The path to one’s realization that he/she is a transsexual (TS = male or female transsexual) is variable. Most transsexual individuals, quite early in life, seem to know they are different from others in how they view themselves. Transsexual males (M2F = male-to-female) brought up as boys and transsexual females (F2M = female-to-male) reared as girls see this as a cruel mistake of fate (Blanchard and Steiner 1990; Zucker 1990; Zucker, Bradley, and Sullivan 1992). In their own minds, there is no doubt they are of the opposite sex and should be reared accordingly. They see the gender identity given to them by society is at variance with the sexual identity they possess internally and personally.1 They want to live life transformed so their anatomy fits their conviction and mental image of self. Toward this end, the TS eventually presents to a psychotherapist, physician or other professional with the urge to have sex-change surgery. When doing so, such individuals recount lives in which they had manifested or recognized a disposition toward cross-gender lifestyle events and behaviors. Their day-to-day social life, an experiential living-test as it was, told them their internal signals were not synchronized with the external ones and their internal ones won out. They typically recount many incidents where sex-of-birth appropriate behaviors were felt to be or were actually impossible or difficult to manage (e.g., Bolin 1987; Green and Money 1969; Wålinder 1967).

Benjamin’s (1966) original definition of transsexualism was relatively clear: “True transsexuals feel that they belong to the other sex, they want to be and function as members of the opposite sex, not only to appear as such” (page 13). [Emphasis original]. Since then, however, a second part has often been added. For example Ziegler in 1994 follows the practice started at least twenty years earlier (e.g., Fisk 1975; Mehl 1975) in offering a multipart definition of a transsexual. The first part is the same as offered by Benjamin. In the second part, Fisk, Mehl, and Ziegler add, in effect: the transsexual persistently engages in behaviors attempting to live as the other sex. Examples would be the male TS who cannot and would not bear to wear boy’s or men’s clothing and instead wears female garb and is a failure at sports or won’t even attempt them, or the female TS who insisted on binding her breasts, dressing as a man and engaging in masculine pursuits. These persons were often seen by themselves and others as “failures” in their birth sex. Most often, this aroused the ire of parents and sibs; hardly ever was this behavior reinforced for long. Stoller (1968) essentially defined a (male) transsexual as an XY individual fully identified with the female role, has as many feminine mannerisms, interests, and fantasies as a little girl his age, and openly expresses wishes to have his body turn into a female’s (page 92).

This current paper documents, however, a phenomenon which more than a few transsexuals undergo in trying to reconcile their disparity of sexual and gender identities. These are the behaviors of persons who, for an extended duration, overindulge in rather than shun behaviors typical of their assigned sex. I label this a process of self-testing.

Self-testing is challenging oneself significantly to personally measure “Am I male or female?” This may be a particularly crucial set of incidents or events or years of experiences. It has two interdependent components. The first component is the situation. It is subjecting oneself, consciously or unconsciously, to situations or processes personally dramatic or significant enough for them to take on the status of a sex/gender marker. The second component of the self-test is the analysis. For the male-to-female transsexual it is saying, in simplistic terms, something like: “Although all my male peers enjoy playing with guns, I don’t. I tried it for a year or so and, although I am good at it and can outdraw my buddies and shoot more accurately, I would rather crochet and this proves to me I am truly a female.” A nontranssexual male in the same circumstance, in contrast, might say to himself: “Although all my male peers enjoy playing with guns, I don’t. I tried it for a year or so and, although I am good at it and can outdraw my buddies and shoot more accurately, I would rather crochet and this proves to me I am truly a female.” Or, “Although all my male peers enjoy playing with guns, I don’t. … I would rather crochet and this proves to me I am not a typical or good male.” Or, “Although all my male peers enjoy playing with guns, I don’t. … I would rather crochet and this proves to me I am probably different.” Later on, with greater age and experience this last individual might come to say “Perhaps I’m gay.” Most individuals, never having heard of transsexualism, will not know how to identify such feelings at all. TSs often think themselves unique in all the world. As they go over the possibility of being gay, that too doesn’t seem to satisfy them and could repel them. For someone very young, along with fictional beliefs of Santa Claus and the Tooth Fairy, it might be easier to contemplate growing up into the other sex or saying, without full understanding, “I am really a boy/girl (opposite sex noun).”

