Clinical Patterns Among Male Transsexual 
    Candidates with Erotic Interest in Males 

   Frank Leavitt, Ph.D.,1,3 and 
   Jack C. Berger, M.D.2 
   Male-to-female transsexuals who reported an erotic interest in males showed 
different patterns of sexual activity.  Sexual history was used to categorize 
a transsexual sample into three groups: 44% abstained from sexual activity 
(Inactive group), 19% were sexually active but avoided using their penis in 
sexual activity (Avoidant group), and 37% were sexually active and derived 
pleasure from their penis (Pleasure group).  The groups were compared for 
differences in gender identification, developmental patterns, and personality.  
Transsexuals in the Avoidant group showed patterns of traits and experiences 
that generally conformed to characteristics of the nuclear transsexual.  They 
were dissimilar from the other two groups on measures of feminine functioning, 
heterosexual history, and fetishism.  Transsexuals who interact with males in 
ways that are viewed as more classically homosexual shared more in common with 
the transsexual group which abstained from sexual activity with males.  Both 
groups displayed more masculinity in development and more evidence of 
emotional disturbance.  The implications of these findings for diagnosis and 
treatment are discussed. 
   KEY WORDS: gender dysphoria; male-to-female transsexual; homosexual 
   1Department of Psychology and Social Sciences, Rush Medical College, 1653 
West Congress Parkway, Chicago, Illinois 60612.  
   2Department of Psychiatry, Rush Medical College, Chicago, Illinois.  
   3To whom correspondence should be addressed.  
   Male-to-female transsexuals meeting DSM-III criteria (APA, 1980) for the 
gender disorder are heterogeneous in sex object preference.  By far, the 
majority of males seeking reassignment are attracted to males and labeled 
homosexual transsexuals.  Smaller percentages show heterosexual and bisexual 
attraction.  The rest are asexual (Blanchard, 1985).  The homosexual 
transsexual label is both confusing and controversial among males seeking sex 
reassignment.  Transsexuals, as a group, vehemently oppose the label and its 
pejorative baggage (Morgan, 1978).  As a rule, they are highly invested in a 
heterosexual life-style and are repulsed by notions of homosexual relations 
with males.  Attention from males often serves to validate their feminine 
status.  For many biological male transsexuals, acts of intimacy with women 
are truncated, because sexual attraction and relations with women pose the 
homosexual issue. 
   Recent research presents a different view of sexual activity among male 
transsexuals.  In a study of 44 transsexual males (Langevin et al., 1977), 88% 
(35/44) allowed a male partner to touch their penis, 29% (17/40) received 
fellatio, and 2% (1/44) performed anal intercourse.  These findings indicate 
that erotic pleasure in the penis is more common among male transsexuals than 
formerly assumed and suggest that the homosexual label may be justified in a 
subgroup of transsexuals.  These patients also differed on variables measuring 
emotional stability and cross-dressing.  Those patients who derived erotic 
pleasure from their penis were more likely to be emotionally unstable, and 
less likely to have switched to full-time living as women, suggesting that 
clinicians may be dealing with different disorders that require separate 
explanations.  This is in line with Stoller's claim (1973) that erotic 
pleasure in the penis does not exist in the true transsexual. 
   Patients with histories of deriving erotic pleasure from the penis voice 
complaints of gender dysphoria that do not distinguish them from other 
patients seeking gender reassignment.  Most meet DSM-III criteria which are 
broadly written.  Their form of sexual gratification runs so counter to the 
majority view of the fundamental features of the transsexual disorder as to 
require clarification.  At minimum, it may simply mean that popular notions of 
transsexualism that developed on an anecdotal basis need to be revised.  On 
the other hand, the "atypical" pattern of sexual gratification could mean that 
patients presenting with this history are pseudo-transsexuals who really 
experience other disorders.  In these cases, it may be legitimate to question 
whether the disturbance is one of gender, sexual disturbance, or 
   The purpose of this paper is to offer a broader view of male transsexuals 
showing erotic interest in males.  The general hypothesis is that transsexual 
males deriving erotic pleasure from the penis represent a different diagnostic 
entity and should show important developmental, gender, and personality 
differences that distinguish them from male transsexuals who do not involve 
the penis in sexual activity with males. 
