The Development of Female Transsexualism Vamik D. Volkan, M.D.* Charlottesville, VA As'ad Masri, M.D.** Charlottesville, VA
Characteristics by which to classify a woman as authentically transsexual are offered from earlier investigations and supplemented by findings from recent work with this type of patient. Developmental issues are discussed and six psychodynamic accompaniments listed. A case demonstrates how to identify the true female transsexual and how to understand her psychological processes. Seen rightly as a tragic individual, the transsexual is a challenge to mental health professionals from a number of disciplines and educational levels. There is a danger of losing something of the developmental twists and complicated dynamics in the controversies that surround therapeutic handling of such patients. This paper focuses on the female transsexual. Beginning with data gathered in the course of our earlier work, supplemented by more recent work with the same type of patient, we will describe the true female transsexual and then summarize developmental issues and their accompanying psychodynamics. We will outline a new illustrative case, indicating how one goes about diagnosing a true female transsexual and identifying on what one must focus to understand the psychological processes involved. A surprisingly large number of men and women claim to be victims of a cruel trick of nature and to be imprisoned in bodies of the wrong sex. Those with perfect female bodies maintain that, in spite of appearances, they are in truth men; and those with characteristically male bodies assert that they are nonetheless women. These people, called transsexuals, demand surgical and endocrinological treatment to correct nature's mistake, to be freed from a state they find intolerable. Their eagerness to submit to surgery and physical pain in their desire to relieve internal psychological pressure remains a baffling clinical phenomenon. Volkan and his coworkers1-6 have studied how true male and female transsexualism develops, and what kinds of psychodynamics are involved. Their method of investigation included a systematic diagnostic workup; a series of interviews before the surgical change and, when possible, afterward; and interviews with parents and sex partners when feasible. Twelve of those studied underwent psychoanalytically oriented psychotherapy, and psychoanalysis was attempted with one. Most of these patients were given psychological tests, including the Wechsler Adult Intelligence Scale, the Rorschach, the Multiple Affect Adjective Check List, the Minnesota Multiphasic Personality Inventory, the Strong Vocational Interest Blank, the Mooney Problem Check List, and the 16 Personality Factor Inventory. A hundred patients were seen during a five-year period; all underwent physical examination and endocrinological evaluation. All were considered by gynecologists, endocrinologists, and others to be respectively normal male and female persons. The developmental process and accompanying psychodynamics of the transsexual are complex. When these complex issues are presented in theoretical terms in order to summarize our findings, we may find ourselves turning away from the actual clinical situation and adding to the confusion. Therefore, a further report on cases useful for elucidating relevant theoretical formulations and dealing with the complexity of developmental processes becomes necessary. CLINICAL DESCRIPTION Many women have disturbances in their gender identity and are masochistic they may be preoccupied with a sex-change operation for a number of reasons. This preoccupation may be associated with clinical conditions that vary from neurosis to psychosis, so it becomes necessary to identify who among the many women seeking surgical change are real female transsexuals and classify in the core group those who share the same phenomenological characteristics and metapsychological makeup. The first four of the characteristics true female transsexuals share were described originally by Socarides,7 who suggested that they apply to the male transsexual also. They are (1) the intense, insistent, and overriding desire to be transformed bodily into a person of the opposite sex; (2) a conviction of being trapped in a body of the wrong sex; (3) concomitant imitation of the behavior of one of the opposite sex; and (4) an insistent search for sexual transformation by means of surgery and endocrinological supplements. The true female transsexual seems to have a need from the pre-oedipal phase of life to patch her body and psyche by putting something between her legs, inside her panties. For example, a little girl may need to put a Q-tip between her legs in order to sleep. The adult patient when telling of such childhood activity refers to the inanimate object as a penis substitute, and points to its use as proof that her identity as a male began in the early years of her life. Although such objects become eventually phallic symbols, the child is compelled to assign different meanings for them at different phases of her development. At different times, throughout the childhood of future true female transsexuals, inanimate objects, are utilized as transitional objects, childhood fetishes dealing with separation anxiety and adult fetishes dealing with oedipal issues. Nonetheless, the habitual placing of something between the legs from the pre-oedipal period on is a criterion of true female