Self-testing challenges the idea that an adequate self-esteem system only develops when life situations are positive vis-à-vis a developing and wanted ego (Epstein 1973). As Docter (1988) puts it in terms of identity: “If [for example] a male predicts, for whatever reason, that he will be likely to fail in roles requiring masculine-gender competencies and skills—then either the formation of that subsystem would be weakened (or stopped), or a feminine gender identity will develop, thereby facilitating pleasure and self-esteem” (Docter, 1988, pages 81-82). Negative reinforcement to one’s identity will supposedly lead to transsexual ideation. Feinbloom (1976) writes: “One can see transsexualism as a career gone sour. That is, one can examine the lives of transsexuals, both preoperative and postoperative, in terms of previous failure to … issues in a life that have made one’s particular life pattern untenable. It is not stretching the definition of career to say that transsexualism itself is a career constructed on the ruins of one that has failed” (pages 149-150). Put in other terms, getting reinforced as a male (or female) will supposedly establish and fix one’s identity as a male (or female); not getting reinforced adequately will thwart proper development of suitable sexual identity.

Concomitant with this, when conflict or doubt as to which true sex exists, the individual might follow up with the thought: “If I do such-and-such successfully [test myself] it will mean I really am a male and my thoughts of being female will pass.” With the female-to-male transsexual the opposite would hold. She says to herself: “If I do thus-and-so successfully it will really mean I am a female and my thoughts of truly being male will pass.” Certainly, normal individuals might come away from their own self-testing with feelings of inadequacy as a boy or girl, but it doesn’t challenge their basic sexual identity.

Simple self-testing events and demands occur early, usually pre-school, and are interpreted and resolved rather unremarkably for most children. For atypically developing individuals, however, the testing period can be prolonged, quite involved, and dramatic. With convinced transsexuals, repeated normal encounters with living, from early on, seem an affirmation that they are of the other sex. Failure in gender-stereotypic behaviors, accepted or rejected without fanfare or concern by nontranssexuals, is cause for internal reification by convinced transsexuals that they are “in the body of the wrong sex.” They do not need or seek any self-test; their living-test convinces them early on.

Unconvinced transsexuals, while also harboring doubts from early on, nevertheless continue to question this disparity between inner and outer sex and eventually only decide they are transsexuals after a period of direct and usually prolonged self-examination. This process is often quite deliberate. It may, however, become apparent only in retrospect. Individuals of this second group of transsexuals are self-tested transsexuals.

Another matter might be considered for self-tested transsexuals. Kando (1973) found that the typical transsexual is highly stereotyped in accepting cultural ascriptions of gender. In their eyes, a good woman should be “comfortable in the kitchen and home,” and “a good man should be macho and the bread-winner.” Indeed, among the 17 M2F transsexuals interviewed by Kando, almost all either considered themselves full-time housewives or in women-typical jobs such as secretaries, waitresses, and dancers. The self-tested transsexual is not that hide-bound. He or she feels capable in either the male or female role and can see that for others as well. But he or she, for self, believes that ability notwithstanding, it is an inner identification that must be dealt with. The postsurgical avocation is unimportant as long as done in the preferred sex.

For everyone, the second part of the self-test is its personal evaluation: the analysis. In this evaluation, male-to-female transsexuals inevitably conclude, to the effect, “I was tested or tested myself as a male in the most rigorous manner I can imagine and even though I was successful as far as society was concerned, it was insufficient to satisfy myself. I must therefore be the female I feel within.”

Self-testing of identity is dramatically demonstrated by transsexuals, but is seen in lesser degree among transvestites, then homosexuals and bisexuals, and least by heterosexuals. Homosexuals, bisexuals, and heterosexuals might test their masculinity or femininity, but rarely question if they are male or female. They might question their (social) gender identity, apperance, and adequacy, but not their introspective (core) sexual identity.

Several cases seen by the author and several others known to him will exemplify the phenomenon of self-testing.

Male-to-Female Transsexuals

Case 1: (A.A.)

Some two decades ago, a 36-year-old XY individual presented himself with his wife of 6 years. They came to my office for advice and counseling regarding their marriage and the management of their future lives. The gist of the situation was that they had met and dated for about a year and married when he was 30 and she 40.

