Archives of Sexual Behavior, Vol. 1, No. 4, 1971
The Adolescent Transvestite on a Psychiatric Service: Family Patterns 1 James Spensley,
M.D., 2' 4
and James T. Barter~ M.D. 3
The symptom of transvestism & explored in a study of 18 adolescent boys who dressed in women's clothing and of their families. Twelve of this group who exhibit similar manifest behavior and family interaction are designated as transvestites. Their stated or apparent purpose in cross-dressing is to appear as a girl, with masturbation apparently of secondary importance. A sister is present in these families and is always the mother's preferred child. The mother-daughter relationship is characterized by relative absence of overt hostility. There is an intense interdependent interaction between the mother and the transvestite son; hostility is directed by the mother toward masculinity and specifically toward the son's masculine strivings. Dressing as a girl is openly or subtly encouraged by the mother. The father is present but relates to the son in a distant and passive manner. These observations are tentative, and further study is needed of the dynamics of transvestism. Direct observation of entire families may provide important information about the dynamics of many sexual deviations. INTRODUCTION
The symptom complex of transvestism, like other sexual deviations, is poorly understood. The preponderance of literature consists of single case reports. While these reports frequently elucidate interesting individual dynamics, they fail to present a broad, comprehensive picture of the variety of patients who manifest this symptom. Study is further complicated because of a tendency in the past to lump together diverse sexual deviants such as transvestites, fetishists, transsexuals, and homosexuals who occasionally cross-dress. Other studies have grouped deviant sexual behavior together with types of delinquent behavior. Overlap of symptoms and family patterns in addition to multiple and changing symptoms makes precise definition of a syndrome difficult. 1 Revised from a paper read at the Biannual Meeting, Western Psychiatric Association, August 26, 1969. 2 Assistant Clinical Professor, Department of Psychiatry, University of California, Davis School of Medicine, Davis, California. 3 Associate Clinical Professor, Department of Psychiatry, University of California, Davis School of Medicine, Davis, California. 4 Reprint requests should be addressed to Dr. James Spensley,2315 Stockton Boulevard, Sacramento, California 95817. 347 © 1972 Plenum Publishing Corporation, 227 West 17th Street, New York, N.Y. 10011.
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Spensley and Barter Table I. Characteristics of 18 Adolescent Boys Who Cross-Dressed
Age Family composition
Range 13-17 Mean 1 4 . 9 Median Natural mother and father Natural mother and stepfather Natural mother only--father absent Siblings Female 9 Male 3 Both 5 Neither 1 Maternal sib preference Female 11 Male 1 No preference 6 Family dominance Mother: Masculine 13 Feminine 1 Smothering 4 Father: Never dominant 18 Family interaction High degree closeness with mother Entire family close Diverse or chaotic interaction Mother: Symbiotic/hostile Adolescent's interaction with parent Symbiotic Father: Distant or absent Distant/fearful Pattern of cross-dressing Complete women's clothes Underwear (bra, panty, and nylon hose) Occurrence of cross-dressing Spontaneous 16 [age 3-9 (6), age 13 up (10)] Dressed by mother or grandmother 2 Mother: Delight 8 Subtle reinforcement 9 Family reaction to cross-dressing Mixed delight and hostility 1 Father: No expressed reaction 14 Ridicule 3 Puzzled 1 Poor 16 Average 2 (always below capability) School performance None 16 Sports 2 (not up to expectations of Outside activities father) Sexual behavior Masturbation prominent with and without female clothing Masturbation only with cross-dressing (female clothing provokes sexual excitement) Masturbation not apparent Homosexual Antisocial behavior (stealing and vandalism) Prominent feature Present only in obtaining clothes Not present Transient psychotic episodes Present 10 Absent 8 Transvestism Classification of cross-dressing behavior Polymorphous perverse sexuality Homosexual Transexual Unclassified
15 10 5 3
10 6 2 14 4 16 2 11 7
5 5 7 1 1 4 13 12 2 1 1 2
F o r the p u r p o s e of study, 18 boys who dressed in w o m e n ' s clothing one or more times in adolescence were evaluated together with their families. A composite of data is presented in Table I. Twelve patients present some consistent features a n d share certain characteristics with adult transvestites. W e call these twelve "adolescent transvestites." The other six are more heterogeneous a n d share only the feature of partial cross-dressing.