transsexualism.2,6 Volkan6 holds that a search for perfection is yet another. The patient hopes - even believes, against all odds - that she can not only be transformed into a man but that she will be an outstanding man, powerful and strong, the superman created by her own idealizing imagination. It is seldom enough for her to have one surgical procedure; she is likely to seek further surgical modification; thus "surgical addiction" appears as another criterion. After going through adolescence the true female transsexual crystallizes her delusion of belonging to the opposite sex. Then the articles once used as penis substitutes are abandoned and an intense search to obtain a penis of flesh begins. From then on she singlemindedly aims to prove her case and achieve transformation by surgical and endocrinological means, seeming narcissistic and exhibiting an exaggerated sense of entitlement. Although her reality testing in respect to events without great emotional content may appear intact, it is occasionally blurred in emotionally charged areas as she struggles to fit the world around her to her inner demands, and she gives the impression of being self-centered. Developmental Issues and Inner Structure We believe that the final diagnosis of true female transsexualism should wait examination of the patient's developmental issues and determination of her inner psychological structure; the formulation of the nature of her self- and object representations; and conflicts within the sphere of internalized object relations. *Director of the Center for the Study of Mind and Human Interaction; Professor of Psychiatry, University of Virginia Medical School; Medical Director, Blue Ridge Hospital. Mailing address: Blue Ridge Hospital, University of Virginia Medical Center, Charlottesville, VA 22910 **Clinical Professor of Psychiatry, Department of Behavioral Medicine and Psychiatry University of Virginia Medical School, Medical Director, Poplar Springs Hospital, Petersburg VA. After studying 12 male and female transsexuals awaiting surgical change and hearing their dream reports, Volkan and Bhatti1 identified six themes characteristic of the female transsexual's psychology: (1) The mother has been martyred, depressed, and sexually hungry, and her child has developed intense rescue fantasies accordingly. (2) The female child has had unconscious fantasies that she could save her mother only if she herself were male. (3) She then begins to place something between her legs and these objects (a Q- tip, a plastic bottle, for example) are precursors of the penis-she longs to have surgically made available, and link her to her mother like childhood fetishes8-10 that deal with her separation anxiety. (4) Contrariwise, as a symbolic penis the substitute object separates the girl from the depressed mother who lacks a penis. Thus such objects are used both to link and to unlink the child's self-representation from the mother's representation as an object. (5) When the girl arrives at the oedipal age, she yearns to escape from the troubled but intense relationship with her mother's representation by being loved by the father. When he fails to reassure her, she consoles herself by identifying with him, and this identification changes the dominant meaning of her inanimate object. It is then unconsciously experienced as the father's phallus.11 (6) During the adolescence passage, the girl gives up her inanimate object and now demands a penis to be constructed surgically. These findings were examined further and refined; the presence of a depressed and sexually hungry mother seemed crucial at the start of a complicated road toward female transsexualism. Stoller12 has identified a similar family background among his patients of this type. There is much in the literature about the way in which a mother's depression may awaken rescue fantasies in her child,13-15 although this maternal characteristic by itself does not bring about transsexualism. Maternal depression may be likened to a picture frame in which different pictures can be displayed. It may lead a child to pursue a healing profession in adult life, indeed, to become a psychoanalytic therapist. Thus we must examine the kind of message the depressed mother conveys to her daughter, and what kind of help she unconsciously expects from her. Mother/daughter interaction helps make the rescue fantasies of the latter rather specific. The mother associates her depression with the loss of a penis, for which she searches, feeling that only by obtaining one can she assuage her depression, and she views her daughter as a "special being" who can provide one. Being regarded as special leads the daughter to a self- centered, narcissistic attitude as she grows up. The daughter's desire to rescue her mother is actually selfish since the depression is an impediment to the provision of good mothering to her child. Although here we speak objectively about this process, neither mother nor daughter is aware of it. It is experiential, unconscious, and never put into words. The female transsexual's "unconscious fantasies" become evident in clinical work when the patient as an adult exhibits her conscious derivatives in free association, dreams, stories involving transference, and projective psychological tests. As Beres16 states, we surmise the presence of unconscious fantasies from their effects. This is like a physicist surmising the existence of the particles of an