Archives of Sexual Behavior, Vol. 4, No. 1, 1975
Effeminacy. I. A Quantitative Rating Scale Alan F. Schatzberg, M.D., hs,6 Michael P. Westfall, M.D., 2's A n t h o n y B. Blumetti, Ph.D., 3 and C. Lee Birk, M.D. 4
Although effeminacy is recognized to be a complex and important phenomenon, until now it has been only scantily studied, and has not been clearly defined or measured. In this paper, we review the literature and present an Effeminacy Rating Scale that quantifies the behavioral fragments comprising the overall clinical picture o f effeminacy. We also present data obtained in a trial o f the scale on a sample o f 16 homosexual and 16 heterosexual males. The scale was found to have a high interrater reliability (0.93) and can therefore be used to study effeminacy quantitatively. KEY WORDS: effeminacy; homosexual; heterosexual; rating scale.
INTRODUCTION
Effeminacy has been defined according to Webster's Third International Dictionary as "the quality or state of being effeminate: a womanlike delicacy, weakness, or softness in a man." This common definition is not a useful operational definition. For the scientific study of the phenomenon, it is unfortunate that efferrinacy elicits negative emotional reactions in many people: such pejorative terms as "swishy," "faggy," and "flaming queens" show how disquieting
1Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts. 2Clinical Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts. 3Assistant Professor of Psychiatry, Division of Clinical Psychology, Upstate Medical Center, Syracuse, New York. 4Assistant Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts, and Director of the Laboratory of Behavioral Psychiatry, Massachusetts Mental Health Center, Boston, Massachusetts. SAt the time this work was done, Dr. Schatzberg and Dr. Westfall were both Clinical Fellows in Psychiatry at the Massachusetts Mental Health Center, Harvard Medical School. 6Reprint requests should be sent to Dr. Alan F. Schatzberg, McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02178. 31 @ 1 9 7 5 P l e n u m Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, N e w Y o r k , N . Y . 1 0 0 1 1 . N o part o f this p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval system, or t r a n s m i t t e d , in a n y f o r m or bY any means, e l e c t r o n i c , mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , r e c o r d i n g , or otherwise, w i t h o u t w r i t t e n permission o f the publisher.
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effeminate behavior may be to the noneffeminate, but do not serve to clarify the behavioral properties involved. Moreover, a critical review of the psychiatric literature did not reveal a more precise clinical definition. We found that most studies of effeminacy have been done on children. Zuger (1966), for example, studied 16 young males who had manifested "effeminate" traits in childhood. His criteria for effeminacy included the display of an unusual interest in feminine roles, the desire to be a female, and the wearing of women's clothing, jewelry, and lipstick. He was apparently defining "effeminacy" in terms of "feminine-type behavior." Green and Money (1960, 1961) in their studies of children used a similar set of criteria. Zuger and Taylor (1969), studying the prevalence and persistence of such tendencies in effeminate ("cross-gender type") boy populations vs. noneffeminate boy populations, found them to be very common though often transistory. In some cases, however, there was a persistence of "effeminate" behavior into adulthood, and this was accompanied by conspicuous difficulties in gender identity. Other authors also have noted that such "effeminacy" may persist into adulthood (Green, 1968). Stoller (1967) and Zuger and Taylor (t969) have placed great emphasis on the prognostic importance of the intensity with which these so-called effeminate activities are pursued. Bakwin (1968)contended that effeminacy is most noticeable between the ages of 3 and 7 and that much of the behavior is later suppressed because of social disapproval. He found no correlation between body build and effeminacy in a population of ten males, but such a sample is obviously too small to substantiate any firm conclusion. Green and Money (1961) described effeminacy as a phenomenon of "middle childhood," while Lebowitz (1972) cited two key periods when "effeminate behavior" might first appear: before the age of 6 and after the age of 10. He also stated that effeminacy of early onset often presaged the later manifestation of genderidentity problems. Follow-up studies are limited, and have generally involved children with gender difficulties serious enough to warrant psychiatric attention. Bakwln (1968) reassessed patients 2 - 2 9 years after they had been diagnosed as effeminate, but followed only two patients beyond adolescence. Zuger (1966)studied a group of 20 boys referred for psychiatric consultation but failed to follow them past adolescence. Lebowitz (1972) found a high incidence of transsexualism (three of eight patients) on adult follow-up of patients who as young children had been referred for evaluation and treatment of "feminine behavior." Stoller (1968, 1971) has separated effeminacy from transsexualism and transvestism and views effeminacy as a hostile mimicry of women. Holemon and Winokur (1965) compared groups of effeminate and noneffeminate homosexuals and concluded that effeminate homosexuality is a "disease of childhood" and that the disorder of effeminacy precedes the disorder of homosexuality. Gross gestures were used as criteria for effeminacy but were not deafly defined.
Effeminacy. A Quantitative Rating Scale
33
In summary, the literature on effeminacy amounts largely to anecdotal descriptions of "feminine-type behavior" in children. Green, Bakwin, and Lebowitz appear to have studied a variety of serious gender disorders which go beyond simple effeminacy, but they did not address themselves to effeminacy as it occurs in mild to marked forms in adult heterosexual and homosexual men -- a problem which is examined in this paper. A more precise behavioral definition of effeminacy is needed for further study and illumination of the phenomenon and its possible etiologies. The main purpose of this paper is to offer such a definition, using a quantitative rating scale of tested interrater reliability. In addition, this paper reports data obtained from the application of this scale and attempts to look at the relationship between sexual orientation and effeminacy. METHODOLOGY Although clinicians can agree generally on terming certain males effeminate, they find it difficult to pinpoint the factors which lead to that impression or to quantify their impressions. We began to observe effeminate men with the aim of clarifying the components of the phenomenon. We first observed certain gross behavioral items which fell into the following categories: speech, gait, posture-tonus, and gestures. When rudimentary scales were employed to assess the degree of effeminacy in these categories, using a 0 to 4+ rating system, it was impossible to obtain a satisfactory degree of reliability. It was also impossible, even with the use of experienced professionals as raters, to obtain an acceptable degree of interrater reliability on a 5-point scale designed to measure overall effeminacy. We therefore decided to observe effeminate behavior with the aim of breaking it down into discrete behavioral fragments. This resulted in a list of 67 behavioral items. Based on these items, we devised a simple binary (yes-no) scale (Effeminacy Scale; see Table I). This scale records the presence or absence of the behavior, thus minimizing subjective judgments; and facilitating high interrater reliability. A few items -- e.g., "Does he smile seductively?" - do require subjective judgment; nevertheless, it seems that raters are able to agree yes or no with consistency. We also devised a binary rating scale of 30 questions dealing with dress and grooming, in order to test a priori hypotheses that such items would be poor indicators of effeminacy and that such a Dress-Grooming Scale would correlate poorly with the Effeminacy Scale. 7 The latter proved to be true. The Effeminacy Scale was tested on a nonpatient population consisting of heterosexuals and homosexuals. We advertised in a widely read and respected 7Dress-Groomirlg Scale is available on request.