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DATA C O L L E C T I O N All patients in the study were seen at the University of Colorado Medical Center. Twelve were inpatients on the adolescent ward and known personally to one or both authors. Five were outpatients in the Children's Diagnostic Center, and one was a resident of a group home where one author (J. B.) was consulting psychiatrist. These cases represent all adolescent cross-dressers seen at this psychiatric service over the period specified. All had an extensive social history recorded from both patient and family and were given a psychiatric evaluation and physical examination. Eight had psychological testing. None was in therapy more than 20 weeks; most were evaluated over a 4-8 week period. Five boys were seen after this study was begun, and they and their parents were directly observed and interviewed together. With the earlier patients, records were relied upon heavily. Inpatients were seen between 1966 and 1969. Outpatients were seen between 1964 and 1969. Because of the reliance upon case records for all but five patients, the data that we would most like to focus on were not always available, being not clearly specified or included in the written records. Most consistently lacking were detailed observations on the subtle interpersonal and intrafamilial interaction, particularly in the context of the adolescent's relationship with his mother. The inclusion of the subtleties of behavior that were noted does provide, however, some data which appear worthy of note. Detailed descriptions of dreams, extensive transference, or other manifestations of the unconscious were unfortunately not available for these patients. TRANSVESTITES Table II compares the group of 12 transvestites with the other six cross-dressers. We do not know if this group typifies adolescent transvestites in general. The group does present in this small series striking and consistent features which will each be discussed in some detail. 1. A sister is the preferred child of the mother. The mother-daughter relationship is characterized by a relative absence of overt hostility. Table II. Twelve Adolescent Transvestites and Six Others Who Cross-Dressed
Mothers prefer sister or sister substitute Masturbation absent or secondary to appearing female Mothers' reaction to dressing: Overt reinforcement (delight) Subtle reinforcement Masculine dominant mother Natural father present Stepfather present Frequency of dressing Less than 5 times More than 5 times
12 transvestites (%)
6 other cross-dressers (%)
100 92
0 16
67 33 92 84 16
0 84 33 50
25 75
50 50
0
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These boys have a sister or sister substitute who is admired and preferred by their mother. All but one boy had a sister who was so preferred, and in this case the mother had for 3 years prior to his initial evaluation cared for her brother's two daughters. It was during this period of time that his cross-dressing first began. One boy dressed up in girl's clothing when his sister was a competitor in a teenage beauty contest. Another stated that he felt it was better to be a girl than a boy because in his family a girl was more cared for. 2. The stated or apparent purpose of the cross-dressing is to appear as a girl; masturbation is of secondary importance to appearing as a female. The 12 boys, when cross-dressing, usually dressed completely in women's clothing. When underclothing only was worn, it usually consisted of nylon hose in addition to bra and panties or girdle. Most essential with this group is the need to appear as a girl. One boy stated that he would walk around the house in his sister's clothes and look at himself in the mirror. Another noted that it felt good to appear as a woman. Most boys unfortunately had great difficulty in describing their behavior and their thoughts and fantasies associated with it. Masturbation was not a prominent feature but was intermittently associated with excitement stimulated by wearing female clothing in about half the cases. In all but two cases, the mothers overtly condemned masturbation. 3. Dressing as girl is greeted with delight and pleasure or subtle encouragement by the mother. There was no other behavior on the part of their son which elicited such an unequivocally positive reaction from some of these mothers as his dressing as a girl. Other mothers were quite clear in expressing their feelings that there was nothing particularly wrong about their boys dressing up in women's clothing. Unconscious cues were often given, such as when Sam's mother "mistakenly" included a bra in his clothing (case history 1). 4. The mother is a masculine, dominant woman who has an intense interaction with her son of the symbiotic-hostile type. s The mother's hostility is directed toward masculinity in general and her son's masculine strivings in specific. 6 The relationship between this type of mother and all these boys contains very characteristic features. The natural mother is always present, an obvious but important factor. There is always a history of close, protective, and infantilizing dependent attachment to the mother from the earliest years of life, which we call symbiotic. This dependent relationship contains elements of a very subtle hostility which appears to be directed especially toward things masculine and in general includes aggressivity, independence, and sexuality. One mother asked, " A m I rejecting Peter because he's a boy ?" She herself felt rejected as a child and related this to being a girl. The boy does not have to show masculine behavior to be eligible for hostility, however, just being a boy seems to suffice. 5 Behavior was classified as masculine and dominating if it included dressing in a very masculine way, a lack of femininity in makeup and hair styling, dominating aggressive behavior, overt controlling in interpersonal transactions, functioning as major breadwinner for the family, and aggressively detailing this in family interaction. 6 This was particularly notable when the mothers were involved in an interpersonal situation with a man who acted in a nonpassive, unsubmissive way.
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5. The relationship with the father is marked by distance and passivity on the part of both father and son. The father, though usually passive, is an ever-present member of the family. Usually, these men maintain great distance between themselves and their families. When in close relationship with wife or family, it is always in a very dependent, passive manner. They show little regard for their son's dressing in women's clothing, and one son described the situation by saying "Father doesn't blame me for taking their clothes (sisters) if they leave them around." 6. Gender identity is conflicted but substantially male. All these boys retained a sense of being male and had no doubt as to their gender. Dressing as a girl appeared to serve to decrease the intensity of the mother's everpresent hostility and may have led to increased affection. In addition to the features mentioned above, we observed some other characteristics of these boys which seem important. They are characterized by serious ego weakness and deficiencies. A large number had at least one transient psychotic episode. The diagnosis of psychosis was made only when both the characteristic disturbance of affect (fiat or inappropriate affect) and a thought disorder (loose associations with or without hallucinations and delusions) were present on examination. AlthOugh few were classified as schizophrenic, they showed numerous and serious psychopathological traits. They consistently presented with low self-esteem and below-capacity performance in school. They had confused thoughts, particularly about their body functions: eating, digestion, excretion, and breathing, as well as sexuality. Intense fears of destruction were frequently noted. Aggressive behavior was observed only rarely, and never was observed in the presence of the mother. The following two case histories were selected because they are representative of the other cases classified as transvestism and were seen by both authors. CASE HISTORY 1 Sam, a 17-year-old boy, was admitted after referral by a psychologist friend of the family. His father died 2 years prior to admission. In the yeal preceding admission, he stole clothing from his sister and mother, and from several stores in the small community where the family lived. He also stole a wig. He dressed up several times in an entire female costume, including underwear, nylons, and outer garments as welt as the wig. Sam denied sexual fantasies while wearing this clothing, stating only that "It makes me feel good." He was apprehended after the clothing store thefts, placed on probation, and saw a local psychiatrist about six times. Treatment was terminated by his mother when the family went to visit relatives abroad. His mother felt her son did not need further treatment, but when his school performance continued to fail and the cross-dressing behavior persisted she reluctantly agreed to his hospitalization. Sam's mother was born in Europe; she married his father at the close of World War II. They returned to Colorado, where the patient was born. His birth was essentially uncomplicated, and his early childhood was unremarkable. Two siblings were born, a sister when he was aged 3 and a brother when he was aged 5. His father was a respected businessman in the small community where they lived.