atom by the effects they produce. The mother cares for the child she needs, so the child cannot integrate a representation of the caring mother with that of the needy one, but unconsciously rescues it and maintains it as good by providing it with an illusory penis. Under these circumstances, the illusory penis is invested with libido and serves to bridge the gap between the caring mother and the selfishly rescuing child. The adult female transsexual wants to gain a fleshy penis by surgery; in her mind this males real the fusion between the good child and the rescued mother. But the "penis" made available through surgery, like its precursors, the inanimate objects used symbolically, cannot magically maintain the sought-for psychic equilibrium; within a few months or years after acquiring it, the patient is likely to dream of being once again a woman. This disturbs her illusion of being truly a man, and she starts to look for more surgery to make her external appearance conform more nearly to that of a man - to give her mother a penis, to save her, and to fuse with her. The illusory penis put between the child and her mother becomes invested with aggression in a paradoxical way; instead of wanting to save the representation of the caring mother, the daughter dreads fusion with that of the demanding, depressed, and needy parent. When she experiences herself as the owner of the illusory penis she feels separated from the bad mother who is without one, perceiving her as representing a dangerous environment and wanting to take away the illusory penis. The child's penis is invested with aggression toward the bad environment An adult female transsexual may see in the Rorschach test an image of the bad mother as a black widow spider, bleeding, or with a tail cut off.4 Clinical investigation has identified the following goals behind the true female transsexual's search for perfection: (1) Denial or more complete detachment from derivatives of the aggressive-drive characteristic in rather unneutralized form; if she is now powerful or special in some way she will be above frustration and the need to display aggression. (2) The defense against anxiety by hoping to be rid of aggression. Although we have noted the likelihood of repeated surgery being sought to maintain or re-establish the link to the good mother, we now see that aggression toward the needy mother is a feature of surgical addiction also. Both libidinously and aggressively determined motives combine to make the patient a surgery addict. Metapsychological Formulation Let us summarize in metapsychological terms what has been described. The female transsexual splits her mother representations and corresponding self- representations. On one side is a representation of the depressed mother and a corresponding representation of her child; fusion rescues the mother from her depression and makes a caring representation. On the other, another representation of the depressed mother exists from fusion with which the child protects her corresponding self-representation. Her perception of the illusory penis is also split; when invested with libido it fuses representations of both persons, but when-invested with aggression it separates them. It is clear that the inner psychological structure of the true transsexual resembles the organization of a person with a borderline personality except in one particular: Self- and object representations are differentiated by the person with a typical borderline personality organization while defensive splitting and related defense mechanisms are in operation.3,17 Though in most areas, the female transsexual also "knows" where she ends and her mother's representation begins in relation to genital images, in either case the representations are fused.6 A similar formulation was proposed by Bak18 in respect to perversions in general. In clinical terms there remains confusion and-ambiguity in the representation of genital body parts because the illusory penis is shared by both parties, and because the child identifies with the mother who has a penis but remains afraid of the one without because of the possibility that she will steal hers. The Issue of Specificity: Actual Trauma Yet, the developmental issues described outline a picture that, when refined, does not always indicate female transsexualism. Many women with borderline personality do not exhibit transsexualism, so what must we add to the outline? What characterizes the specific clinical picture of female transsexualism? Specificity is difficult in any emotional illness because of the different condensations of different variables in different individuals. However, Volkan6 suggests that the occurrence of an actual trauma in the child's life that is congruent in or echoed by her unconscious fantasy is crucial in the development of female transsexualism. The historical trauma may involve body parts; an example would be the small girl who suffers from frequent urinary infections and has her genital areas repeatedly stimulated by the application of medication; such stimulation can awaken sensations connected with her being the reservoir of an illusory penis - or she may perceive the adult's interference as an attempt to rob her of her genitalia. The contributory trauma may not occur to her body but be something congruent with her unconscious fantasies. For example, a child seeing her mother use a dildo could promote the illusion that she stood in