In general, the couple seemed to be getting along well. They professed to loving each other and having few difficulties of consequence that typically beset couples. They reported themselves sexually compatible with a mutually satisfying frequency and intensity of genital play and coitus. There was, however, one major hurdle that had developed and they sought help in its resolution. About a year before coming to see me, A.A. had told his wife about his desires to cross-dress. She reluctantly accepted this. Following that revelation, he did occasionally cross-dress in her presence. Recently, however, he confided to her that he had always felt to be a female, at least since the age of four. He now desired sex-change surgery and the ability to live as a female.

The wife, a highly intelligent woman, originally thought the cross-dressing and female aspirations were temporary aberrations that would pass. The magnitude of the present situation confused her and she wanted answers to what was happening and suggestions on how to proceed. Both husband and wife wanted to maintain the relationship, if possible.

During my evaluation and sexual history interview with transgendered individuals, I typically ask about self-testing. The questions are posed as a sort of challenge and follow the gist of: “You have a penis and scrotum and total body build of a male, you were raised as a male and treated as a male in all instances that you can recall. And, in your particular case appear to be in a satisfactory marriage with a comparably satisfying sex life. Yet, you nevertheless consider yourself a female. What makes you think so? Can you give me examples of how you know you are female and not a male? How did you convince yourself of the correctness of this unusual feeling?” This will be a series of questions framed to fit the individual.

In response to such questions, most XY individuals then try to impress with occurrences documenting how “female” they had been all their lives. This is in dramatic contrast with the story which A.A. told. A.A. told a “hyper-male” story.

A.A. was the eldest of 12 children in a poor and abusive dysfunctional family where the number of actual fathers involved was not known. Despite routine beatings for even minor childhood infractions, from his mother or any of the men around, A.A., even as a child, was expected to work at chores doing much of the “man’s work” around the house. This was even considered more important than school work. His family lived with cousins and other relatives to help defray costs. Some 20 or so children of all ages lived together with the boys in the basement, the girls in the attic, and the adults in-between. This was in a very small Midwestern town.

From about the age of four, A.A. recalled feeling as if he were a girl rather than a boy. He dates his first self-revelation from the time he had to wear a girl cousin’s pants when his were unavailable. Until that experience, A.A. said, “For reasons I couldn’t explain, I didn’t believe I was in tune with the way people were treating me. This, wearing of my girl cousin’s clothes, which I took as being treated as a girl, seemed right.” In private, he would take to occasional cross-dressing with the profusion of girls’ clothes that were always available in the house. With so many people around, privacy was rare. When possible, he “made do” with wearing the sexually ambiguous “boys’” clothes of his sisters and girl cousins. Fearing physical abuse and ridicule, he dressed in outright female clothes only rarely and always in secret.

When A.A. was about ten, he dared his one-year-younger brother to dress in girl’s clothes. The brother was discovered and severely beaten and ridiculed within the family and at school; his mother made him wear a dress to school the next day. A.A. vowed that would not happen to him. However, when A.A. was about 12, his mother caught him cross-dressed and beat him with the admonition to “act like a man.” She informed the rest of the house of his behavior and most of the household joined in the ridicule.

Academically, A.A. did not do well although he says he tried hard. He also felt he was a “loner.” This led to truancy and school fights when other kids teased him. He claims to have won all these fights and was soon accepted because of his strength and athletic ability. Indeed, sports and athleticism were A.A.’s strong suit. At elementary, middle, and high school A.A. was known as a medal-winning athlete in track and field, wrestling, and football.

At the age of 12, taking his friend’s bike as a prank and riding it around town, A.A. was charged as a thief. He was jailed for two weeks to “cure him from being a problem kid.” When in jail, he was sent for psychological testing and counseling. A.A. was found to be dyslexic, but with an IQ he claims tested at 160. Teachers vouched for his willing and bright participation in class but poor test performance. As a result of his test scores and the psychologist’s recommendation, A.A. was advanced a grade but no treatment was available for his dyslexia. This led to further ridicule from his family and schoolmates (and more fights).

With puberty, A.A. started to masturbate. He masturbated without touching his penis, touching his thighs and nipples and fantasizing an erotic relationship in which he was a female and was with a heterosexual male.

A.A., as a cover of his burgeoning erotic and romantic interest in cross-dressing and boys from about the age of 14, developed a relationship with a girl who lived in a distant town. The distance between the two towns reduced the opportunities for physical contact. During this period A.A. didn’t engage in any heterosexual or homosexual activities.