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As a result of his job, he was away from home a great deal. As a consequence, Sam never felt particularly close to his father. His overt reaction to his father's death was minimal. His mother is described as being the dominant force in the family. Sam saw his relationship with his mother as being an especially close and dependent one. When seen with her, Sam always adopted a passive role. His mother frequently pointed out the many sacrifices she made for him and exhibited a great deal of thinly veiled hostility about the trouble Sam had caused her. This was in contrast to her feelings about the other two children. The younger brother is athletic and envied by the patient. The sister was described by the mother as "my joy in life." Sam stated that his sister always got many compliments for being a girl and for being so easy to take care of. On most occasions, his mother avoided discussing Sam's cross-dressing. However, on one occasion, she brightened considerably while discussing how attractive Sam appeared when dressed as a girl. In another incident, his mother "mistakenly" included one of his sister's bras in a bundle of clothing she brought to the hospital for Sam. While in the hospital, Sam was able to resolve some of his feelings about his father's death. He viewed his hospitalization as preparing him to return home and assume a role as head of the household. He reacted with anxiety to any attempts to discuss his cross-dressing and tried to avoid sexual subjects entirely. Placement in a boarding school was accomplished, but both Sam and his mother refused outpatient therapy following discharge. CASE HISTORY 2 Ed was a 14-year-old boy admitted to the Adolescent Inpatient Service on referral from Juvenile Hall following psychological testing. He was placed in Juvenile Hall when his mother contacted the Court and requested help in controlling his repeated episodes of running away. The patient stated that he is beaten frequently by his stepfather and on one occasion was chained to keep him from running away. He admitted to running away frequently from home or school. He described his running away as being due to inability to get along with his family over a 6 month period. Ed's crossdressing was discovered only by chance. In discussing the sexual history, he mentioned that on an occasion a year ago he had dressed in women's clothes. In discussing this with his mother, it became apparent that he had actually dressed in women's clothes on a number of occasions. She stated that she didn't feel it was too much to get excited about, although she was bothered because he bought or stole women's clothing rather than taking hers or his sister's. Ed's birth and infancy were unremarkable. His early memories consisted mainly of his parents fighting a lot. His parents were divorced when he was approximately 2½, several months after the birth of his sister. Ed stated that following the divorce his mother went out a lot with "a bunch of clowns" and finally married when he was 6. He stated that his stepfather was the best of the lot. He described his stepfather as being very strict but nice. In fact, he appeared to have a very distant relationship with his stepfather, who interacted with him only to punish him when he had done something wrong. His relationship with his mother, on the other hand, was an extremely intense one.
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His mother was a hostile, paranoid woman who inevitably managed to evoke negative feelings in all the ward staff she came in contact with. Her relationship with Ed appeared to be alternately close and hostile. At times, she would treat him very warmly, though in an infantilizing manner. At other times, she would be extremely harsh and angry with him. She stated that she spent a great deal of time with both her children between her divorce and remarriage. The mother's relationship with her daughter did not appear to contain the hostility evident in her relationship with her son. Ed's relationship with his sister is one of both jealousy and pseudomature protectiveness of her. Ed stated that he didn't like to daydream because it was a waste of time. He said he had few dreams and was never willing to discuss them in any detail. He, in fact, stated that he didn't like to think about "that stuff." On admission to the hospital ward, Ed appeared to be grossly psychotic. He had loosened associations, blocking, hallucinations, withdrawn behavior, and intermittently peculiar affectual responses. He was an extraordinarily polite boy who maintained great distance between himself and all other adolescents on the ward. He was never more than superficially involved in individual or milieu therapy and always maintained that his mother would sign him out of the hospital. Often, he appeared to be disorganized and confused and on one occasion experienced severe, overt anxiety with loose associations following a discussion of his transvestic episodes. Ed was signed out of the hospital against medical advice by his mother, and attempts by the ward staff to obtain a court order confining him for hospitalization were not effective. COMPARISONS The six patients not classified as transvestites are discussed in brief for purposes of comparison. An attempt is made to classify the sexual deviation. One boy was classed as transsexual and met many of Stoller's (1968) criteria. He was dressed at an early age as a girl and raised as a girl for some 3 years between the ages of 2 and 5 by his grandmother. At the time of admission, he believed himself actually to be a girl and frequently referred to himsetf as a girl. We felt his gender identity to be female, in contrast to all the other patients seen in this study. The boy classed as homosexual was mentally retarded and a patient in a training school for 3 years prior to admission. He was adopted, and the adoptive father died 5 years prior to admission and the mother died 3 years prior to admission. He was referred because of overt homosexuality, and his dressing in women's clothing occurred only in association with overt homosexuality. Data regarding this boy's relationship with his mother prior to her death were not available. Two boys were classified in the category "polymorphous perverse sexuality." One boy was admitted because of pedophilic experience with a 10-year-old girl when he attempted to persuade her to take her underpants off. He also had a history of cross-dressing, voyeuristic, and homosexual behavior. Details of his cross-dressing were not available. The other bey placed in this category was hospitalized because of depression over leaving home for a boarding house at the recommendation of his outpatient therapist. He had a history of homosexuality, voyeurism, and cross-dressing.