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Sehatzberg, Westfall, Blumetti, and Birk Table I. Effeminacy Scale
Speech: 1. Does he speak with soft tones? (The designation "soft tones" includes low volume, slurring o f consonants, and a poor definition o f word-ending.) 2. Does he at times make statements with a rising inflection? (A paradoxical message where a statement is vocalized in a questioning manner.) 3. Does he speak with a high voice? (A consistently high tone or occasional falsetto.) 4. Does he at times elongate certain vowel sounds to an extraordinary degree? (e.g., " H l i i . . . ") 5. Does he use many dramatic adjectives or superlatives? (e.g., "Smashing," "horrid;" and "most wonderful.") a 6. Does he lisp or use sibilant S's? 7. Does he accentuate certain words in a sentence, that is, inappropriately beyond ordinary usage? (e.g., "How sweet! .... He is a wonderful man.") 8. Does his voice trail off in the midst of or at the ends o f sentences? 9. Does he speak with breathy, seductive tones? 10. Does his speech have an overprecise or prissy quality? 11. Does he seem self-consciously proper about his grammar or vocabulary? 12. Does his speech seem affected or stilted? (This refers mainly to intonation and syllabic stress.) 13. Does he giggle or smile nervously? 14. Does he affect a pert or effervescent way o f speaking? 15. Does he use nouns in a bizarre, diminutive fashion? (e.g., "Drinkie" or even "drinkiep o o h " for drink.J a 16. Does he use neologisms o f the type associated with young children? (These may be diminutive contractions o f c o m m o n words like "marvey,'" meaning marvelous, or infantile terms dealing with body functions like "tinkle" or "pooh-pooh.") a 17. Does he try to convey a sense o f his heightened esthetic sensitivity?a 18. Does he frequently use expletives to express enthusiasm? (e.g., "Fabulous!") a 19. When describing his feelings, does he seem to exaggerate their intensity? (e,g., "I feel simply wretched!") a 20. Do his expressions o f enthusiasm go beyond what he seems to really feel? 21. Does he resort to sarcastic mimicry? 22. Does he sigh deeply or seductively? a Gait: 23. 24. 25. 26. 27. 28.
Does he move sinuously? Does he walk in small mincing steps? Do his thighs rub together when he walks? a Does he bounce or skip when he walks? When walking, does he move his hips or pelvis excessively? As he walks, do his buttocks noticeably roll in an up-and-down direction? a
Posture and tonus: 29. 30. 31. 32.
When he sits, does he double cross his legs, that is, at both knee and a n k l e ~ Does he sit in a chair with one leg tucked under him? a Does he sit in a chaff with both legs tucked under him? a Does he cross his legs high and tightly? (The legs are crossed more than 3 inches above the knee or with little space between the thighs.) 33. Does he display a limp wrist? 34. Does he strike modeling poses? (e.g., Tilt of the head with a posed smile; poised display o f the ventral surface o f the forarms and palms.)
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35
Table I. Continued 35. Does he strike languid poses? 36. Does he strike a styfized pose in holding a cigarette, pipe, or cigar? (e.g., Holding the cigarette between thumb and index finger while displaying the palm; holding the cigarette between index and middle fingers with supination of the forearm, extension of the wrist, and exposure of the palm.) 37. Are one or both hands placed in the area of the genitals? 38. Does he use his hands in statuesque gestures? 39. Is one shoulder held markedly higher than the other when he sits? 40. In the sitting position, are his knees hyperflexed and his thighs tightly pressed together?a Mouth movements: 41. 42. 43. 44.
Does he Does he Does he Does he
purse his lips when he speaks?a smile seductively? purse his lips when not speaking?a display his tongue?
Upper face and eyes: 45. 46. 47. 48. 49. 50. 51.
Does he flirt with his eyes? Does he roll his eyes as an emphatic gesture? Does he flutter his eyelashes? Is he furtive in terms of eye contact with the interviewer? Does he maintain prolonged, staring eye contact? Does he raise his eyebrows for emphasis? Does he infrequently wrinkle his brow or does his brow have a waxy or shiny appearance?
Hand gestures: 52. Does he use an excessive number of wrist gestures? 53. Does he use excessively "soft" hand movements? (These are rolling hand movements with smooth and flowing upward-and-downward movements.) 54. Does he arrange to touch the interviewer? (Shaking hands is not included here.) 55. Does he use flamboyant gestures? (These are abrupt and of a wide arc.) Hand and torso gestures: 56. As he sits does he make sinuous movements? 57. Does he roll his head as he talks? 58. Does he rock his pelvis while sitting? Body type: 59. 60. 61. 62. 63.