need of a penis. One mother took pictures of her own naked body with self-developing film in the presence of her daughter, and sent them to her husband, who was stationed in Japan. This led to the child's fantasizing that her mother was sexually hungry.6 The Father's Role Still another developmental issue should be taken into account as a contributory factor in female transsexualism; this is the father's absence, either in the physical or psychological sense, when the girl is at the oedipal age. Since he is not at hand to extricate the child from too close an involvement with the mother, the former remains psychologically in the latter's orbit. Latency and Adolescence The latency period of the true female transsexual is active; the girl cannot put to rest the unnegotiated developmental tasks or her object- relations conflicts, and her efforts toward their resolution. The second individuation19 that takes place in adolescence does not loosen her psychological investment to early representations of father and mother. She uses splitting as a dominant defense mechanism and cannot form usual and expected peer relationships. She feels different from her peers and effective "new" identifications with them do not take place; whatever identity crystallizes at this crucial phase of her life is based on childhood myths and fantasies. She now develops more concretely the identity of a male youngster, and in mid- or late adolescence she seeks out a sexual partner according to this crystallized identity; another female can provide a support system for her belief that she is a man. The two girls create an illusory shared penis just as in childhood the female transsexual had created one shared with her mother. Demonstration of the belief in the male identity of one of the pair defends both against any acknowledgement of a lesbian attachment. Homosexuality is denied.7 It is during her adolescence that the potential transsexual first reads about this state and learns of what can be accomplished through "sex- reassignment surgery," which should more properly be called "aggression- reassignment surgery." She then uses secondary-process reasoning in an obsessional and narcissistic way as she embarks on a stubborn search for surgical and endocrinological transformation. AN ILLUSTRATION CLINICAL DESCRIPTION Carla, a pretty girl of 17, calls herself Carlos and believes she is a man trapped in the body of a woman. She has felt this as long as she can remember, and from early childhood stuffed folded toilet tissue or a sock in her panties to pretend that she had a penis. She hated wearing girls' clothing, and recalls that between the age of six and nine she prayed that Santa would bring her a "weenie." At fourteen she read about sex operations, and became obsessed with the idea that all her problems would be solved were she to have one. She saw a few therapists and her parents agreed that she should have a sex-change operation. She came to our attention for a final evaluation and treatment at a time when she was exhibiting some evidence of depression and had broken off her relationship with a special girlfriend in school. The two girls had been in the habit of lying together with a pillow between them, and hugging and kissing. She felt both "believed" that she had a penis although both "knew" that she did not. Whenever her partner made a seductive remark, Carla would imply that this gave her an erection. Both girls spoke of the illusory penis as "the killer." Carla refused to undress before her friend, but masturbated when alone and thinking of her, rubbed her genitalia on the mattress. Neither girl considered herself a lesbian since both believed that Carla was truly a boy trapped in a female body. When the girlfriend's father learned of her association with Carla, he forbade her to see her friend. Carla dressed in unisex fashion, and she was mercilessly teased at school. She became very lonely after breaking off with her friend, and more preoccupied than ever with having a sex-change operation. All the time not required by school and her job in a restaurant, she spent alone in her room. Her belief in being a man could not be shaken. She once challenged her therapist, saying that if a sonogram examination demonstrated the presence of a uterus in her body she would give up, so certain was she that the interior of her body was that of a male. Since the therapist's experience indicated that to confront a patient with proof of her delusions was not to persuade her of their nature, he did not set up a sonogram appointment. Physical and Laboratory Examinations Just before becoming our patient Carla was found to be biologically a normal woman according to a physical examination, laboratory tests, and chromosomal studies at a university hospital. Her Mother's Depression Carla's mother, Maria, a woman in her early 50s, was born and reared in Spain, and still speaks English with an accent. She was the third and last child in her family, two sisters being six and five years her senior respectively. Her memories of her early childhood recall the dangerous and frightening family environment, and a father who drank heavily and beat her mother. She believed that the authorities forced her father to join the army and be stationed away from his hometown in order to relieve the family. Eventually however, he returned home and continued beating his wife. When Maria was 12 her mother fell ill with appendicitis