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The interaction between these boys and their mothers was significantly different than that of our larger group of transvestites. Their mothers were much more overtly seductive and did not appear to manifest hostility toward their sons' masculine activities. Rather, they related to them in a smothering, infantilizing manner with subtle flirting and other sexual overtones. Relationship with the father of the first boy was distant and passive. The second had a stepfather who was a sadistic alcoholic who continually ridiculed his stepson. Those two boys not classified both confined their cross-dressing to underclothes. Neither had ever dressed in nylons, and masturbation was a prominent part of their use of women's underclothing. Both mothers were overtly concerned about their sons' sexual development and frequently observed their sons bathing or dressing. One boy on occasion when angry would masturbate in front of mother. His mother reacted to this overt sexual behavior with coy criticism. The mother-son relationship of these two boys was overtly seductive in nature. The son responded to this overt seduction on the part of his mother by open hostility as he moved into the adolescent phase of development. Both mothers during the latency phase of their sons' development tended to overlook misbehavior and open rebelliousness on the part of their sons in an attempt to demonstrate their love. Both mothers were indulgent and overprotective and related to their sons in an immature manner tinged with seductiveness and alternating fearfulness. Some people might classify these boys as fetishists. LITERATURE REVIEW The psychoanalytic formulation of adult transvestism is discussed by Fenichel (1953), Friedemann (1966), Friedman (1959), Friend et al. (1954), Segal (1965), and many others. Reports on adolescent transvestites are few in number. Shankel and Carr (1956) report a case history of an adolescent who dressed in women's clothing and partially strangled himself by hanging on several occasions. Bakwin and Bakwin (1966) comment, in line with this, on the number of accidental deaths by hanging of adolescent boys dressed in female clothing. Liakos (1967) reports a brief case history of a family with two transvestite sons and a transvestite father. Stoller (1967) describes several patterns of hostile interaction between the mother, wife, or other significant female figure and the adult male transvestite. He notes the woman's hostility but not the dependent or symbiotic-like relationship which we observed in the adolescent transvestites in our study. The case of a 5-year-old transvestic boy described in detail by Littin et al. (1.956) provides data which illustrate how the behavior of the mother particularly encouraged and fostered her son's cross-dressing. A few reports on other sexual deviancies describe family patterns. Rickles (1942) discusses the development of exhibitionism within the context of the exhibitionist's relationship with his mother. He provides a convincing description of the specific interaction which occurs within the exhibitionist's family in relationship to this symptom complex. Macht and Mack (1968) describe both family patterns and the fantasies and dreams of fire-setters. They stress the highly overdetermined nature of this phenomenon and convincingly relate it to specific family interactions. Shoor et al. (1966) describe characteristics of adolescent child molesters but do not provide
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adequate enough descriptions of family interactions so as to enable one to delineate specific family patterns in relationship to this symptom complex. The same is true of the work of Mohr (1962) concerning pedophilics. The family patterns noted both by Rickles and by Macht and Mack are significantly different from those reported here. DISCUSSION Until recently, the dynamics of transvestism was formulated in individual intrapsychic terms. And within this framework the predominant emphasis was on the sexual nature of this syndrome. The observations reported in this paper reveal this syndrome to be both intra- and interpsychic, and we feel that an appreciation of the family patterns of interaction enriches the understanding of this syndrome. The relationship between mother and daughter is qualitatively different than that between mother and son. In the former, the mother is seen as being both warm and giving, whereas in the latter she is hostile and rejecting. The son has to learn to cope with this hostility in order to gain security and gratification. He discovers that his mother is less angry and more accepting of him when he dresses in female clothing. Crossdressing behavior then may begin primarily as nongenital behavior and only later on become eroticized. As such, it has implications of identification with the favored sister and with the aggressive mother. Although we have emphasized the mother-daughter mother-son relationship as being central to this syndrome, the role of the father is also important. The father is not a strong, adequate masculine figure for identification. Rather, the adolescent's model for masculine identification is distant, weak, and helpless. Thus the family interactional pattern determining this syndrome is quadrangular, involving mother, sister, adolescent transvestite, and father. These patterns are significantly different not only from those of other crossdressers but also from those of the exhibitionist and the fire-setter. In the case of the exhibitionist, the father is absent and the mother relates to this boy as though the sight of his penis alone brings her joy (Rickles, 1942). Her control of the exhibitionist lacks the hostility we observe in the mother of the transvestite. In the fire-setter, there are emotional links around fires related to the father or a father figure (Macht and Mack, 1968). Of central importance is the absence of the father during the fire-setting, with the behavior representing a cry for help of the overburdened adolescent. The absence of the father also carries with it feelings of abandonment and rage. Much of the burden of the adolescent involves a close relationship with the mother, who expects her son or daughter to meet many of the mother's sexual and dependency needs. An extension of this work is necessary before our findings can be generalized to all adolescent transvestites. Analysis of observations of adolescent transvestites not brought for psychiatric care might yield different results. Our finding that transvestism seems to be the result of collusion between mother and son is in apparent contrast to the history given by many adult transvestites who recall cross-dressing secretively in adolescence and who uniformly find transvestism sexually stimulating (Stoller, personal communication). While the adults' recollections of their feelings during adolescence are notoriously distorted, this disparity between recollections of
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a d u l t transvestites a n d o u r findings m a y also be a result o f some selective f a c t o r in o u r sample. Nonetheless, we feel t h a t direct o b s e r v a t i o n o f the f a m i l y is an exceedingly i m p o r t a n t m e t h o d for gaining m o r e u n d e r s t a n d i n g o f sexual deviations.