Does he have a noticeably pear-shaped body with large hips and buttocks?a Does he have a chest suggestive of female breasts? Does he appear younger than his stated age or have little facial hair for his age? Does he have a noticeably slender, asthenic, or willowy build? Does he give the impression of being not just small but petite and dainty? a
Body narcissism: 64. Does he preen his hair? a
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Schatzberg, Westfall, Btumetti, and Birk Table I. Continued
65. Does he caress himself? (This includes face stroking and head or moustache stroking.) 66. Does he cuddle himself?. (This is crossing of the arms with bowing forward of the shoulders.)a Other: 67. Does he take his shoes off during the interview?a aNot endorsed for any of 32 subjects during intake interviews.
weekly newspaper dealing with arts, entertainment, and politics and in the daily paper of a local university. Separate advertisements called for "well-adjusted homosexuals" and "physiologically and psychologically normal males." No mention was made of the exact purpose of the study; subjects were told that we were interested in studying group interaction in an encounter setting. Although encounter group meetings were held and additional data obtained, primary data in this paper are derived from individual intake interviews. For these individual interviews, all subjects were seen by two of the authors (A.F.S. and M.P.W.) for 15 min, using a semistructured interview. After the meeting, they were rated independently by these two raters using the Effeminacy Scale (Table I) and the Dress-Grooming Scale. A history of sexual behavior was taken and all subjects were assigned a Kinsey number (Kinsey 0, completely heterosexual; Kinsey 6, completely homosexual) (Kinsey et al:, 1948). Thirty-three males were interviewed consecutively, The thirty-third, a psychotic male homosexual with a history of long-term hospitalization, was deemed unsuitable for the group and was not rated. None of the subjects was a transvestite or a transsexual.
DATA Sixteen of 32 subjects received Kinsey scores of 4~6 and thus were considered homosexual. Their ages ranged from 21 to 50 with a mean of 29.3. Educational levels ranged from 12 to 20 years with a mean of 15.8. There was no statistically significant difference in terms of age and education between the homosexual and heterosexual groups (Table II). For the homosexual subjects the mean Kinsey number was 5.3 and for the heterosexual subjects 0.6, significantly different at the 0.01 level. The mean score on the Effeminacy Scale for homosexual subjects was 7.0, almost twice the mean score of 3.7 for heterosexual subjects. This difference is significant at the 0.05 level. Because of the distribution of scores on the Effeminacy Scale, we felt that the assumption of homogeneity of variance may have been violated. For this reason, a n / ; m a x test was performed on the Effeminacy Scale scores, which proved insignificant. As pre-
Effeminacy. A Quantitative Rating Scale
37
dicted, there was no significant difference between heterosexual and homosexual subjects on the Dress-Grooming Scale. The interrater reliability for Scale I was 0.94 (Pearson r), based on the total Effeminacy scores for all subjects. The percentage of agreement (total number of items agreed on/total number of items endorsed) was 54%. Two independent, nonprofessional raters subsequently observed and scored two videotaped sections for each of a random subsample of ten subjects. Their interrater reliabilities for the two periods were 0.93 and 0.94, similarly obtained. Interrater reliability for the Dress-Grooming Scale was 0.86. The percentage of agreement was 64%. The extremely high coefficients for the Effeminacy score indicate its high reliability for both professional and nonprofessional raters. The correlation between the Effeminacy Scale and the Dress-Grooming Scale was 0.09, which indicates that effeminate behavior and dress vary independently. For example, some theatrical people, some blacks, and some Latin Americans may dress in flamboyant fashions which some people alien to the subcultural mores involved may construe as "effeminate," but these variations are culturally and socially determined and do not necessarily reflect effeminacy, as measured in this paper. Ever-changing fashions and the strong current trend toward increasing liberation of males regarding grooming and hair styling make the unsuitability of a scale based on these factors seem obvious. In the final analysis, of course, even though it does seem obvious, the clinical relevance of the Effeminacy Scale vis-d-vis the Dress-Grooming Scale needs to be subjected to empirical test. In reviewing the data on our 32 subjects, we tentatively categorized the numerical ratings on the Effeminacy Scale in the following manner: 0-5 5-9 9-13 13 and over
not effeminate mildly effeminate moderately effeminate markedly effeminate
Table II. Mean Scores on Kinsey Rating, Age, Education, and Scales I and II for Homosexual and Heterosexual Groups Homosexuals (IV= 16)
Kinsey Education Age Effeminacy Scale Dress-Grooming Scale aTwo-tailed test. bp < 0.01. Cp < 0.05.
Heterosexuals (N = 16)
Ma
SD
M2
SD
ta
5.31 15.50 29.81 7.03
0.85 2.24 4.42 3.83
0.56 16.13 28.88 3.66
0.86 2.23 8.04 2.99
15.24b 0.77 (N.S.) 0.40 (N.S.) 2.69c
0.66
0.91
0.44
0.77
0.71 (N.S.)
3chatzberg, Wesffall, Blumetti, and Birk
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Table Ili. Kinsey and Effeminacy Ranges Effeminacy ranges Not (0-5) Mild (5-9) Moderate (9-13) Marked (13)
Kinsey 0-2 (N = 16) 12 2 2 0
Kinsey 4-6 (N = 16) 6 4 5 1
Ratings on the Effeminacy Scale ranged from 0 to 17, with 18 subjects scoring below 5. Included within this "noneffeminate" group were six subjects with Kinsey scores of 4 and above, three of whom had a Kinsey score of 6. On the other hand, eight subjects rated 9 or over on the Effeminacy Scale, two of whom had a Kinsey score of 0. With respect to the relationship between Kinsey numbers and Effeminacy scores, a Pearson product-moment correlation between the two variables yielded a correlation coefficient (r) of 0.45 (statistically significant at the 0.01 level) and a coefficient of determination (r 2) of 0.20. This coefficient of determination, when multiplied by 100, can be interpreted as the percentage of variance in Kinsey numbers that is accounted for by the variance in Effeminacy scores. Table III compares degrees of effeminacy with ranges of relative homosexuality as indicated by Kinsey numbers. Tile X coefficient (Hays, 1963) for association between Kinsey number and Effeminacy score is 0.09, which indicates that knowledge of the Effeminacy score reduces error in predicting Kinsey numbers by only 9%. Thus although there is a small but statistically significant difference between homosexuals and nonhomosexuals with respect to Effeminacy scores, knowledge of a subject's Effeminacy rating would be of littte predictive value with respect to his sexual orientation.
