, from within a sociological point of view, be related to more general understandings of both social and sexual ties between men and women. Surely, a basic aspect of personal identity in American society is sexual identity. Gender identity (the fact of being male or female) fundamental to, though not inclusive of, sexual identity. Social roles and definitions, insofar as they pertain to or limit the behaviors appropriate to men and women, encompass conceptions of “proper” and “improper” sexual relations between people. Obviously sexual relations occur between members of one sex; until recently homosexual relations have been illegal; in most of the United States. In large part, views of homosexual relations have been defined through their contrast with “proper” sexual relations. The prototypical example proper sex in America is sex between men and women married to each other. Images of sex intertwine with images of women, men, and the family.

It is useful to look at American notions of the family and of sex within that context before turning to legislation concerning sex and to recent changes in that body of law. The paradigmatic relation of sexual love in American culture is that between spouses. Sex is not only presumed proper within the context of the marital bond but is presumed necessary. This presumption has legal as well as more general consequences, and within this context, sex has traditionally been considered proper primarily for the purpose of procreation. The bond of marriage is defined by the law and allows the legal reproduction of people in the form of the family. David Schneider, in his study of American kinship as a cultural system, has identified sexual intercourse as the key symbol of American kinship. This is so, in that sexual intercourse combines the two aspects of kinship as it is understood by Americans: “blood” (or substance) and code-for-conduct or law. Through intercourse, the archtypic relation in law, marriage, is expressed and relations in “blood” (child/parent) are created. The duality of relations in blood (or substance) and in code-for-conduct or law is predicated upon more general notions of nature and culture, respectively. In this frame, relations in law include not only those which are the explicit content of legislation but also relations based in lawlike, ordered sets of interactions. Schneider suggests that in American culture a similar structure of relations in “blood” or substance and relations in law underlies the cultural construction of nationality and religion as well as of kinship.

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Sexual differences in the behavior of children have been studied from several angles. The most traditional are those studies carried out by Sears and Beller and Neubauer. These focused on children’s behavior, that which is observable and measurable and omitted childhood sexuality. The differences between boys and girls were studied for the level of aggressive behavior and dependency. According to Sears, boys consistently showed more physical aggression and negative behavior than girls did. In Sears’s study this difference in the level of aggressive behavior was detectable as early as age three. In Beller’s and Neubauer’s study, the difference in the amount of aggressive behavior was apparent between the ages of two and five. The problem with these and similar studies is that they reflect the cultural bias of the examiners and the different patterns of child-rearing practices used by parents according to the sex of the child. The same is true of those studies examining the difference between sexes with respect to dependency behavior. It is interesting that there is no appreciable difference in dependency behavior between sexes early in life, short of more negative attention-seeking behavior among boys (Sears), which Mischel attributes to boys’ greater physical aggression rather than to their psychological differences. As children’s ages increase, there is increasing incidence of dependent behavior in females (Beller and Turner; Beller and Neubauer).

With the advent of the women’s movement during the last few years and the more independent and assertive roles that women are assuming in Western cultures, the validity of these early-sixties studies has become more questionable. Abstract concepts defining masculine-feminine by dichotomies such as aggressive-friendly, rational-emotional, extroverted-introverted, are oversimplifications that attempt to reduce personal confusion and cultural anxieties (Michael and others). Aggressive or dependent behavior is complex and may express a variety of motivations, tendencies, and styles of adaptation.

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Comparison of the various data sources on the incidence of adultery is difficult because of differences in the collection and presentation of data. Even so, results of the few studies we do have are consistent enough to tell us something about trends and to reveal some surprises.

Kinsey and others provided an interesting essay on extramarital sex among males, but very little data. A major reason for this, explained by the authors, was the inability to get adequate representation in the male sample of older married men from upper educational and social levels: “We have every reason for believing that extramarital intercourse is the source of the hesitance of many of the individuals in such groups to cooperate”. Frequency figures given are thus held to be a minimum, the truth perhaps being 10% to 20% higher.

From available data and allowing for the “cover-up,” Kinsey estimated that about half of all married males had intercourse with women other than their wives, at some time while they were married. Age, social level, and religion were important variables for this sample, the first two, especially, introducing some interesting differences. Among lower-level males, 45% of the youngest married cohort reported having had extramarital intercourse, whereas only 27% did so by age forty and not more than 19% by age fifty. On the other hand, among college-level males, the lowest frequencies were found among the youngest group, in which only 15% to 20% had, the incidence increasing steadily to age fifty, when about 27% was having extramarital relations. Kinsey suggested that lower-level males were more likely to have a great deal of premarital intercourse, with some carryover into marriage followed by a slowing down, which he did not attempt to explain, among the older males. By contrast, upper-level males had a history of greater restraint in the premarital years which continued to be characteristic for some years after marriage, loosening up as they grew older. Though not nearly as great as the differences among social levels, a difference was found between church and non-church related males, the more devout having significantly less experience with extramarital sex.

The data for Hunt’s most closely comparable group revealed that only 41% of the males had ever had extramarital sex. Hunt thought that the lifetime accumulative incidence for the entire sample would be somewhat higher, but still not more than 50%, since the data showed no rise after the age of forty-four. Though Hunt found a slight increase among the youngest cohort, it was small compared to the increases in other types of sexual outlets for this group. Likewise, he found little change compared to the Kinsey data for educational level and religion.

Kinsey and others presented much more data on extramarital activity among females than in the earlier volume on males. His female sample, however, had a much higher ratio of previously married to married women, than is the case in the general population. Since previously married women have a much higher incidence of extramarital relations than do women who have been married only once (Bohannon), this had the effect of inflating Kinsey’s figures. When Hunt “rebalanced” Kinsey’s figures to account for this and compared them with his own sample, he concluded that there was no difference in the accumulative incidences up to age forty-five for the two groups. By age forty-five, 20% of Kinsey’s sample had had extramarital intercourse, compared to 18% of Hunt’s sample. Broken down by age groups, however, a remarkable change was found in the group of women below age twenty-five. Whereas only 8% of Kinsey’s group had had such experience, 24% of Hunt’s had. Comparisons between the generations sampled in these two studies, then, suggest that, in spite of widespread beliefs to the contrary, the incidence of extramarital intercourse has changed little if any among male and female groups in general; it has increased slightly among under-twenty-five males, and greatly among under-twenty-five females, bringing them nearly to the level of their male cohorts. Extramarital sex is increasing in the direction of equality, with the greater increase being among females.

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