ACKNOWLEDGMENTS W e wish to express o u r a p p r e c i a t i o n to Drs. E l e a n o r Steele a n d R o b e r t Stoller, who r e a d an earlier d r a f t a n d c o n t r i b u t e d m a n y helpful c o m m e n t s a n d suggestions which are i n c o r p o r a t e d herein.
REFERENCES Bakwin, H., and Bakwin, R. (1966). Clinical Manifestations of Behavior Disorders in Children, W. B. Saunders, New York. Fenichel, O. (1953). The psychology of transvestism (1930). In Collected Papers, Vol. 1, W. W. Norton & Co., New York. Friedemann, M. (1966). Reflection on two cases of male transvestism. Amer. J. Psychotherap. 20: 270--283. Friedman, P. (1959). Transvestism. In Arieti, S. (ed.), American Handbook of Psychiatry, Vol. II, Basic Books, New York. Friend, M., Schiddel, L., Kline, B., and Dunaeff, D. (1954). Observations on development of transvestism in boys. Amer. J. Orthopsyehiat. 24: 563-575. Liakos, A. (1967). Familial transvestism. Brit. J. Psychiat. 113: 49-51. Littin, E., Griffin, N., and Johnson, A. (1956). Parental influence in unusual sexual behavior in children. PsychoanaL Quart. 25: 37-55. Macht, L., and Mack, J. (1968). The firesetter syndrome. Psychiatry 32: 277-289. Mohr, J. (1962). The pedophilias: Their clinical, social and legal implications. Canad. Psychiat. Ass. J. 7: 255-260. Rickles, N. (1942). Exhibitionism. J. Nerv. Ment. Dis. 95: 11-17. Segal, M. (1965). Transvestism as an impulse and as a defense. Int. J. Psychoanal. 46: 209-217. Shankel, W., and Carr, A. (1956). Transvestism and hanging episodes in a male adolescent. Psychiat. Quart. 30: 478-493. Shoor, N., Speed, M., and Bartlett, C. (1966). The syndrome of the adolescent child molester. Amer. J. Psychiat. 122(7): 783-790. Stoller, R. (1967). Transvestite's women. Amer. J. Psychiat. 124(3): 333-339. Stoller, R. (1968). Sex and Gender, Science House, New York.
The Adolescent Transvestite on a Psychiatric Service: Family Patterns 1 James Spensley,
M.D., 2' 4
and James T. Barter~ M.D. 3
The symptom of transvestism & explored in a study of 18 adolescent boys who dressed in women's clothing and of their families. Twelve of this group who exhibit similar manifest behavior and family interaction are designated as transvestites. Their stated or apparent purpose in cross-dressing is to appear as a girl, with masturbation apparently of secondary importance. A sister is present in these families and is always the mother's preferred child. The mother-daughter relationship is characterized by relative absence of overt hostility. There is an intense interdependent interaction between the mother and the transvestite son; hostility is directed by the mother toward masculinity and specifically toward the son's masculine strivings. Dressing as a girl is openly or subtly encouraged by the mother. The father is present but relates to the son in a distant and passive manner. These observations are tentative, and further study is needed of the dynamics of transvestism. Direct observation of entire families may provide important information about the dynamics of many sexual deviations. INTRODUCTION
The symptom complex of transvestism, like other sexual deviations, is poorly understood. The preponderance of literature consists of single case reports. While these reports frequently elucidate interesting individual dynamics, they fail to present a broad, comprehensive picture of the variety of patients who manifest this symptom. Study is further complicated because of a tendency in the past to lump together diverse sexual deviants such as transvestites, fetishists, transsexuals, and homosexuals who occasionally cross-dress. Other studies have grouped deviant sexual behavior together with types of delinquent behavior. Overlap of symptoms and family patterns in addition to multiple and changing symptoms makes precise definition of a syndrome difficult. 1 Revised from a paper read at the Biannual Meeting, Western Psychiatric Association, August 26, 1969. 2 Assistant Clinical Professor, Department of Psychiatry, University of California, Davis School of Medicine, Davis, California. 3 Associate Clinical Professor, Department of Psychiatry, University of California, Davis School of Medicine, Davis, California. 4 Reprint requests should be addressed to Dr. James Spensley,2315 Stockton Boulevard, Sacramento, California 95817. 347 © 1972 Plenum Publishing Corporation, 227 West 17th Street, New York, N.Y. 10011.