DISCUSSION The Effeminacy Scale represents an attempt to analyze effeminacy into discrete components of behavior and body types. We have introduced a rigorous method for evaluating the degree of effeminacy; previously, this had to be based on amorphous impressions. We have demonstrated that the scale has a high interrater reliability for both professional and nonprofessional observers. Our impression of the Dress-Grooming Scale, the same as our a priori impression, is that it has very limited usefulness. In addition, a California Psychological Inventory femininity scale (Gough Scale, 1952, 1966) was filled out by a subgroup of individuals (N = 19) who participated in the encounter sessions. The Gough Scale was devised 20 years ago and measures psychological femininity by a series of questions relating to interests. The correlation coefficients between Gough scores and Effeminacy Scale ratings and Gough and Kinsey scores were 0.23 and
Effeminacy. A Quantitative Rating Scale
39
0.31, respectively. The obvious low correlation of Gough scores with either Kinsey scores or Effeminacy Scale scores we feel reflects the irrelevance of the Gough Scale. Interests are largely culturally determined, are in constant flux, and are poor indicators of masculinity, femininity, or effeminacy. For example, with the Gough Scale a negative response to "I would like to be a soldier" is judged a feminine one. Today this would probably be a common response among younger males, especially well-educated urban ones. Although gestures are also partially culturally determined, we feel that compared to interests and dress/grooming they are less affected by cultural artifacts. Effeminacy scores for the 32 males ranged from 0 to 17. Most subjects (30/32) scored positively on at least one item. Although the scores may appear low in relation to the potential maximum score of 67, they are not low compared to the highest score of 17 found in our sample. Differences in scores of 3 or 4 points reflect definite observable differences in the degree of effeminacy. Clinically we feel that it would be unusual to find an individual who would rate positively on more than 20 items in a 15-min interview, although of course this would depend in part on the population sampled. To construct a scale which was acceptably precise, it was necessary to aim for an exhaustive inventory of gestures. Certain items may appear contradictory and in fact cannot c o e x i s t - e.g., prolonged eye contact/furtive eye contact -- but these in fact describe relevant effeminate behavioral items at opposite ends of spectra. In addition, categories do not contain equal numbers of items, and, although all categories were endorsed, some items within categories were endorsed more frequently than others while a few were not endorsed. Also, the similarity of certain items appeared to reduce the percentage of agreement, especially in the initial stages of the work. To condense and refine the scale, large-scale population studies and item analyses should be performed to determine which items are most significant and which can or should be eliminated. This can be done without great difficulty because our experience, even with nonprofessional raters, has been that despite its length the scale becomes easy to use after only a few hours. In our sample population, three men with a Kinsey number of 6 scored less than 5 on the Effeminacy Scale, while two men with a Kinsey 0 number scored 9 or above on Effeminacy. Data analysis revealed a low but significant correlation and a minor degree of association between Kinsey and Effeminacy ratings. It is necessary, however, to comment on some of the limitations inherent in using number/statistics and scales in studying such complex phenomena as effeminacy and sexual orientation. Although the Effeminacy Scale measures degrees of effeminate behavior, in and of itself it does not describe the possible purposes and distinct subpatterns (e.g., sarcastic mimicry) of effeminate behavior. We have yet to cluster and weight those items which may be significant.
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Schatzberg, Westfall, Blurnetti, and Birk
Thus two individuals who score 7 on the Effeminacy Scale may appear somewhat different. Similarly, although Kinsey numbers define ranges of heterosexual/homosexual activity, they do not describe the many possible purposes, forms, and psychodynamic etiologies of one's sexual behavior or orientation. Thus two individuals with the same Kinsey number may have distinctly different psychodynamics, histories, patterns of behavior, fantasy, etc. Initially our intention was to get a random, representative sample of homosexuals. However, because of the recruiting procedures, we became more and more aware that this may not be a truly representative sample. Thus larger-scale studies are indicated. It must be emphasized that we are presenting the Effeminacy Scale as a possible method for further study o f the phenomenon. We feel the Effeminacy Scale can be used to delineate possible subpatterns of effeminate behavior and to study in great depth the relationship between effeminacy with its particular subpatterns and subtypes of homosexual or heterosexual behavior and fantasy. In addition, the scale opens the way to solving the many still unanswered questions about effeminacy: its psychodynamic and hormonal etiologies, its relationship to behavior in females, its course, and its variation with social context. The last question is addressed in Part II of this work (following article in this journal issue).
ACKNOWLEDGMENTS The authors are indebted to Dr. Chester Swett for his valuable contribution to the pilot work which led to this paper. Thanks are also due Ms. Nancy Silverman, who assisted in the collection and recording of data, and Dr. Ann Brinkley, who provided valuable editorial assistance.
REFERENCES Bakwin, H. (1968). Deviant gender-role behavior in children- relations to homosexuality. Pediatrics 41 : 620-629. Gough, H. G. (1952). Identifying psychological femininity. Educ. Psychol. Meas. 12: 427-439. Gough, H. G. (1966). A cross-cultural analysis of the CPI femininity scale. £ Consul~. Psychol. 30: 136-141. Green, R. (1968). Childhood cross-gender identification. J. Nerv. Merit. Dis. 147: 500-509. Green, R., and Money, J. (1960). Incongruous gender role: Non-genital manifestation in prepubertal boys. J. Nerv. Ment. Dis. 131 : 160-168. Green, R., and Money, J. (1961). Effeminacy in prepubertal boys. Pediatrics 27: 286-291. Hays, W. L. (1963). Statistics for Psychologists, Holt, Rinehart, and Winston, New York. Holemon, E., and Winokur, G. (1965). Effeminate homosexuality: A disease of childhood. Am. J. Orthopsychiat. 35: 48-56. Kinsey, A. C., Pomeroy, W. B., and Martin, C. E. (1948). Sexual Behavior in the Human Male, Saunders, Philadelphia.
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Lebowitz, P. S. (1972). Feminine behavior in boys: Aspects of its outcome. Am. J. Psychiat. 128: 1283-1289. Stoller, R. J. (1967). "It's only a phase": Femininity in boys. JAMA 201: 314-315. Stoller, R. J. (1968). Sex and Gender, Science House, New York. Stoller, R. J. (1971). The term "transvestism." Arch. Gen. Psychiat. 24: 230-237. Zuger, B. (1966). Effeminate behavior present in boys from early childhood. 1. The clinical syndrome and follow-up studies. J. Pedlar. 69:1098-1107. Zuger, B., and Taylor, P. (1969). Effeminate behavior present in boys from early childhood. II. Comparison with similar symptoms in non-effeminate boys. Pediatrics 44:375-380.