   The sample consisted of all biological males seeking presurgical 
psychiatric evaluation for sex reassignment in a gender identity clinic; 112 
males who were otherwise unselected formed the initial study pool.  These 
subjects were classified for erotic attraction to males using the Androphilia 
Scale developed by Freund et al. (1982) and later modified by Blanchard 
(1985).  A score of 7.49 or higher on the modified Androphilia scale was 
required for inclusion in the study.  This score was set so as to exclude 
patients with scores more than 1 standard deviation below the mean of 
Blanchard's homosexual transsexual group (X 9.86; SD 2.37).  On the basis of 
the cutoff score, 81 subjects were erotically attracted to males and defined 
the homosexual transsexual study pool.  The 81 subjects were divided into 
three groups on the basis of their answers to questions concerning prior 
sexual contact with males.  Sexual contact was operationalized along six 
dimensions articulated by Langevin et al. (1977).  These involve males 
masturbating the subject, males performing fellation on the subject, males 
performing anal intercourse on the subject, the subject masturbating other 
males, the subject performing fellatio on other males, and the subject 
performing anal intercourse on other males.  These six areas were covered by 
24 questions on a questionnaire.  Based on answers to these questions three 
groups were formed.  Criterion for inclusion in the Pleasure group was 
admission of five sexual experiences specifying sexual activity involving use 
of the patient's penis in either masturbation, fellatio, or anal intercourse.  
Admission of five sexual experiences with males, but not involving the 
subject's penis resulted in placement in the Avoidant group.  The remaining 
subjects constituted the sexually Inactive group.  This resulted in 30 
Pleasure subjects, 15 Avoidant subjects, and 36 sexually Inactive subjects.  
Subjects were also classified into the same three categories on the basis of 
an extensive interview.  All but four subjects were assigned to the same 
category as derived from questionnaire data.  These four subjects were not 
included in the analyses.  The three groups were comparable in age.  The 
Inactive group was slightly more educated than the Pleasure group (see Table 
   The three groups were quite discrete even though the cutoff score was 
arbitrarily set.  In the Avoidant group, 10 never allowed their partners to 
touch their penis, 2 admitted to one experience, 2 admitted to two, and 1 to 
three.  In the Pleasure group, the lowest number of experiences was 9, and at 
least one third of the group reported more than 100 experiences.  In the 
Inactive group, over 75% reported no sexual experiences with males. 
   Table I.  Demographic Data of Patients 
   in Three Transsexual Groups 
                                    Avoidant  Pleasure  Inactive 
                                    (n = 15)  (n = 30)  (n = 36)    F value p 
 Age Mean                           29.9      32.8      34.5       1.7      ns 
 SD                                  4.2       7.5       9.6 
 Education                          13.2      12.7      14.6       6.70     0.002 
 Months living full time as a woman 59.4      37.1       8.8       5.80     0.005 
 Age of cross-dressing onset         9.0       9.0       8.3       0.28     ns 
   The BEM Sex Role Inventory (BSRI), the MF scale of the Minnesota 
Multiphasic Personality Inventory (MMPI), and the Draw-A-Person Test (DAP) 
were used to measure aspects of gender identity.  The BSRI (Bem, 1977) is a 
self-administered 60-item scale consisting of 20 personality characteristics 
that are stereotypically masculine, 20 that are stereotypically feminine, and 
20 that are embedded as buffer items.  Each item is scored along a 7-point 
scale ranging from never or almost never true (1) to always or almost always 
true (7).  Two kinds of scores are obtained.  One is a simple indicator of 
masculinity or femininity derived by adding masculine and feminine items 
separately.  The other is obtained by classifying patient's scores as either 
falling above or below normative (Bem, 1981) median-split scores (4.90 for 
femininity and 4.95 for masculinity) and then classifying them as androgynous 
(above median on both masculinity and femininity), feminine or masculine sex 
typed (high on the named scale, and low on the other), or undifferentiated 
(below median on both). 