While still craving the parental love and affection he was denied, to get away from the abuse and ridicule at home and obtain a modicum of freedom and privacy, A.A. left home at the age of 16 and went to live alone in a barn outside of town. He continued in school and supported himself by working after school and weekends as an airplane mechanic’s helper at a nearby airport. (A.A. had, at the age of 12, joined the Civil Air Patrol for the thrill of flying and, as a cadet, worked as an airplane mechanic’s helper.)

While alone in his crude lodgings, the sheriff came to look in on A.A. and found him fully cross-dressed. In consultation with A.A.’s mother, the sheriff offered A.A. three choices: go to jail for breaking the local law against cross-dressing; go to a psychiatric facility to “get cured” of his fetish; join the military and leave town. A.A. chose to enlist. He also saw this as an opportunity to prove that, indeed, he really was a man.

While still 16, A.A. passed the test for Navy enlistment but had to wait until his 17th birthday to report for service. A.A. chose and was granted training in the Navy’s Aircraft Maintenance school. While in school, A.A.’s physical and athletic abilities so impressed his drill instructors they recommended him for additional training that could use his physical abilities.

With this he learned he had been “volunteered” to become part of the Navy’s Underwater Demolition Team and then, when activated, part of the Navy’s first class of SEALs (Sea, Air, and Land special forces recognized as requiring among the most demanding physical and diverse abilities of any military special forces units). As a SEAL team member, A.A. reenlisted and served two tours of duty in Vietnam under extremely hazardous and demanding conditions. In the Navy for seven years and as a SEAL for five of them, A.A. wanted to be and was seen and accepted as a man among men. A.A. had a girlfriend at home as a “cover” during much of this time, but since he was overseas and she in the United States, his lack of overt sexual activity did not arouse suspicion among his shipmates. While in the military, A.A. had his first homosexual experience at 17 and first heterosexual coitus at 20. During his military career he never cross-dressed.

One night, A.A. got very drunk and broke into the enlisted men’s club after hours and was caught by the authorities drinking at the bar. For this he was sentenced to the brig. While in the brig, he physically fought with his cell mate and both had to be hospitalized. His injuries were such that A.A. was granted a medical discharge.

A.A. returned home and over the next several years took a series of jobs as an airplane mechanic, crewman on a tugboat, and other masculine identified jobs: bodyguard, stud in both heterosexual and homosexual “adult” movies, commercial diver repairing ocean-going vessels, martial-arts instructor. During these years, he simultaneously attended school and obtained a Master’s degree in Physical Education and then went to work as a P.E. instructor at a high school. Out of service and in private, A.A. resumed cross-dressing. During this period, at the age of twenty-six, A.A. first heard of the Erickson Educational Foundation and became aware of resources of possible aid to transsexuals. This to him “offered a prayer to all the problems about what I was.”

Despite outward success in these demanding masculine situations, and even after marriage and life as a heterosexual husband, A.A. could not displace his own doubts that his true sex was female. Although he could meet the rigorous tests of masculinity required by the SEALS and the erotic demands of his wife, he still believed himself a female trapped into a muscular body. Passing of these successful self-tests, to his inner female convictions, was insufficient to reinforce his male identity or dispel his female identity. He flunked all his tests. His wife was sympathetic to his inner feelings, but confused by the external realities with which she was presented.

Subsequently A.A. has had depilation, went onto estrogens, and planned sex reassignment surgery. A.A. and her ex-wife presently live together as platonic sisters. A.A. stays at home and does the housework while her ex-wife provides the major family support. A.A. is more content with life now than in the past when living as a man.