Effeminacy. I. A Quantitative Rating Scale Alan F. Schatzberg, M.D., hs,6 Michael P. Westfall, M.D., 2's A n t h o n y B. Blumetti, Ph.D., 3 and C. Lee Birk, M.D. 4
Although effeminacy is recognized to be a complex and important phenomenon, until now it has been only scantily studied, and has not been clearly defined or measured. In this paper, we review the literature and present an Effeminacy Rating Scale that quantifies the behavioral fragments comprising the overall clinical picture o f effeminacy. We also present data obtained in a trial o f the scale on a sample o f 16 homosexual and 16 heterosexual males. The scale was found to have a high interrater reliability (0.93) and can therefore be used to study effeminacy quantitatively. KEY WORDS: effeminacy; homosexual; heterosexual; rating scale.
INTRODUCTION
Effeminacy has been defined according to Webster's Third International Dictionary as "the quality or state of being effeminate: a womanlike delicacy, weakness, or softness in a man." This common definition is not a useful operational definition. For the scientific study of the phenomenon, it is unfortunate that efferrinacy elicits negative emotional reactions in many people: such pejorative terms as "swishy," "faggy," and "flaming queens" show how disquieting
1Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts. 2Clinical Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts. 3Assistant Professor of Psychiatry, Division of Clinical Psychology, Upstate Medical Center, Syracuse, New York. 4Assistant Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts, and Director of the Laboratory of Behavioral Psychiatry, Massachusetts Mental Health Center, Boston, Massachusetts. SAt the time this work was done, Dr. Schatzberg and Dr. Westfall were both Clinical Fellows in Psychiatry at the Massachusetts Mental Health Center, Harvard Medical School. 6Reprint requests should be sent to Dr. Alan F. Schatzberg, McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02178. 31 @ 1 9 7 5 P l e n u m Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, N e w Y o r k , N . Y . 1 0 0 1 1 . N o part o f this p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval system, or t r a n s m i t t e d , in a n y f o r m or bY any means, e l e c t r o n i c , mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , r e c o r d i n g , or otherwise, w i t h o u t w r i t t e n permission o f the publisher.
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Schatzberg, Westfall, Blumetti, and Birk
effeminate behavior may be to the noneffeminate, but do not serve to clarify the behavioral properties involved. Moreover, a critical review of the psychiatric literature did not reveal a more precise clinical definition. We found that most studies of effeminacy have been done on children. Zuger (1966), for example, studied 16 young males who had manifested "effeminate" traits in childhood. His criteria for effeminacy included the display of an unusual interest in feminine roles, the desire to be a female, and the wearing of women's clothing, jewelry, and lipstick. He was apparently defining "effeminacy" in terms of "feminine-type behavior." Green and Money (1960, 1961) in their studies of children used a similar set of criteria. Zuger and Taylor (1969), studying the prevalence and persistence of such tendencies in effeminate ("cross-gender type") boy populations vs. noneffeminate boy populations, found them to be very common though often transistory. In some cases, however, there was a persistence of "effeminate" behavior into adulthood, and this was accompanied by conspicuous difficulties in gender identity. Other authors also have noted that such "effeminacy" may persist into adulthood (Green, 1968). Stoller (1967) and Zuger and Taylor (t969) have placed great emphasis on the prognostic importance of the intensity with which these so-called effeminate activities are pursued. Bakwin (1968)contended that effeminacy is most noticeable between the ages of 3 and 7 and that much of the behavior is later suppressed because of social disapproval. He found no correlation between body build and effeminacy in a population of ten males, but such a sample is obviously too small to substantiate any firm conclusion. Green and Money (1961) described effeminacy as a phenomenon of "middle childhood," while Lebowitz (1972) cited two key periods when "effeminate behavior" might first appear: before the age of 6 and after the age of 10. He also stated that effeminacy of early onset often presaged the later manifestation of genderidentity problems. Follow-up studies are limited, and have generally involved children with gender difficulties serious enough to warrant psychiatric attention. Bakwln (1968) reassessed patients 2 - 2 9 years after they had been diagnosed as effeminate, but followed only two patients beyond adolescence. Zuger (1966)studied a group of 20 boys referred for psychiatric consultation but failed to follow them past adolescence. Lebowitz (1972) found a high incidence of transsexualism (three of eight patients) on adult follow-up of patients who as young children had been referred for evaluation and treatment of "feminine behavior." Stoller (1968, 1971) has separated effeminacy from transsexualism and transvestism and views effeminacy as a hostile mimicry of women. Holemon and Winokur (1965) compared groups of effeminate and noneffeminate homosexuals and concluded that effeminate homosexuality is a "disease of childhood" and that the disorder of effeminacy precedes the disorder of homosexuality. Gross gestures were used as criteria for effeminacy but were not deafly defined.
Effeminacy. A Quantitative Rating Scale
33
In summary, the literature on effeminacy amounts largely to anecdotal descriptions of "feminine-type behavior" in children. Green, Bakwin, and Lebowitz appear to have studied a variety of serious gender disorders which go beyond simple effeminacy, but they did not address themselves to effeminacy as it occurs in mild to marked forms in adult heterosexual and homosexual men -- a problem which is examined in this paper. A more precise behavioral definition of effeminacy is needed for further study and illumination of the phenomenon and its possible etiologies. The main purpose of this paper is to offer such a definition, using a quantitative rating scale of tested interrater reliability. In addition, this paper reports data obtained from the application of this scale and attempts to look at the relationship between sexual orientation and effeminacy. METHODOLOGY Although clinicians can agree generally on terming certain males effeminate, they find it difficult to pinpoint the factors which lead to that impression or to quantify their impressions. We began to observe effeminate men with the aim of clarifying the components of the phenomenon. We first observed certain gross behavioral items which fell into the following categories: speech, gait, posture-tonus, and gestures. When rudimentary scales were employed to assess the degree of effeminacy in these categories, using a 0 to 4+ rating system, it was impossible to obtain a satisfactory degree of reliability. It was also impossible, even with the use of experienced professionals as raters, to obtain an acceptable degree of interrater reliability on a 5-point scale designed to measure overall effeminacy. We therefore decided to observe effeminate behavior with the aim of breaking it down into discrete behavioral fragments. This resulted in a list of 67 behavioral items. Based on these items, we devised a simple binary (yes-no) scale (Effeminacy Scale; see Table I). This scale records the presence or absence of the behavior, thus minimizing subjective judgments; and facilitating high interrater reliability. A few items -- e.g., "Does he smile seductively?" - do require subjective judgment; nevertheless, it seems that raters are able to agree yes or no with consistency. We also devised a binary rating scale of 30 questions dealing with dress and grooming, in order to test a priori hypotheses that such items would be poor indicators of effeminacy and that such a Dress-Grooming Scale would correlate poorly with the Effeminacy Scale. 7 The latter proved to be true. The Effeminacy Scale was tested on a nonpatient population consisting of heterosexuals and homosexuals. We advertised in a widely read and respected 7Dress-Groomirlg Scale is available on request.