and due to poor medical treatment, died within two months. Maria remembers seeing a needle stuck into her swollen belly as she lay in the hospital. The news of her death made Maria laugh, and this reversal of affect characterized the way she handled events in later life, denying grief and concealing depression. She was unable to cry or to go through the normal processes of grief at a time she was biologically becoming a woman and was faced with the loss of her mother. She clung to a representation of her mother as a victim unable to meet her child's needs. She went to her mother's funeral and saw the casket lowered into the ground although she had been unable to view the corpse; her mother was not "really" dead, and she exhibited symptoms of established pathological grief10 being haunted by her mother's ghost over and over in her fantasies and nightmares. Her two sisters married in the year their mother died, and Maria was left alone in the family home with their father, who was often drunk and who approached her sexually. His overtures were hard to resist. Her Catholic training made her feel sinful and guilty in this situation, and her self- esteem was reduced. For the next nine years her sisters alternated taking her into their homes to ensure her safety. The two families had in time six children altogether, and Maria felt left out; she still needed a mother and maintained in her mind the image of a caring mother alongside a rejecting and unhelpful one. She felt guilt over resenting her sisters' children, to whom she had to play second fiddle, and her self-esteem was even further reduced. Vowing never to have children herself, she viewed woman's lot as one of exposure to suffering. Hiding her depression, she smilingly cared for the children of her sisters until at the age of 21 she contracted tuberculosis and was sent to a sanatorium. This experience contributed further to her identity as someone masochistic and depressed. Released from the tuberculosis hospital, she returned to her sisters and found employment in a store and befriended a Spanish boy who shared her cultural system. She also met Tom, an American soldier, stationed in Spain; to her he represented a way out from her traumatic existence in Spain, so she married him. When she arrived in the United States with him she had no English and found the environment alien and hostile. Although she had vowed not to let herself become pregnant, in the fourth year of her marriage she gave birth to a girl who almost died of intestinal obstruction. Again womanhood and motherhood seemed to Maria horrifying. When her first child was 15 months old, Tom was sent to the Philippines and she returned to Spain, living alternately in the home of one or the other sister. The situation created by the loss of her mother was being repeated due to the "loss" of her husband, and she still searched for someone to mother her. The sisters' children were no longer young, but they had other preoccupations that made Maria feel still unwanted. One sister with whom she stayed lost her husband to cancer and a son to a traffic accident a few months later. A little over a year later, Maria joined Tom, who was by then stationed in Germany, and had a few years with him before he received another assignment for 15 months and she returned to Spain. This time she took an apartment of her own, living with her daughter in a state of open depression and great loneliness. Carla's Birth and Her Mother's Fantasies about Her While awaiting Tom's return, Maria developed a rich fantasy life to ward off depression, fantasizing that various Spanish male movie stars were her lovers. She refrained from taking a lover in reality because she considered it sinful. She was, however, very much aware of her sexual hunger and her sexual fantasies. As soon as Tom returned, Maria wanted to get pregnant, and when she succeeded, she thought of the child she was carrying as a boy. Tom spent much of his time drinking with other men, and when at home showed little interest in her. Maria was persuaded that her new baby would be a boy who would grow up to be quite different. For two months after Carla's birth Maria referred to her as "he," since she had a firm mental representation of the baby as a son. She was to say later, "This sounds silly, but is it possible that I could transmit my thoughts about this to my daughter?" During her first six years, which she spent in Spain, Carla was a partner in a highly stormy relationship with her mother. Maria considered her child difficult and frustrating, but she could not bear to be separated from her. The baby often cried, and the mother was deeply aware of sexual hunger which Tom was unwilling or unable to satisfy. She daydreamed much of men and the male member, and often masturbated. When Carla was five, Tom left for another 15-month tour in the Philippines and the relationship between mother and daughter intensified. Eventually the family regrouped in the States, only to move to Germany again before settling permanently in the States. During these moves Carla had language- and culture-related problems in trying to adjust to her peers. The Mother's Unconscious Fantasies Maria was aware of having thought of Carla before her birth as a boy, but was not conscious of regarding the child as a psychic reservoir for a penis. She consciously acknowledged her loneliness and sexual hunger, and thought of Carla as "special." The child slept