   The MF scale of the MMPI provides a single measure of masculinity and 
femininity based on respondents' answers to 60 true-false questions dealing 
with interest, vocational choice, aesthetic preference, and activity-passivity 
dispositions.  High scores (> 70) on the male scale imply femininity of 
emotional interest.  Low scores imply masculinity of emotional interest. 
   On the DAP, the subject is asked to draw a whole person (Machover, 1949).  
Following this drawing, the subject is asked to draw a person of the opposite 
sex to the first figure drawn.  The gender of the first figure drawn is 
recorded and taken as an indicator of gender identification.  It has been 
shown that 80 to 90% of males (Fleming et al., 1979) draw a male figure first. 
   Two variables were measured from responses to the Rorschach test.  Adequacy 
of reality testing was assessed using the F + percentage and number of popular 
responses seen by the subject.  Sexual concern was assessed using the number 
of sex responses elicited in evaluation.  The Rorschach was administered and 
scored according to Beck et al. (1961).  Reliability of scoring has been 
documented (Leavitt and Garron, 1982). 
   General psychopathology was assessed using the MMPI.  The test was 
individually administered and scored for 3 validity scales and 10 clinical 
   Demographic and developmental data were obtained from a questionnaire 
included in the comprehensive psychological examination administered by a 
clinical psychologist with more than 10 years experience in examining 
transsexuals.  The questionnaire consisted of items documenting age, 
education, marital history, age when subject first started cross-dressing, 
either fully or partially, years living full time in the cross-gender role, 
repugnance for genitals, and history of sexual attraction to women.  Cross-
gender fetishism was measured by an item borrowed from the work of Blanchard 
(1985).  "Did you every feel sexually aroused when putting on females' 
underwear or clothing?" Developmental history involving preference for 
feminine toy play, feminine play partners, and avoidance of masculine activity 
was obtained using items on the Gender Identity Scales for Males (Freund et 
al., 1977).  These items are detailed in Table II. 
   Table II.  Psychosocial Characteristics of Transsexual Males Varying in the 
Sexual Expression of Their Erotic Preference for Males 
                                        Avoidant   Pleasure    Inactive 
                                        (n = 15)   (n = 30)    (n = 36)   Variable                               %          %       %      X2      P 
  Never married                        100.0       76.7        52.8      12.2     0.002 
  Avoids masculine activity             73.3       40.0        52.8       4.5     ns 
  Preference for feminine toy play      86.7       53.3        50.0       6.3     0.000 
  Preference for female play partners   86.7       63.3        52.8       5.8     0.050 
  Repugnance for own genitals           93.3       16.7        36.1      24.9     0.001 
  History of sexual attraction to women  0.0       33.3        58.3      15.7     0.001 
  History of fetishistic arousal         6.7       33.3        50.0       8.8     0.010 
   Table III.  Sex-Role Identity Scores from the BSRI, 
   the MF Scale, and the DAP 
                                     Pleasure  Avoidant  Inactive 
                                     (n = 30)  (n = 15)  (n = 36)   F value p 
   BSRI Masculine scale               4.60      4.66      4.77      0.397   ns 
   Feminine scale                     5.41      5.49      5.32      0.861   ns 
   MMPI MF scale                     83.70     82.20     84.80      0.690    ns 
   X2 Value DAP Drew female first    60%       80.0%     65%        3.340    ns 
   Gender identity scores of the masculine and feminine scales of the BSRI 
were analyzed in two ways following the work of Bem (1977).  First, one-way 
analyses of variance were used to test for gender difference among the three 
transsexual groups.  Results of separate analyses of male and female scores 
are presented in Table III.  There were no statistically significant gender 
differences among the three groups.  Subjects in the three groups scored below 
the normative median for males (4.95) on the masculine scale and above the 
normative median (4.90) on the feminine scale (Bem, 1981). 