Case 2: (Jan Morris)

The life of Jan Morris, as presented in her book “Conundrum” (1974), offers another case of self-testing. After Christine Jorgensen (Hamburger, Stürup, and Dahl-Iversen, 1953), Morris is perhaps the best-known male to female transsexual. Morris offers testimony to what might be considered components of her self-testing. She writes:

  • “I was three or perhaps four years old when I realized that I had been born into the wrong body, and should really be a girl (page 15) … I was never treated as one. … I was not … thought effeminate …” (page 16)
  • “[I] volunteered for the army at 17 … and [although I was successful in my position and accepted by my colleagues in arms] far from making a man of me, it made me feel profoundly feminine at heart” (page 39) “… the insight it afforded me of life in an entirely male adult world was curiously gentle and considerate” (page 40) “… The army had confirmed my intuition that I was fundamentally different from my male contemporaries” (page 43)
  • “ … as to my sense of gender, I knew it to be as different from that of my friends as cheese from chalk … I could not share the urgency of the male impulse, or the unquestioning sense of manhood which bound these soldiers together … I realized … how deeply a male sexuality lay beneath their conduct, and [although I could fake it] how profoundly I lacked it” (page 43).
  • “How could I be sure of my predicament? If I thought I felt like a woman, how could I know what a woman felt? What did I mean when I said I was feminine?were there confusions of identityWhen I left the Army I resolved to explore myself more deeply” (page 55)  “… was I sure that I was not just a suppressed homosexual, like so many others?” (page 60). [Emphasis mine.]
  • Morris had heard of Harry Benjamin and went to see him. Benjamin accepted Morris’s feelings but counseled: “Stick it out [as a male]. Do your best. Try to achieve an equilibrium, that’s the best way. Take it easy! This advice I accepted…” (page 63).
  • Morris fell in love, married, and fathered five children, with a preference to have been mother rather than father. “But for me the actual performance of the sexual act seemed of secondary importance and interest” (page 68). There was, however, a great deal of affection, hugging, and erotic intimacy.
  • Morris spent several years after his military stint traveling and working as a reporter covering wars and intrigue. In this capacity, he jumps at the chance to join the first ascent of Mount Everest. Afterward, Morris writes: “I think for sheer exuberance the best day of my life was my last on Everest” (page 96) but “My sense of detachment [from the other climbers] was extreme … I hated to think of myself as one of them.” … “A wayward self-consciousness … compelled me to keep up male appearances, perhaps as much for my own persuasion as for anyone else’s. I even overdid it rather. I grew a beard and when at the end of the expedition I walked into the communications room at the British Embassy in Katmandu with my tin mug jangling from the belt of my trousers, the wireless operator asked acidly if I had (sic) to look so jungly. He did not know how cruelly the jibe hurt, for in a few words it cut this way and that through several skins of self-protection” (page 100).
  • “Everest taught me new meanings of maleness, and emphasized once more my own inner dichotomy” (page 100).
  • “I have only lately come to see that incessant wandering as an outer expression of my inner journey” (page 116. [Emphasis mine.]

Despite success in the military, as a war correspondent, climbing Mount Everest, and as a father, despite social reinforcement as a male and the advice of Benjamin, Morris felt compelled to live life as a woman. His masculine experiences, rather than confirming his maleness, bolstered his hatred and resentment of his maleness and feelings of being female. Morris returned to Benjamin for sex-change advice and after prolonged endocrine therapy had the surgery in 1972.

Case 3: (Nancy Hunt)

Nancy Hunt, another male-to-female transsexual, chronicled her life in a book Mirror Image (1978). She also self-tested:

  • “I know by the age of four I was already aware that I had a girl’s mind” (page 40).
  • “By the day I graduated [Prep school], I had achieved the status of a minor celebrity [withstanding the fights and attacks of the other boys without crying]. More than that, I had survived the annealing fires of manhood … I knew well enough that I was not a girl—had only to look at what my body had become: … muscles hard, beard growing, hair sprouting on chest and stomach. Secret dreams aside, I was locked in an undoubtedly male body, and like most adolescent male bodies it was bubbling with hormones and potent as a cocked pistol” (page 59).
  • With puberty, Hunt began to masturbate and occasionally dated. His feelings about girls he expressed thus: “I seethed with envy while at the same time becoming sexually aroused—I wanted to possess them even as I wanted to become them. In my nighttime fantasies, as I masturbated or floated toward sleep, I combined the two compulsions, dreaming of sex but with myself as the girl, my partner blanked out because I so loathed the male body, even my own” (page 60).
  • With the start of World War II, Hunt was determined to enlist. At the end of his basic training he was convinced he was a: “tough, rugged, fighting Infantryman … I could march twenty-two miles with a full field pack and an M-1 rifle, carry a 60-mm mortar up a mountain, chin myself fifty times with my hands the wrong way around on the bar, [and] kill a man with any of seventeen weapons … Now when I studied myself in the company mirror, I thought I saw a tough, dangerous, competent man” (page 61).
  • “And for two blissful years of Army service I believed I had established my credentials as a man among men. I cherished this belief even as, night after night, lying on my iron cot, I dreamed of being a girl” (page 62). [Emphasis mine.]
  • … as buck sergeant … those chevrons on my sleeves symbolized my membership in the community of men, my acceptance by … all the other soldiers whose self-assured virility I so much envied. To this day, I secretly celebrate the anniversary of my promotion to sergeant … though I have long since forgotten the dates of my college gradation, my two weddings, and my children’s birthdays” (page 65).
  • “… here was I, a former buck sergeant, tough, profane, and determined to succeed as a man” (page 39).
  • “[Following discharge and while going to college] I associated almost exclusively with veterans, attempting to extend the manly triumph of my Army career” (page 68).
  • “Never having heard of transsexualism, I supposed I must be a homosexual, and the thought sickened me … To contemplate homosexuality, to imagine the embrace of sinewy arms and hairy legs so like my own, dismayed me” (page 69).
  • “[Upon being recalled to active duty for the Korean War] military life had lost its power to assure me of my manhood” (page 71) … “I knew now that the military life was a delusion, but I had no other[After discharge] I turned my face resolutely in another direction and set out once more to prove myself a man” (page 72). [Emphasis mine.]
  • Hunt became a reporter and then a copy-editor. “Newspaper city rooms ranked then with the locker rooms of professional football teams among the great bastions of masculinity. … I drew comfort from the hearty environment of the city room and felt myself to be a man among men, much as I felt in the Army” (page 76).
  • [Later, at twenty-nine years of age and again living at home] “Continuing to fantasize about being a woman, I remained a male virgin. In that depressing situation, marriage seemed a likely way to gain approval as a male and as a human being. To prove my claim … I married …” (page 77).
  • “Until I became a parent [with two daughters and a son], I assumed that sex-typed behavior is acquired, but my own children convinced me that it arises spontaneously” (page 83).
  • “[My wife] saw in me those male attributes she had come to hate and fear accentuated all the more by my determination to practice them and be as much of a man as I could. And to the extent that I succeeded in those efforts I failed in my marriage” (page 85).
  • “I wormed my way into the sailboat-racing fraternity … crewing… in the big offshore boats … on whose sails the wind exerted terrifying forces. … And if a gale caught us with everything standing, my heart filled with cold fear. But though I was often frightened, I continued to sail. It was a man’s world … If I could survive there I could prove myself a man” (pages 85-86). [Emphasis mine.]
  • “[As a reporter] I specialized in the most masculine stories I could find or devise, anything that would take me into a world where I could study and enjoy the way men conduct themselves– … firemen, high-tension linemen, parachute jumpers, treasure divers … I slept in the open with the Green Berets … I spent countless nights with policemen, breaking down doors on vice raids and accompanying them into the most perilous cesspools of the city where snipers would fire on us … (page 87).
  • “I had made a fetish and a profession of manhood. (Indeed I had once written an article on what it means to be a man, and the United States Marine Corps [rewarded me for it])” (page 150).
  • “And there lay the heart of my dilemma: I could no longer endure pretending to be something I was not. Deceit is a tiring occupation, and despite all biological evidence to the contrary, despite my military record and my Yale degree, despite my swearing and my mustache, I knew my masculinity was fraudulent. If I were ever to make peace with myself, I would have to confront not the hairy, balding, tweed-clad façade that I presented to the world, but the person who lived inside—myself, Nancy, a woman” (page 262).

Thus, Hunt provides another example of an individual that tested himself, found social success as a male, reinforced by his peers, family, and culture, yet goes on to transsexual surgery and life as a contented woman. Despite external clues to his masculine nature and gender identity, Nancy’s internal cues to her female sexual identity were more potent.

Female-to-Male Transsexuals

Case 4: (B.B.)

B.B. is my example of self-testing in a female-to-male transsexual. As the cases of the M2F presented above, B.B. is unusual in the extent to which this phenomenon is seen. B.B. first appeared in my office with her husband. She was dressed in jeans with a loose shirt and her long hair up in a tight bun. They came as a couple, but each had a very separate agenda. His desire was for me to convince his wife that she really was a woman and not the man she claimed to be. B.B. wanted my advice on how to proceed in her desire to live as a man. A striking brunet, B.B. was a most attractive woman in face and figure. B.B., then in her early thirties, first became convinced she was male about the age of 7. Even then, she recalls always being seen as a tomboy by others but as a real boy to herself.