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Sehatzberg, Westfall, Blumetti, and Birk Table I. Effeminacy Scale
Speech: 1. Does he speak with soft tones? (The designation "soft tones" includes low volume, slurring o f consonants, and a poor definition o f word-ending.) 2. Does he at times make statements with a rising inflection? (A paradoxical message where a statement is vocalized in a questioning manner.) 3. Does he speak with a high voice? (A consistently high tone or occasional falsetto.) 4. Does he at times elongate certain vowel sounds to an extraordinary degree? (e.g., " H l i i . . . ") 5. Does he use many dramatic adjectives or superlatives? (e.g., "Smashing," "horrid;" and "most wonderful.") a 6. Does he lisp or use sibilant S's? 7. Does he accentuate certain words in a sentence, that is, inappropriately beyond ordinary usage? (e.g., "How sweet! .... He is a wonderful man.") 8. Does his voice trail off in the midst of or at the ends o f sentences? 9. Does he speak with breathy, seductive tones? 10. Does his speech have an overprecise or prissy quality? 11. Does he seem self-consciously proper about his grammar or vocabulary? 12. Does his speech seem affected or stilted? (This refers mainly to intonation and syllabic stress.) 13. Does he giggle or smile nervously? 14. Does he affect a pert or effervescent way o f speaking? 15. Does he use nouns in a bizarre, diminutive fashion? (e.g., "Drinkie" or even "drinkiep o o h " for drink.J a 16. Does he use neologisms o f the type associated with young children? (These may be diminutive contractions o f c o m m o n words like "marvey,'" meaning marvelous, or infantile terms dealing with body functions like "tinkle" or "pooh-pooh.") a 17. Does he try to convey a sense o f his heightened esthetic sensitivity?a 18. Does he frequently use expletives to express enthusiasm? (e.g., "Fabulous!") a 19. When describing his feelings, does he seem to exaggerate their intensity? (e,g., "I feel simply wretched!") a 20. Do his expressions o f enthusiasm go beyond what he seems to really feel? 21. Does he resort to sarcastic mimicry? 22. Does he sigh deeply or seductively? a Gait: 23. 24. 25. 26. 27. 28.
Does he move sinuously? Does he walk in small mincing steps? Do his thighs rub together when he walks? a Does he bounce or skip when he walks? When walking, does he move his hips or pelvis excessively? As he walks, do his buttocks noticeably roll in an up-and-down direction? a
Posture and tonus: 29. 30. 31. 32.
When he sits, does he double cross his legs, that is, at both knee and a n k l e ~ Does he sit in a chair with one leg tucked under him? a Does he sit in a chaff with both legs tucked under him? a Does he cross his legs high and tightly? (The legs are crossed more than 3 inches above the knee or with little space between the thighs.) 33. Does he display a limp wrist? 34. Does he strike modeling poses? (e.g., Tilt of the head with a posed smile; poised display o f the ventral surface o f the forarms and palms.)
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35
Table I. Continued 35. Does he strike languid poses? 36. Does he strike a styfized pose in holding a cigarette, pipe, or cigar? (e.g., Holding the cigarette between thumb and index finger while displaying the palm; holding the cigarette between index and middle fingers with supination of the forearm, extension of the wrist, and exposure of the palm.) 37. Are one or both hands placed in the area of the genitals? 38. Does he use his hands in statuesque gestures? 39. Is one shoulder held markedly higher than the other when he sits? 40. In the sitting position, are his knees hyperflexed and his thighs tightly pressed together?a Mouth movements: 41. 42. 43. 44.
Does he Does he Does he Does he
purse his lips when he speaks?a smile seductively? purse his lips when not speaking?a display his tongue?
Upper face and eyes: 45. 46. 47. 48. 49. 50. 51.
Does he flirt with his eyes? Does he roll his eyes as an emphatic gesture? Does he flutter his eyelashes? Is he furtive in terms of eye contact with the interviewer? Does he maintain prolonged, staring eye contact? Does he raise his eyebrows for emphasis? Does he infrequently wrinkle his brow or does his brow have a waxy or shiny appearance?
Hand gestures: 52. Does he use an excessive number of wrist gestures? 53. Does he use excessively "soft" hand movements? (These are rolling hand movements with smooth and flowing upward-and-downward movements.) 54. Does he arrange to touch the interviewer? (Shaking hands is not included here.) 55. Does he use flamboyant gestures? (These are abrupt and of a wide arc.) Hand and torso gestures: 56. As he sits does he make sinuous movements? 57. Does he roll his head as he talks? 58. Does he rock his pelvis while sitting? Body type: 59. 60. 61. 62. 63.