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Spensley and Barter Table I. Characteristics of 18 Adolescent Boys Who Cross-Dressed
Age Family composition
Range 13-17 Mean 1 4 . 9 Median Natural mother and father Natural mother and stepfather Natural mother only--father absent Siblings Female 9 Male 3 Both 5 Neither 1 Maternal sib preference Female 11 Male 1 No preference 6 Family dominance Mother: Masculine 13 Feminine 1 Smothering 4 Father: Never dominant 18 Family interaction High degree closeness with mother Entire family close Diverse or chaotic interaction Mother: Symbiotic/hostile Adolescent's interaction with parent Symbiotic Father: Distant or absent Distant/fearful Pattern of cross-dressing Complete women's clothes Underwear (bra, panty, and nylon hose) Occurrence of cross-dressing Spontaneous 16 [age 3-9 (6), age 13 up (10)] Dressed by mother or grandmother 2 Mother: Delight 8 Subtle reinforcement 9 Family reaction to cross-dressing Mixed delight and hostility 1 Father: No expressed reaction 14 Ridicule 3 Puzzled 1 Poor 16 Average 2 (always below capability) School performance None 16 Sports 2 (not up to expectations of Outside activities father) Sexual behavior Masturbation prominent with and without female clothing Masturbation only with cross-dressing (female clothing provokes sexual excitement) Masturbation not apparent Homosexual Antisocial behavior (stealing and vandalism) Prominent feature Present only in obtaining clothes Not present Transient psychotic episodes Present 10 Absent 8 Transvestism Classification of cross-dressing behavior Polymorphous perverse sexuality Homosexual Transexual Unclassified
15 10 5 3
10 6 2 14 4 16 2 11 7
5 5 7 1 1 4 13 12 2 1 1 2
F o r the p u r p o s e of study, 18 boys who dressed in w o m e n ' s clothing one or more times in adolescence were evaluated together with their families. A composite of data is presented in Table I. Twelve patients present some consistent features a n d share certain characteristics with adult transvestites. W e call these twelve "adolescent transvestites." The other six are more heterogeneous a n d share only the feature of partial cross-dressing.
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DATA C O L L E C T I O N All patients in the study were seen at the University of Colorado Medical Center. Twelve were inpatients on the adolescent ward and known personally to one or both authors. Five were outpatients in the Children's Diagnostic Center, and one was a resident of a group home where one author (J. B.) was consulting psychiatrist. These cases represent all adolescent cross-dressers seen at this psychiatric service over the period specified. All had an extensive social history recorded from both patient and family and were given a psychiatric evaluation and physical examination. Eight had psychological testing. None was in therapy more than 20 weeks; most were evaluated over a 4-8 week period. Five boys were seen after this study was begun, and they and their parents were directly observed and interviewed together. With the earlier patients, records were relied upon heavily. Inpatients were seen between 1966 and 1969. Outpatients were seen between 1964 and 1969. Because of the reliance upon case records for all but five patients, the data that we would most like to focus on were not always available, being not clearly specified or included in the written records. Most consistently lacking were detailed observations on the subtle interpersonal and intrafamilial interaction, particularly in the context of the adolescent's relationship with his mother. The inclusion of the subtleties of behavior that were noted does provide, however, some data which appear worthy of note. Detailed descriptions of dreams, extensive transference, or other manifestations of the unconscious were unfortunately not available for these patients. TRANSVESTITES Table II compares the group of 12 transvestites with the other six cross-dressers. We do not know if this group typifies adolescent transvestites in general. The group does present in this small series striking and consistent features which will each be discussed in some detail. 1. A sister is the preferred child of the mother. The mother-daughter relationship is characterized by a relative absence of overt hostility. Table II. Twelve Adolescent Transvestites and Six Others Who Cross-Dressed
Mothers prefer sister or sister substitute Masturbation absent or secondary to appearing female Mothers' reaction to dressing: Overt reinforcement (delight) Subtle reinforcement Masculine dominant mother Natural father present Stepfather present Frequency of dressing Less than 5 times More than 5 times
12 transvestites (%)
6 other cross-dressers (%)
100 92
0 16
67 33 92 84 16
0 84 33 50
25 75
50 50
0
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These boys have a sister or sister substitute who is admired and preferred by their mother. All but one boy had a sister who was so preferred, and in this case the mother had for 3 years prior to his initial evaluation cared for her brother's two daughters. It was during this period of time that his cross-dressing first began. One boy dressed up in girl's clothing when his sister was a competitor in a teenage beauty contest. Another stated that he felt it was better to be a girl than a boy because in his family a girl was more cared for. 2. The stated or apparent purpose of the cross-dressing is to appear as a girl; masturbation is of secondary importance to appearing as a female. The 12 boys, when cross-dressing, usually dressed completely in women's clothing. When underclothing only was worn, it usually consisted of nylon hose in addition to bra and panties or girdle. Most essential with this group is the need to appear as a girl. One boy stated that he would walk around the house in his sister's clothes and look at himself in the mirror. Another noted that it felt good to appear as a woman. Most boys unfortunately had great difficulty in describing their behavior and their thoughts and fantasies associated with it. Masturbation was not a prominent feature but was intermittently associated with excitement stimulated by wearing female clothing in about half the cases. In all but two cases, the mothers overtly condemned masturbation. 