in her parents' room, and often in her mother's bed, as though she were her mother's extension. Maria clung to the child as though she were something secret, finding it hard to take her out in public; she rationalized that the child was too active to be seen by others, and treated her as a nonhuman entity. She thought of her as "a Martian," and her description to the therapist of Carla's activity brought the phrase "prick-like" to the therapist's mind. When Carla was a baby a physician had told Maria that the child's vagina was not properly opened. Although it is unclear whether or not there was an actual physical anomaly, the importance of this diagnosis is its consequences since the mother was instructed to massage Carla's vagina with a prescribed cream as often as possible; and when Carla was three her mother obtained what must have been a speculum, which she would insert in an effort to keep the vagina open. This intrusion into Carla's body was the actual trauma necessary for the specificity of female transsexualism. Although Maria stopped the focused intrusion when her daughter was six, she continued to peek at Carla's vaginal area for years when dressing her, etc. Was she searching for a fantasized penis? Was her finger or the speculum perceived as a penis they shared? Certainly this sexually focused interaction symbolically created a penis in the psychic space between the two. Her conscious daydreams indicate that she was searching for someone to make love to her, and by thrusting her finger into her own vagina to masturbate and by putting it also in her daughter's, she was making love to herself and her daughter with an illusory penis. Mother and child identified with one another and shared this illusory penis. Although when she grew up Carla could differentiate her self-representation from that of her mother, her perception of her genital area remained at best confused and ambiguous. We also suspect aggression in Maria's intrusion into Carla's body, and recall that her memory of her own dying (rejecting) mother was that of a belly with a needle thrust into it. Her symbolic, forced sex with Carla was also Maria's way of expressing in action what her father had tried to do to her, and seen in this way, the illusory penis can be viewed as invested with aggression. Maria's search for "something" in her child's body was so compelling that when Carla got "tonsillitis" at the age of six, she displaced her concern from Carla's vagina to her mouth. The child would refuse to open her mouth to take a pill, and her mother would pinch the child's nose until she had to open it to breathe, whereupon the mother would insert her finger. Maria boasted that it once took six people to open her daughter's mouth! Carla's Unconscious Fantasies Responding to Her Mother's We need clinical evidence that in response to Maria's behavior toward her Carla unconsciously began to fantasize an illusory penis that was given to her by her mother or developed for the mother, or shared in order to mark a special relationship - or used as a tool of aggression by both in response to fearing fusion between them. One of Carla's symptoms was her refusal to eat meat and to eat in the presence of her mother. This seems to echo the vagina-mouth equation already noted. By her refusal Carla was defending herself against her mother's penetration. The illusory penis was clearly perceived as being tinged with aggression here, and Carla built a defense against it when it belonged to her mother. In her treatment Carla could remember nothing about penetration by her mother's finger or the speculum. It was only recently, at the suggestion of a previous therapist, that Maria had told her daughter about her vaginal difficulty and the remedies attempted, but she left out many details and Carla grasped only that here was another proof that she lacked a vagina but had a hidden penis. Carla had, however, a "screen memory" that might reflect the long-repressed reality, so we can say that she was remembering symbolically a real trauma. In this memory Carla is a small child sitting on the steps of an apartment building in Spain when she sees a "small seed or something" and sticks it up her nose. Thus the earliest memory was one of her going into a body orifice. The following conscious daydream and its pictorial representation indicates the intertwining of the actual trauma with unconscious fantasy formation. Carla feels that her skin could be zipped open and she could step out of it with a penis as Carlos. As her request for a sonogram shows, she was confident that male characteristics lay hidden in her body. The dreams of her childhood reflected, even in manifest content, these unconscious fantasies. For example, her dream of a giraffe wound up with her astride the animal's long neck - a phallus. This was not altogether a happy circumstance in the dream, for the giraffe was sometimes aggressive and this made the child astride its neck apprehensive. At present her dream world is also full of obviously phallic symbols; like recent dreams of her mother they are mostly about such aggressive things as exploding missiles. It is no wonder that her illusory penis is named "the killer." Her custom of placing objects in her vagina, and her desire for a penis of flesh are more direct expressions of her unconscious fantasy The Father The psychodynamic patterns of Carla's father Tom indicate that he is what we have come to expect of