   The second analysis used Bem's median-split scoring system to classify all 
subjects into four sex role identity groups.  Subjects were labeled as 
masculine (high masculine-low feminine score), feminine (high feminine-low 
masculine score), androgynous (high masculine-high feminine score), and 
undifferentiated (low masculine-low feminine score) based on this separation.  
Percentages of the three groups falling into the four sex role groups are 
presented in Table IV.  The relation between type of transsexual and sex role 
identity was not significant, X2(6) = 3.32, p > 0.77.  As seen in Table IV, 
the majority of transsexuals in all three groups tended to be either feminine 
or androgynous. 
   Table IV.  Incidence of Sex-Role Identity in Transsexuals 
   Varying in Sexual Activity with Males 
    x-role                   Inactive  Avoidant  Pleasure 
   identity                  (n = 36)  (n = 15)  (n = 30) 
   Androgynous          n     13        4        10     
    %                         36.1     26.7      33.3 
   Feminine             n     13        9        15     
    %                         36.1     60.0      50.0 
   Masculine            n      4        1         2     
    %                         11.1      6.7       6.7 
   Undifferentiated     n      6        1         3    
    %                         16.7      6.7      10.0 
   Table V.  Mean Scores of the Three Transsexual Groups 
   on the MMPI Scales and Rorschach Variables 
   Variable             Avoidant  Pleasure  Inactive    F value p 
                       (n = 15)   (n = 30)  (n = 36) 
   MMPI scale 
    L                   54.4      50.1      49.9       1.81      ns 
    F                   51.0      60.1      57.5       2.40      0.05 
    K                   56.9      56.1      57.1       0.09      ns 
    Hs                  48.2      58.2      56.0       2.47      0.05 
    D                   64.9      64.0      65.1       0.07      ns 
    Hy                  58.5      62.5      62.9       1.21      ns 
    Pd                  61.1      70.4      68.3       2.52      0.05 
    Pa                  55.5      62.8      63.3       2.59      0.05 
    Pt                  58.8      62.8      62.9       0.66      ns 
    Sc                  57.7      70.1      68.3       2.84      0.05 
    Ma                  52.4      59.2      55.6       1.65      ns 
    Si                  55.4      52.3      54.3       0.43      ns 
    Responses           42.8      44.6      43.9       0.87      ns 
    F + %               70.5      57.8      51.1       9.60      0.001 
    Popular responses    7.4       6.6       7.2       0.63      ns 
    Sex responses        0.7       6.4       5.7       4.87      0.01 
   Gender scores from the DAP and the MF scale of the MMPI are presented in 
Table III.  At least 60% of each group drew the female first indicating a high 
degree of femininity in all three groups.  Differences among groups were not 
statistically significant.  In a similar way, their mean T scores of over 80 
on the MF scale of the MMPI is consistent with their identification with the 
female sex.  The differences among groups were again nonsignificant. 
   A series of one-way analyses of variance were performed on MMPI scale 
scores transformed into K-corrected, T-score equivalents.  Significant 
differences were observed among groups on five MMPI scales (see Table V).  
Post hoc testing using Duncan Multiple Range Test revealed the following 
significant (p < 0.05) between-group differences, with higher scores 
reflecting greater psychological impairment.  The Pleasure and Inactive groups 
both scored higher than the Avoidant group on scales F, Hs, Pd, Pa, and Sc.  
The differences between the Pleasure and Inactive groups were nonsignificant 
on these five scales. 
   The Avoidant transsexual sample produced a mean MMPI profile indicative at 
best of a modest level of psychological impairment.  Only scores on Scales D 
and Pd were more than 1 standard deviation (T score of 60) above the normative 
mean score of 50.  On the other hand, the peak scale scores on the Sc and Pd 
scale in both the Pleasure and Inactive transsexual groups are often obtained 
by males who show significant psychopathology in areas of general functioning. 