3. Dressing as girl is greeted with delight and pleasure or subtle encouragement by the mother. There was no other behavior on the part of their son which elicited such an unequivocally positive reaction from some of these mothers as his dressing as a girl. Other mothers were quite clear in expressing their feelings that there was nothing particularly wrong about their boys dressing up in women's clothing. Unconscious cues were often given, such as when Sam's mother "mistakenly" included a bra in his clothing (case history 1). 4. The mother is a masculine, dominant woman who has an intense interaction with her son of the symbiotic-hostile type. s The mother's hostility is directed toward masculinity in general and her son's masculine strivings in specific. 6 The relationship between this type of mother and all these boys contains very characteristic features. The natural mother is always present, an obvious but important factor. There is always a history of close, protective, and infantilizing dependent attachment to the mother from the earliest years of life, which we call symbiotic. This dependent relationship contains elements of a very subtle hostility which appears to be directed especially toward things masculine and in general includes aggressivity, independence, and sexuality. One mother asked, " A m I rejecting Peter because he's a boy ?" She herself felt rejected as a child and related this to being a girl. The boy does not have to show masculine behavior to be eligible for hostility, however, just being a boy seems to suffice. 5 Behavior was classified as masculine and dominating if it included dressing in a very masculine way, a lack of femininity in makeup and hair styling, dominating aggressive behavior, overt controlling in interpersonal transactions, functioning as major breadwinner for the family, and aggressively detailing this in family interaction. 6 This was particularly notable when the mothers were involved in an interpersonal situation with a man who acted in a nonpassive, unsubmissive way.
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5. The relationship with the father is marked by distance and passivity on the part of both father and son. The father, though usually passive, is an ever-present member of the family. Usually, these men maintain great distance between themselves and their families. When in close relationship with wife or family, it is always in a very dependent, passive manner. They show little regard for their son's dressing in women's clothing, and one son described the situation by saying "Father doesn't blame me for taking their clothes (sisters) if they leave them around." 6. Gender identity is conflicted but substantially male. All these boys retained a sense of being male and had no doubt as to their gender. Dressing as a girl appeared to serve to decrease the intensity of the mother's everpresent hostility and may have led to increased affection. In addition to the features mentioned above, we observed some other characteristics of these boys which seem important. They are characterized by serious ego weakness and deficiencies. A large number had at least one transient psychotic episode. The diagnosis of psychosis was made only when both the characteristic disturbance of affect (fiat or inappropriate affect) and a thought disorder (loose associations with or without hallucinations and delusions) were present on examination. AlthOugh few were classified as schizophrenic, they showed numerous and serious psychopathological traits. They consistently presented with low self-esteem and below-capacity performance in school. They had confused thoughts, particularly about their body functions: eating, digestion, excretion, and breathing, as well as sexuality. Intense fears of destruction were frequently noted. Aggressive behavior was observed only rarely, and never was observed in the presence of the mother. The following two case histories were selected because they are representative of the other cases classified as transvestism and were seen by both authors. CASE HISTORY 1 Sam, a 17-year-old boy, was admitted after referral by a psychologist friend of the family. His father died 2 years prior to admission. In the yeal preceding admission, he stole clothing from his sister and mother, and from several stores in the small community where the family lived. He also stole a wig. He dressed up several times in an entire female costume, including underwear, nylons, and outer garments as welt as the wig. Sam denied sexual fantasies while wearing this clothing, stating only that "It makes me feel good." He was apprehended after the clothing store thefts, placed on probation, and saw a local psychiatrist about six times. Treatment was terminated by his mother when the family went to visit relatives abroad. His mother felt her son did not need further treatment, but when his school performance continued to fail and the cross-dressing behavior persisted she reluctantly agreed to his hospitalization. Sam's mother was born in Europe; she married his father at the close of World War II. They returned to Colorado, where the patient was born. His birth was essentially uncomplicated, and his early childhood was unremarkable. Two siblings were born, a sister when he was aged 3 and a brother when he was aged 5. His father was a respected businessman in the small community where they lived.