Does he have a noticeably pear-shaped body with large hips and buttocks?a Does he have a chest suggestive of female breasts? Does he appear younger than his stated age or have little facial hair for his age? Does he have a noticeably slender, asthenic, or willowy build? Does he give the impression of being not just small but petite and dainty? a
Body narcissism: 64. Does he preen his hair? a
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Schatzberg, Westfall, Btumetti, and Birk Table I. Continued
65. Does he caress himself? (This includes face stroking and head or moustache stroking.) 66. Does he cuddle himself?. (This is crossing of the arms with bowing forward of the shoulders.)a Other: 67. Does he take his shoes off during the interview?a aNot endorsed for any of 32 subjects during intake interviews.
weekly newspaper dealing with arts, entertainment, and politics and in the daily paper of a local university. Separate advertisements called for "well-adjusted homosexuals" and "physiologically and psychologically normal males." No mention was made of the exact purpose of the study; subjects were told that we were interested in studying group interaction in an encounter setting. Although encounter group meetings were held and additional data obtained, primary data in this paper are derived from individual intake interviews. For these individual interviews, all subjects were seen by two of the authors (A.F.S. and M.P.W.) for 15 min, using a semistructured interview. After the meeting, they were rated independently by these two raters using the Effeminacy Scale (Table I) and the Dress-Grooming Scale. A history of sexual behavior was taken and all subjects were assigned a Kinsey number (Kinsey 0, completely heterosexual; Kinsey 6, completely homosexual) (Kinsey et al:, 1948). Thirty-three males were interviewed consecutively, The thirty-third, a psychotic male homosexual with a history of long-term hospitalization, was deemed unsuitable for the group and was not rated. None of the subjects was a transvestite or a transsexual.
DATA Sixteen of 32 subjects received Kinsey scores of 4~6 and thus were considered homosexual. Their ages ranged from 21 to 50 with a mean of 29.3. Educational levels ranged from 12 to 20 years with a mean of 15.8. There was no statistically significant difference in terms of age and education between the homosexual and heterosexual groups (Table II). For the homosexual subjects the mean Kinsey number was 5.3 and for the heterosexual subjects 0.6, significantly different at the 0.01 level. The mean score on the Effeminacy Scale for homosexual subjects was 7.0, almost twice the mean score of 3.7 for heterosexual subjects. This difference is significant at the 0.05 level. Because of the distribution of scores on the Effeminacy Scale, we felt that the assumption of homogeneity of variance may have been violated. For this reason, a n / ; m a x test was performed on the Effeminacy Scale scores, which proved insignificant. As pre-
Effeminacy. A Quantitative Rating Scale
37
dicted, there was no significant difference between heterosexual and homosexual subjects on the Dress-Grooming Scale. The interrater reliability for Scale I was 0.94 (Pearson r), based on the total Effeminacy scores for all subjects. The percentage of agreement (total number of items agreed on/total number of items endorsed) was 54%. Two independent, nonprofessional raters subsequently observed and scored two videotaped sections for each of a random subsample of ten subjects. Their interrater reliabilities for the two periods were 0.93 and 0.94, similarly obtained. Interrater reliability for the Dress-Grooming Scale was 0.86. The percentage of agreement was 64%. The extremely high coefficients for the Effeminacy score indicate its high reliability for both professional and nonprofessional raters. The correlation between the Effeminacy Scale and the Dress-Grooming Scale was 0.09, which indicates that effeminate behavior and dress vary independently. For example, some theatrical people, some blacks, and some Latin Americans may dress in flamboyant fashions which some people alien to the subcultural mores involved may construe as "effeminate," but these variations are culturally and socially determined and do not necessarily reflect effeminacy, as measured in this paper. Ever-changing fashions and the strong current trend toward increasing liberation of males regarding grooming and hair styling make the unsuitability of a scale based on these factors seem obvious. In the final analysis, of course, even though it does seem obvious, the clinical relevance of the Effeminacy Scale vis-d-vis the Dress-Grooming Scale needs to be subjected to empirical test. In reviewing the data on our 32 subjects, we tentatively categorized the numerical ratings on the Effeminacy Scale in the following manner: 0-5 5-9 9-13 13 and over
not effeminate mildly effeminate moderately effeminate markedly effeminate
Table II. Mean Scores on Kinsey Rating, Age, Education, and Scales I and II for Homosexual and Heterosexual Groups Homosexuals (IV= 16)
Kinsey Education Age Effeminacy Scale Dress-Grooming Scale aTwo-tailed test. bp < 0.01. Cp < 0.05.
Heterosexuals (N = 16)
Ma
SD
M2
SD
ta
5.31 15.50 29.81 7.03
0.85 2.24 4.42 3.83
0.56 16.13 28.88 3.66
0.86 2.23 8.04 2.99
15.24b 0.77 (N.S.) 0.40 (N.S.) 2.69c
0.66
0.91
0.44
0.77
0.71 (N.S.)
3chatzberg, Wesffall, Blumetti, and Birk
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Table Ili. Kinsey and Effeminacy Ranges Effeminacy ranges Not (0-5) Mild (5-9) Moderate (9-13) Marked (13)
Kinsey 0-2 (N = 16) 12 2 2 0
Kinsey 4-6 (N = 16) 6 4 5 1
Ratings on the Effeminacy Scale ranged from 0 to 17, with 18 subjects scoring below 5. Included within this "noneffeminate" group were six subjects with Kinsey scores of 4 and above, three of whom had a Kinsey score of 6. On the other hand, eight subjects rated 9 or over on the Effeminacy Scale, two of whom had a Kinsey score of 0. With respect to the relationship between Kinsey numbers and Effeminacy scores, a Pearson product-moment correlation between the two variables yielded a correlation coefficient (r) of 0.45 (statistically significant at the 0.01 level) and a coefficient of determination (r 2) of 0.20. This coefficient of determination, when multiplied by 100, can be interpreted as the percentage of variance in Kinsey numbers that is accounted for by the variance in Effeminacy scores. Table III compares degrees of effeminacy with ranges of relative homosexuality as indicated by Kinsey numbers. Tile X coefficient (Hays, 1963) for association between Kinsey number and Effeminacy score is 0.09, which indicates that knowledge of the Effeminacy score reduces error in predicting Kinsey numbers by only 9%. Thus although there is a small but statistically significant difference between homosexuals and nonhomosexuals with respect to Effeminacy scores, knowledge of a subject's Effeminacy rating would be of littte predictive value with respect to his sexual orientation.