   Rorschach variables are presented in Table V.  Inspection revealed that the 
F + % and number of sexual content statistically distinguished the three 
groups.  A control for number of responses was not needed as all groups 
produced approximately the same mean number of responses. 
   Chi-square analyses with 2 degrees of freedom were used to compare 
frequencies of the three groups on variables listed in Table II.  Chi-square 
tests for two independent samples were used for pairwise comparisons.  To 
minimize overestimating chi-square values, Yates Correction for Continuity was 
applied to each analysis involving cell sizes of less than 5.  The groups were 
significantly different on six of the seven variables listed.  The Avoidant 
group differed from the two other groups on six of the seven variables listed.  
All 15 patients in this group were single and all denied a history of sexual 
attraction to females.  By comparison, 10 of the 32 patients in the Pleasure 
group reported a history of sexual attraction; 8 of these had tried married 
life.  In the Inactive group, 21 of the 30 patients reported a history of 
sexual attraction and 17 of these had married.  Differences between the 
Pleasure and Inactive groups of these two variables were also significant.  
There was less attraction to females and fewer marriages in the Pleasure 
   The Avoidant group also showed a much smaller incidence of erotic arousal 
to cross-dressing.  Only one patient in the Avoidant group reported a history 
of fetishistic arousal.  This compares with 10 of 30 in the Pleasure group and 
18 of 36 in the Inactive group.  The difference between the Pleasure and 
Inactive group was nonsignificant, X2(1) = 1.86, p > 0.17. 
   The Avoidant group also differed from the other groups in the amount of 
feminine sex-typed behavior in the developmental history; 86% of the group 
reported a developmental history involving cross-sex preference for both play 
partners and play toys. 
   The three groups also differed relative to attitudes regarding the penis.  
In the Avoidant group, 87% stated that the penis was repulsive, compared to 
36.2% in the Inactive group, and 16.7% in the Pleasure group.  The difference 
between the Pleasure and Inactive group was nonsignificant, X2(1) = 2.21, p > 
   Data relating to cross-dressing are presented at the bottom of Table I.  
While the groups did not significantly differ on mean age of onset, patients 
in the Avoidant group had lived significantly longer in the feminine role than 
patients in either of the other two groups.  Differences in full-time living 
between the Pleasure and Inactive group were also significant (p < 0.05). 
   Level of gender disturbance is not a clinically discriminating variable.  
Whether measured by the Draw-A-Person Test, the MF Scale of the MMPI, or the 
Bem Sex Role Inventory, comparable levels of gender disturbance are found 
among the three transsexual groups, with a higher incidence of femininity and 
a lower incidence of masculinity noted.  All three male groups are clearly 
more feminine than heterosexual males when comparisons are made to normative 
data (Gravitz, 1966; Bem, 1981). 
   Clinically, however, transsexuals in the Avoidant group are different from 
transsexuals in the other two groups along a number of important clinical 
dimensions.  On measures of feminine functioning, they appear to follow a 
different developmental pattern.  They show greater amounts of cross-gender 
behavior early in life and more consolidation of feminine identity later in 
life.  Feminine toy play and feminine playmates are almost universal in their 
histories; whereas only one in two report this in the Inactive group, and only 
slightly more in the Pleasure group.  The Avoidant group also seems to have 
experienced less difficulty adopting the cross-gender role as a full time way 
of living.  On average, they have been living full-time as women for 5 years; 
this contrasts with 3 years in the Pleasure group and less than a year in the 
Inactive group. 