the father of a female transsexual; like his wife, he lost his mother when he was 12, and his recollection of her centers around her being in such pain from cancer that she chewed on her feeding tubes. Two years after her death the father remarried, and Tom lived with his father, stepmother, and stepsisters until he joined the military, which became literally his home and family. Since he was born with a cleft palate, he had had surgical repair, and later in life he was told that his brains could be seen through an opening in the roof of his mouth. Cautery and skin graft were performed, but for some time he had felt that he had a "soft spot" in his mouth. The reconstructive surgery he had undergone lent support to his daughter's belief in corrective surgery. In an interview, Tom readily opened his mouth to show the scar on its roof, and although we cannot fully understand what "a hole in his mouth" meant to this man, it was clear that his preoccupation with his scar was echoed in certain family behavior; it will be remembered that Maria had wanted not only to see into Carla's vagina, but into her mouth as well. One of Carla's childhood fantasies was that she had been born with a penis which had been "burnt off" soon after her birth - after all, she had heard about her father's mouth being "burnt" soon after he was born. Tom spent most of his time with his military comrades, often drinking heavily and playing poker, and his behavior seemed indicative of a conviction, also held by Maria, that women, like his mother, were all born victims. He suffered from premature ejaculation, and had only "hit-and-run" sexual intercourse with his wife, whom he left from time to time. This added to Maria's feeling of sexual hunger; now in his early 50s, he has for the last ten years had intercourse with his wife only a few times a year. For six months or so he has been unable to achieve an erection, and refuses to consult a doctor about this. Having abandoned fantasies of making love with a movie star, Maria keeps dreaming of small animals entering her body. We do not know if there is a physiological reason for Tom's hyposexuality, but we do know that he associates intimacy with a woman with getting cancer. Although Maria had thought of Carla in utero as a boy who would grow up to be the opposite of her father, she sees her as Carlos to resemble her father very much. After all, her fantasy did not come true; Carla/Carlos will be just another sexually ineffective man. "They are like two drops of water in the same bucket," she says. CONCLUDING REMARKS Influenced by the work of Mahler20 on separation-individuation, Socarides21 offers a unitary theory of perversion that our investigation indicates also fits our understanding of true transsexualism. As we described here, female transsexualism is crystallized in adolescence bringing an end to fetishism, a sexual perversion. Moreover, prior to surgery, a great number of female transsexuals use gadgets while having "sexual intercourse" with other women. Socarides's theory is that the pre-oedipal period, especially between 18 months and three years of age, is crucial to the genesis of sexual perversion, since it is in this period that a primary pre-oedipal fixation occurs. This fixation includes not only the desire to fuse with the representation of the mother - to reinstate the primitive mother/child unit - but an equally strong dread of such fusion. To expand this formulation we can say that the true female transsexual seeks to unite only with the good-mother representation, to expand the genital fusion to fusion of the total good representation, while at the same time she dreads merging her own split-off self-representation with the bad-mother representation. A constant search for surgery - for the perfection that stands for the desired merging of good representations, allows the individual to remain in limbo; as long as the search continues, there is hope of obtaining the desired merger, while at the same time dread of merging with the mother's bad representation can be avoided. It is little wonder that Carla spoke of "the killer" and wanted to become a boxer after the proposed surgery. The aggression is clear, and we suggest that through it Carla wants to protect herself from the representation of the intrusive mother. We see as psychologically accurate the observation of Carla's conventional older sister, who often accuses Carla of "killing their mother." Carla's longing for surgery also includes a defensive desire to get rid of the tool of aggression. She has a fantasy about saving the good mother, but has a split-off representation of herself as a boxer. In the more benign fantasy she sees herself entering medical school and learning to deal with depression and transsexual issues. Although we agree with Socarides - with such modifications as indicated - we suggest that the wish to fuse with the mother while dreading to do so does not make a conclusive picture of transsexualism. Socarides's formulation refers to the foundation but not to the shape of the building erected upon it. The evolution of a female transsexual should be examined developmentally and attention should be given to how the influences of the oedipal years are condensed with those of pre-oedipal years. We focus here on the nature of pathogenic unconscious fantasies and actual traumatic events that concertize them and confirm the belief that the girl is actually a boy. It