Life events in her rearing, childhood, and adolescence were not remarkable. As she matured, the attention of the boys and men with which she came into contact continued to emphasize that indeed she was female. She was repeatedly the object of male attention. B.B. denied her attractiveness and explained away the focus of the males as due not to her features or reality but just their indiscriminate lust. Men had been approaching her and touching her sexually since she was a teenager. She herself recalls being attracted to and aroused by females from her teenage years. Her first sexual encounter was with a female at 23 years of age.

Home conditions, in a small farming community, seemed supportive and were considered to have its “normal ups and downs.” She recalls her home life and family as nurturing and caring. At the age of eighteen, B.B. left home after completing high school to follow a career as an actress and professional model. Her success as a beautiful female was in conflict with her inner feelings that she was a male. Again, she felt her appeal was dependent upon males wanting sex. As B.B. got older and modeling positions decreased and acting situations became sparse, someone suggested she try stripping.

In a classic example of self-testing reasoning, B.B. rationalized that her success as a stripper would prove to herself she really was a female and remove all doubt as to her being a male. The men in the audience, she thought, would know she was not available to them and would thus judge her on her female merits alone. To further her career and, in her own words, “leave no stone unturned in proving myself a woman, I had a ‘boob job’.” Suffice it to say she was successful enough as a stripper to achieve national stature sufficient to require a full-time manager. While on a worldwide tour, B.B. came to see me in Honolulu.

She married her manager, her only husband, nine years before seeking counseling. This was his third marriage but her first. Despite the worldly success and adulation as a female, B.B. could not dispel her male feelings and had only several weeks before told her husband of her conviction she was a male despite “fighting such feelings for years” and appearances to him and the world. She thought “exotic romantic Hawaii as the appropriate location to broach the topic.”

Her only bow toward masculine habits seemed to be that she had for some time been wearing men’s jockey shorts as underwear. Her husband just thought that another sign of her “tomboy” nature. B.B. had also, several months earlier, met a female friend with whom she started a close sexual relationship.

B.B.’s satisfactory abilities as a wife were testified to by her loving and attentive husband who thought she was “crazy” with these thoughts. He felt she was “just the woman he wanted.” Before this recent revelation B.B. always wanted to be called by her real (feminine) name rather than her stage name or a male name. Her husband described her as not only beautiful and sexy but also feminine in mannerisms and attitudes. B.B. did not deny that she tried in all ways to please her husband sexually and otherwise. But now she adopted a gender-ambiguous name and wanted to be seen as the male she felt herself to be.

B.B. had a son from a previous relationship who was adopted by her present husband. Having this child was a further additional female self-test in B.B.’s eyes. It simultaneously proved her femininity in the husband’s eyes. The son, ten years old at the time, traveled with his parents and interviewed alone and in private. B.B. had also told her son of her emotional conflicts. He saw his mother as appropriate in demeanor and, her occupation and fame aside, “just like other moms” in regard to femaleness. He was appropriately concerned with the future but wanted to stay with his mom regardless. B.B.’s female lover came to Hawaii and was also interviewed. She claimed she had no preference for B.B. to be male or female. She “loved the person, not the shell.”

Despite B.B.’s success as a female, she now felt she had to live as a male. She said she had always been severely depressed every menses. Having a slight flow, she would often leave her tampon in for prolonged periods so she “would not have to deal with them.” Everything seemed to be coming to a head at once. She now fully realized she could not feel peace as a female and, without her husband’s or female lover’s knowledge, seriously considered suicide. She had also recently informed her parents of her desires and they threatened to disown her, although her mother volunteered, “I always knew you were strange in that way.” B.B. nevertheless wanted to proceed with her female-to-male transition.

After counseling over a three-week period, the couple left Hawaii for scheduled performances in Japan, but B.B. kept in touch by mail. Upon return to the U.S., against her husband’s wishes, the couple divorced. B.B. cut off her long tresses, gave up her lucrative stripping career, and started to live as a man. He bound his breasts to minimize them and was planning to remove the implants. He now took androgens and lived with his female lover. Several months later B.B. wrote to tell me he was working as a salesman and made plans for sex-change surgery. He retained custody of the son. Contact was lost after that.