DISCUSSION The Effeminacy Scale represents an attempt to analyze effeminacy into discrete components of behavior and body types. We have introduced a rigorous method for evaluating the degree of effeminacy; previously, this had to be based on amorphous impressions. We have demonstrated that the scale has a high interrater reliability for both professional and nonprofessional observers. Our impression of the Dress-Grooming Scale, the same as our a priori impression, is that it has very limited usefulness. In addition, a California Psychological Inventory femininity scale (Gough Scale, 1952, 1966) was filled out by a subgroup of individuals (N = 19) who participated in the encounter sessions. The Gough Scale was devised 20 years ago and measures psychological femininity by a series of questions relating to interests. The correlation coefficients between Gough scores and Effeminacy Scale ratings and Gough and Kinsey scores were 0.23 and
Effeminacy. A Quantitative Rating Scale
39
0.31, respectively. The obvious low correlation of Gough scores with either Kinsey scores or Effeminacy Scale scores we feel reflects the irrelevance of the Gough Scale. Interests are largely culturally determined, are in constant flux, and are poor indicators of masculinity, femininity, or effeminacy. For example, with the Gough Scale a negative response to "I would like to be a soldier" is judged a feminine one. Today this would probably be a common response among younger males, especially well-educated urban ones. Although gestures are also partially culturally determined, we feel that compared to interests and dress/grooming they are less affected by cultural artifacts. Effeminacy scores for the 32 males ranged from 0 to 17. Most subjects (30/32) scored positively on at least one item. Although the scores may appear low in relation to the potential maximum score of 67, they are not low compared to the highest score of 17 found in our sample. Differences in scores of 3 or 4 points reflect definite observable differences in the degree of effeminacy. Clinically we feel that it would be unusual to find an individual who would rate positively on more than 20 items in a 15-min interview, although of course this would depend in part on the population sampled. To construct a scale which was acceptably precise, it was necessary to aim for an exhaustive inventory of gestures. Certain items may appear contradictory and in fact cannot c o e x i s t - e.g., prolonged eye contact/furtive eye contact -- but these in fact describe relevant effeminate behavioral items at opposite ends of spectra. In addition, categories do not contain equal numbers of items, and, although all categories were endorsed, some items within categories were endorsed more frequently than others while a few were not endorsed. Also, the similarity of certain items appeared to reduce the percentage of agreement, especially in the initial stages of the work. To condense and refine the scale, large-scale population studies and item analyses should be performed to determine which items are most significant and which can or should be eliminated. This can be done without great difficulty because our experience, even with nonprofessional raters, has been that despite its length the scale becomes easy to use after only a few hours. In our sample population, three men with a Kinsey number of 6 scored less than 5 on the Effeminacy Scale, while two men with a Kinsey 0 number scored 9 or above on Effeminacy. Data analysis revealed a low but significant correlation and a minor degree of association between Kinsey and Effeminacy ratings. It is necessary, however, to comment on some of the limitations inherent in using number/statistics and scales in studying such complex phenomena as effeminacy and sexual orientation. Although the Effeminacy Scale measures degrees of effeminate behavior, in and of itself it does not describe the possible purposes and distinct subpatterns (e.g., sarcastic mimicry) of effeminate behavior. We have yet to cluster and weight those items which may be significant.
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Schatzberg, Westfall, Blurnetti, and Birk
Thus two individuals who score 7 on the Effeminacy Scale may appear somewhat different. Similarly, although Kinsey numbers define ranges of heterosexual/homosexual activity, they do not describe the many possible purposes, forms, and psychodynamic etiologies of one's sexual behavior or orientation. Thus two individuals with the same Kinsey number may have distinctly different psychodynamics, histories, patterns of behavior, fantasy, etc. Initially our intention was to get a random, representative sample of homosexuals. However, because of the recruiting procedures, we became more and more aware that this may not be a truly representative sample. Thus larger-scale studies are indicated. It must be emphasized that we are presenting the Effeminacy Scale as a possible method for further study o f the phenomenon. We feel the Effeminacy Scale can be used to delineate possible subpatterns of effeminate behavior and to study in great depth the relationship between effeminacy with its particular subpatterns and subtypes of homosexual or heterosexual behavior and fantasy. In addition, the scale opens the way to solving the many still unanswered questions about effeminacy: its psychodynamic and hormonal etiologies, its relationship to behavior in females, its course, and its variation with social context. The last question is addressed in Part II of this work (following article in this journal issue).
ACKNOWLEDGMENTS The authors are indebted to Dr. Chester Swett for his valuable contribution to the pilot work which led to this paper. Thanks are also due Ms. Nancy Silverman, who assisted in the collection and recording of data, and Dr. Ann Brinkley, who provided valuable editorial assistance.
REFERENCES Bakwin, H. (1968). Deviant gender-role behavior in children- relations to homosexuality. Pediatrics 41 : 620-629. Gough, H. G. (1952). Identifying psychological femininity. Educ. Psychol. Meas. 12: 427-439. Gough, H. G. (1966). A cross-cultural analysis of the CPI femininity scale. £ Consul~. Psychol. 30: 136-141. Green, R. (1968). Childhood cross-gender identification. J. Nerv. Merit. Dis. 147: 500-509. Green, R., and Money, J. (1960). Incongruous gender role: Non-genital manifestation in prepubertal boys. J. Nerv. Ment. Dis. 131 : 160-168. Green, R., and Money, J. (1961). Effeminacy in prepubertal boys. Pediatrics 27: 286-291. Hays, W. L. (1963). Statistics for Psychologists, Holt, Rinehart, and Winston, New York. Holemon, E., and Winokur, G. (1965). Effeminate homosexuality: A disease of childhood. Am. J. Orthopsychiat. 35: 48-56. Kinsey, A. C., Pomeroy, W. B., and Martin, C. E. (1948). Sexual Behavior in the Human Male, Saunders, Philadelphia.
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Lebowitz, P. S. (1972). Feminine behavior in boys: Aspects of its outcome. Am. J. Psychiat. 128: 1283-1289. Stoller, R. J. (1967). "It's only a phase": Femininity in boys. JAMA 201: 314-315. Stoller, R. J. (1968). Sex and Gender, Science House, New York. Stoller, R. J. (1971). The term "transvestism." Arch. Gen. Psychiat. 24: 230-237. Zuger, B. (1966). Effeminate behavior present in boys from early childhood. 1. The clinical syndrome and follow-up studies. J. Pedlar. 69:1098-1107. Zuger, B., and Taylor, P. (1969). Effeminate behavior present in boys from early childhood. II. Comparison with similar symptoms in non-effeminate boys. Pediatrics 44:375-380.