is necessary to examine the interplay between unconscious fantasies and trauma occurring in real life. For example, one female transsexual with a characteristic background was treated at the oedipal stage by her father, as though she were a boy. When she first saw her father geld a raccoon she was horrified, and her fantasy that she had once had a penis found an echo. She, too, had been gelded by her father. She later demanded that the surgeon/father return her penis.6 The transsexual feels threatened by any block to her defensive search for perfection through surgery; and psychotherapy, perceived as a possible block, is strongly resisted. The psychiatrist who withholds permission for the surgery so eagerly sought may be seen as dangerous, or may be denigrated and his special competence denied. The patient will then seek another, more compliant therapist. The initial development of a therapeutic alliance is very difficult, and in the literature we rarely see detailed reports of intensive psychotherapeutic work with such patients. Very seldom do we collect data from such patients about childhood memories and unconscious fantasies reconstructed during the working through of their transference neuroses. Thus we must depend on alternative methods to map out the inner world of these patients. We suggest psychoanalytically informed interviews with parents, siblings, and sex partners; they should not merely deal with observations these people make about the patient, but should take into account detailed assessment of their own psychological makeups. By putting together a network of information about persons who relate to each other intimately the therapist can then construct a reasonable model of the patient's mind and psychodynamics. Her early identification system, self- and object representations, and belief in belonging to the opposite sex can then be illuminated. We give an example of this approach here, and offer the case of a female transsexual that illustrates the complex developmental issues, the intertwining of the parents' psychopathology with that of their child, the self-identified transsexual. Recent animal studies show that maleness does not appear until the male hormones exert their influence as they normally do in males because of the Y chromosome. Even the chromosomally male (XY) animal will not develop as a male nor act in male fashion unless androgens have been present at the right time in fetal life; and the converse is true. When androgens are added to a fetus that is chromosomally female, maleness and masculinity will result. We can say that the base is female, and that maleness requires an additional step. As far as human beings are concerned, in bisexual states such as Turner's syndrome, Klinefelter's syndrome, and androgen insensitivity syndrome, it seems that hormonal influences modify the fetal brain, permanently changing gender behavior from that expected toward that typical of the opposite sex. Despite the possibility of fetal hormonal influences or other intrauterine events such as a viral invasion, we await definite proof of organic and etiological physical defect or malfunction as the cause of transsexualism. In view of the psychopathology - evident under close scrutiny as presented in this paper - in persons seeking surgical sex reassignment, we believe we are forced to conclude at present that psychological etiological factors must be recognized, and weighted more heavily than any possible influence of fetal sex hormones on the fetal brain. Although many questions remain unanswered, our presentation emphasizes the fact that transsexualism - here female transsexualism especially - is a psychopathological condition of serious import and consequences for both patient and physician. SUMMARY The final diagnosis of true female transsexualism requires examination of the developmental issues of the patient from birth through adolescence and study of the evolution of her self- and object representations. A depressed mother's unconscious fantasies and her daughter's corresponding fantasy of rescuing her from depression promote the development of transsexualism in the girl. Events from every phase of the latter's psychosexual growth affect each advance in the crystallization of transsexualism. The mother/daughter relationship and its representation in the child's mind are contaminated with unneutralized aggression and love. The girl first uses objects such as a Q-tip between her legs to deal with separation anxiety; these come to symbolize the father's phallus. In adolescence, the girl abandons them and focuses on surgical construction of a penis. The constructed penis, like its precursor, provides illusory control over developmental conflicts. The girl feels disorganizing anxiety unless she obtains, or seeks, this relief. A case illustrates the psychodynamics of female transsexualism and criteria for diagnosis. REFERENCES 1. Volkan, V. D. and Bhatti, T. H. Dreams of Transsexuals Awaiting Surgery. Comprehensive Psychiat., 14: 269-79,1973. 2. Volkan, V. D. A Cautionary Psychiatric Insight: A Clinical Report. In Mental and Sexual Counseling in Medical Practice, Abse, D. W., Nash, M. M., and Louden, L. M. R., Eds. Harper and Row, Hagerstown, MD, 1974, pp. 393-404. 3. Volkan, V. D. Primitive Internalized Object Relations. International Universities Press, New York, 1976. 4. Volkan, V. D. and Berent, S. 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