   Transsexuals in the Avoidant group are also distinguishable on the basis of 
heterosexual history.  This group is remarkable for the absence of 
heterosexual behavior.  As a group, they totally deny sexual attraction to 
females, and none report marriage.  This compares with an attraction and 
marriage rate of approximately 50% in the Inactive group and 33% in the 
Pleasure group.  Similar patterns are found for the variables measuring 
fetishistic arousal and attitudes towards the penis.  Transsexuals in the 
Avoidant group share a common aversion to their penis and rarely experience 
fetish arousal.  By contrast, at least 33% of the transsexuals in the other 
two groups report a history of fetish arousal and at least 60% deny being 
repulsed by their genitals. 
   The Avoidant group also differs from the Inactive and Pleasure group on the 
basis of psychopathology.  Transsexuals in this group appear psychologically 
healthy by scores on both the MMPI and the Rorschach.  There is no evidence 
that their disorder is based on psychopathology as suggested by some (Roberto, 
1983).  Transsexuals in both the Inactive and Pleasure group show significant 
psychiatric impairment and interestingly emphasize sex content in responding 
to Rorschach stimuli.  Prominence of sex content in protocols is generally 
interpreted as an indicator of disruptive problems in sexual adjustment 
(Philips and Smith, 1953). 
   Transsexuals who are sexually active with males but do not allow their 
penis to be involved in sexual activity share a constellation of traits and 
experiences that generally conform to characteristics of the nuclear 
transsexual (Buhrich and McConaghy, 1977).  The picture of the nuclear 
transsexual conveyed by the literature is that of sustained, nonfluctuating 
femininity, developmental patterns involving a preference for girls' games and 
company, aversion to rough-and-tumble activity in early childhood, later 
patterns involving a desire to posses a women's body, to live in society as a 
woman, and to attract heterosexual male partners.  The nuclear transsexuals 
experience intense disgust and aversion for their penis and deny a history of 
heterosexual orientation or fetish arousal.  If patients in the Avoidant group 
are accepted as nuclear transsexuals, then only 18.5% of our sample meet those 
criteria.  This implies that most of our sample seeking reassignment are not 
nuclear transsexuals (Newman and Stoller, 1974).  This supports Lothstein's 
claim (1982) that most "patients seeking surgery are secondary transsexuals, 
i.e., transvestite or effeminate homosexuals." 
   Transsexuals who derive pleasure from the penis are clinically more 
puzzling.  They interact with males in ways that are more classically viewed 
as homosexual, yet they share more in common with transsexual males who have 
been the least sexually active with males and the most heterosexually 
oriented.  They are particularly similar to this group on variables involving 
early developmental patterns and psychopathology.  Both display more 
masculinity in their developmental patterns and more emotional disturbance 
probably rooted in the sexual sphere.  They are somewhat less alike in respect 
to repugnance for their genitals and for fetish arousal, but these differences 
are not statistically significant.  Transsexuals who derive pleasure from the 
penis however display substantially less in the way of heterosexual patterns 
than do transsexuals in the Inactive group.  They were less attracted to 
women, fewer had married, and most have lived longer in the feminine role on a 
full-time basis.  The level of psychopathology in this group is similar to 
that of other transsexual groups who have involved their penis to a 
considerable degree in sexual relations.  Langevin et al. (1977) reported 
significantly more suicide preoccupation and more abnormal MMPI patterns for 
this subset of transsexuals.  The prominence of fetishism in this group is 
unusual since it is considerably higher than typically reported for 
transsexual groups.  A fetish rate among homosexuals of only 8% was reported 
by Hellman et al. (1981).  It was noted that the homosexuals who exhibited 
arousal to cross dressing also scored higher on femininity.  This may suggest 
that one feminine form of homosexuality is fetishistic.  If individuals of 
this nature come to look upon themselves as transsexual, this could explain 
the puzzling as sociation of penile pleasure and fetishism in this group. 