Although eminently successful and reinforced as a professional stripper and domestic wife and mother, B.B. felt, nevertheless, she had to live her life as a man. Her inner voice was stronger than any external reinforcement. Her self-test convinced her that although she could easily pass any test of female (social) gender identity, she could not pass her own self-test of internal sexual identity.


There is little doubt that the lives of transsexuals can be quite variable from each other and there is no one life that typifies all (e.g., Bentler 1976; Blanchard and Steiner 1990; Bullough and Bullough 1993; Green 1974; Meyer 1974; Pauly 1969a, 1969b; Tsoi, Kok, and Long 1977). Nevertheless, tabloid presentations of transsexuals often play up the before-and-after contrasts–the macho male becoming the feminine female, and so on. The cases presented here illustrate this to a marked degree. These cases also exemplify that even full and demonstrated success and acceptance in one’s sex-of-birth and rearing can be insufficient to allay a feeling of mismatch between society's imposed and defined gender identity and one's own personal sexual identity (Diamond, 1994). Although reinforcement and success in society and concordance with social expectations exist, an individual can nevertheless feel drawn to a sexual and gender “calling” which may lead to ridicule and social opprobrium. Indeed, many have little hope of “passing” undetected in their new life, yet choose this difficult social path. In all four cases presented here, the individuals were engaged in loving relationships that they had to alter. By leaving their sex-of-birth, they all risked a substantial decrease in income. By rejecting their sex of birth they all left successful professions. There were no indications these individuals were not fully capable, rational, and sentient.

The question arises why such histories as those presented here seem rare in comparison with those for whom life was a succession of events demonstrating attempts or actual success in living as a member of the opposite sex. Part of this is believed due to the criteria originally established for selecting candidates for the limited surgical slots available. As Fisk (1975) recounts: “we [at Stanford] went about seeking so-called ‘ideal candidates,’ and a great emphasis was placed upon attempting to exclusively treat only classical, or ‘textbook cases’ of transsexualism.” Stoller (1971) proposed that only individuals who at no stage in their development showed masculine behavior be diagnosed as transsexual. Other centers, to reduce the likelihood of regrettable surgeries, did similarly. Once establishing such criteria, it is not difficult to see why such cases became dominant in practice and case reports.

The origin of these male and female feelings arises from within, from the individual’s endowment of emotions mixed with the daily living-test confrontation with reality. For the majority of transsexuals, this results in an early-in-life capitulation. Others, however, undergo prolonged self-test periods during which they convince themselves that how one can live is not necessarily how one prefers to live. It must also be clear that the nature of the self-test for any particular individual does not have to be as rigorous or as prolonged as documented here. Each transsexual sets his own test and “passing” criteria.

Lastly, standards of care recommendations for transsexual counseling and presurgical treatment usually require the candidate to undergo a real-life test, usually for one to two years, during which he or she lives as a member of the desired sex (e.g., Clemmensen 1990; Meyer and Hoopes 1974; Money and Wiedeking 1980). This requirement, one of several seen as crucial before sex change surgery by the Harry Benjamin International Gender Dysphoria Association, is to be a period during which the individual sees how the new life confirms or denies expectations (Walker et al. 1990). For the true TS, this real-life test is much easier than the living-test or any self-test. It is seen as a relief.

Previous publications have indicated in broad terms how this inner identity is believed to come about (e.g., Diamond 1965; 1968; 1976; 1979; 1993; 1994) and other types of examples have been offered which show an innate core identity as a male develops despite social reinforcement as a female (Diamond 1982; Diamond and Sigmundson 1996). The details of this process of sexual identity formation are still to be elucidated. Nevertheless, it seems fairly certain that this inner voice can develop without reinforcement and social approval for the desired sex and with ample reinforcement in the nondesired sex. And it can occur in the face of a socially adverse future and provide an inner personal calm more important than any external rewards.



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1 My use of the terms gender identity and sexual identity has been defined elsewhere (Diamond 1976, 1979, 1994). I think the differences are crucial in discussion of transsexualism. One refers to the realization of social (external) views of sex and gender and self in contrast or comparison with internal and personal views of sex and gender.

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