   Other studies have found similar subgroups of transsexuals who show sexual 
patterns that conform to those of nontranssexual homosexuals.  Bentler (1976) 
in a study of 42 postoperative male-to-female transsexuals classified 36% of 
this sample as homosexual on the basis of a five-item sex questionnaire.  All 
members of this group admitted to viewing themselves as homosexual prior to 
surgery; following surgery, they were much more sexually active than either 
the heterosexual or asexual comparison groups.  Sexual activity involving 
fellatio and anal intercourse was prominent, with pleasure reported by 73 and 
33%, respectively.  A 23% incidence of fetish arousal was observed among these 
patients.  Their postoperative adjustment was poor.  One-quarter reported that 
life as a female was not up to expectations in comparison to none in the two 
contrasting groups. 
   Transsexuals in the Inactive group report characteristics that most depart 
from the nuclear transsexual pattern.  Strong heterosexual orientations and 
fetish histories are prominent.  They show the most difficulty in making the 
transition to full-time feminine living.  Despite reporting erotic interest in 
males, the pattern exhibited generally conforms to that exhibited by patients 
referred to as heterosexual transsexuals (Buhrich and McConaghy, 1978).  
Studies by Blanchard et al. (1985) suggested that some heterosexual 
transsexuals adjust their histories of erotic preference to bolster their 
chances of receiving a positive decision on sex reassignment surgery.  Since 
this group accounts for 40% of the sample and shares little in common with 
homosexuals, except a stated erotic interest in males, the use of the 
homosexual label for patients with a stated erotic attraction to males seems 
to have little merit; the label with its pejorative baggage may guide clinical 
thinking in a misleading direction.  Adoption of more neutral descriptive 
terms such as androphilia (Freund et al., 1982) to indicate erotic preference 
for physically mature males may be desirable. 
   The present study contains a potential methodological flaw that needs to be 
considered in evaluating the heterogeneity of results concerning fetish 
arousal.  The study selected transsexuals with strong sexual attraction to 
males using a cutoff score of 7.49 on the Androphilia scale.  It is possible 
that some transsexuals with a strong sexual attraction to males are bisexual 
rather than homosexual.  Sexual attraction to females was not directly 
measured in this study.  Instead, the 7.49 cutting score was calculated to 
eliminate 77% of bisexuals in our study using Blanchard's normative data 
(1985).  His bisexual transsexuals had a mean score of 4.15 (SD 4.18) on the 
Androphilia scale.  Based on probability statistics of the normal curve, it is 
estimated that only five patients in our final sample are bisexual.  While 
fetish arousal is common among bisexuals, an n of 5 cannot account for the 
fact that 18 of 36 subjects in the Inactive group, 10 of 30 in the Pleasure 
group, and 1 of 15 in the Avoidant group report fetish arousal (see Table II).  
It remains possible that the cutting score selected was not as successful as 
planned in excluding bisexual transsexuals. 
   The data suggest several kinds of clinical patterns among candidates for 
sex reassignment surgery who are erotically attracted to males that need to be 
differentiated in the development of topologies.  These types cannot be 
understood on the basis of different levels of gender disturbances, since high 
levels of femininity are experienced by all groups.  It appears clinically 
important to carefully document history of sexual activity with males since 
this variable seems to separate this part of the "presenting transsexual" 
population into three forms that are sufficiently distinct to raise the 
possibility that clinicians may be dealing with separate and distinct 
entities.  Our data point to the centrality of sexual disturbance and 
psychopathology in two of these groups and raise the question whether 
clinicians should be more cautious when history places candidates in either 
the Pleasure or Inactive groups.  Beyond that lies the question of whether 
these are genuine transsexuals or pseudo-transsexuals.  Patients label their 
gender states in terms of the limited cognitions available and/or acceptable 
to them.  Should clinicians accept the same?  There may be entirely different 
paths for shaping feminine gender in males, and these paths may reflect 
entirely different etiologies and disorders.  The data point to no specific 
etiology for those transsexuals who seem to fit the nuclear transsexual 
pattern best.  Though speculative, they show the consolidation of feminine 
behavior and the stability of personality functioning that one might expect to 
see in a condition with an organic cause.  They may represent the most 
appropriate group for surgical intervention. 
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