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As a result of his job, he was away from home a great deal. As a consequence, Sam never felt particularly close to his father. His overt reaction to his father's death was minimal. His mother is described as being the dominant force in the family. Sam saw his relationship with his mother as being an especially close and dependent one. When seen with her, Sam always adopted a passive role. His mother frequently pointed out the many sacrifices she made for him and exhibited a great deal of thinly veiled hostility about the trouble Sam had caused her. This was in contrast to her feelings about the other two children. The younger brother is athletic and envied by the patient. The sister was described by the mother as "my joy in life." Sam stated that his sister always got many compliments for being a girl and for being so easy to take care of. On most occasions, his mother avoided discussing Sam's cross-dressing. However, on one occasion, she brightened considerably while discussing how attractive Sam appeared when dressed as a girl. In another incident, his mother "mistakenly" included one of his sister's bras in a bundle of clothing she brought to the hospital for Sam. While in the hospital, Sam was able to resolve some of his feelings about his father's death. He viewed his hospitalization as preparing him to return home and assume a role as head of the household. He reacted with anxiety to any attempts to discuss his cross-dressing and tried to avoid sexual subjects entirely. Placement in a boarding school was accomplished, but both Sam and his mother refused outpatient therapy following discharge. CASE HISTORY 2 Ed was a 14-year-old boy admitted to the Adolescent Inpatient Service on referral from Juvenile Hall following psychological testing. He was placed in Juvenile Hall when his mother contacted the Court and requested help in controlling his repeated episodes of running away. The patient stated that he is beaten frequently by his stepfather and on one occasion was chained to keep him from running away. He admitted to running away frequently from home or school. He described his running away as being due to inability to get along with his family over a 6 month period. Ed's crossdressing was discovered only by chance. In discussing the sexual history, he mentioned that on an occasion a year ago he had dressed in women's clothes. In discussing this with his mother, it became apparent that he had actually dressed in women's clothes on a number of occasions. She stated that she didn't feel it was too much to get excited about, although she was bothered because he bought or stole women's clothing rather than taking hers or his sister's. Ed's birth and infancy were unremarkable. His early memories consisted mainly of his parents fighting a lot. His parents were divorced when he was approximately 2½, several months after the birth of his sister. Ed stated that following the divorce his mother went out a lot with "a bunch of clowns" and finally married when he was 6. He stated that his stepfather was the best of the lot. He described his stepfather as being very strict but nice. In fact, he appeared to have a very distant relationship with his stepfather, who interacted with him only to punish him when he had done something wrong. His relationship with his mother, on the other hand, was an extremely intense one.
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His mother was a hostile, paranoid woman who inevitably managed to evoke negative feelings in all the ward staff she came in contact with. Her relationship with Ed appeared to be alternately close and hostile. At times, she would treat him very warmly, though in an infantilizing manner. At other times, she would be extremely harsh and angry with him. She stated that she spent a great deal of time with both her children between her divorce and remarriage. The mother's relationship with her daughter did not appear to contain the hostility evident in her relationship with her son. Ed's relationship with his sister is one of both jealousy and pseudomature protectiveness of her. Ed stated that he didn't like to daydream because it was a waste of time. He said he had few dreams and was never willing to discuss them in any detail. He, in fact, stated that he didn't like to think about "that stuff." On admission to the hospital ward, Ed appeared to be grossly psychotic. He had loosened associations, blocking, hallucinations, withdrawn behavior, and intermittently peculiar affectual responses. He was an extraordinarily polite boy who maintained great distance between himself and all other adolescents on the ward. He was never more than superficially involved in individual or milieu therapy and always maintained that his mother would sign him out of the hospital. Often, he appeared to be disorganized and confused and on one occasion experienced severe, overt anxiety with loose associations following a discussion of his transvestic episodes. Ed was signed out of the hospital against medical advice by his mother, and attempts by the ward staff to obtain a court order confining him for hospitalization were not effective. COMPARISONS The six patients not classified as transvestites are discussed in brief for purposes of comparison. An attempt is made to classify the sexual deviation. One boy was classed as transsexual and met many of Stoller's (1968) criteria. He was dressed at an early age as a girl and raised as a girl for some 3 years between the ages of 2 and 5 by his grandmother. At the time of admission, he believed himself actually to be a girl and frequently referred to himsetf as a girl. We felt his gender identity to be female, in contrast to all the other patients seen in this study. The boy classed as homosexual was mentally retarded and a patient in a training school for 3 years prior to admission. He was adopted, and the adoptive father died 5 years prior to admission and the mother died 3 years prior to admission. He was referred because of overt homosexuality, and his dressing in women's clothing occurred only in association with overt homosexuality. Data regarding this boy's relationship with his mother prior to her death were not available. Two boys were classified in the category "polymorphous perverse sexuality." One boy was admitted because of pedophilic experience with a 10-year-old girl when he attempted to persuade her to take her underpants off. He also had a history of cross-dressing, voyeuristic, and homosexual behavior. Details of his cross-dressing were not available. The other bey placed in this category was hospitalized because of depression over leaving home for a boarding house at the recommendation of his outpatient therapist. He had a history of homosexuality, voyeurism, and cross-dressing.
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The interaction between these boys and their mothers was significantly different than that of our larger group of transvestites. Their mothers were much more overtly seductive and did not appear to manifest hostility toward their sons' masculine activities. Rather, they related to them in a smothering, infantilizing manner with subtle flirting and other sexual overtones. Relationship with the father of the first boy was distant and passive. The second had a stepfather who was a sadistic alcoholic who continually ridiculed his stepson. Those two boys not classified both confined their cross-dressing to underclothes. Neither had ever dressed in nylons, and masturbation was a prominent part of their use of women's underclothing. Both mothers were overtly concerned about their sons' sexual development and frequently observed their sons bathing or dressing. One boy on occasion when angry would masturbate in front of mother. His mother reacted to this overt sexual behavior with coy criticism. The mother-son relationship of these two boys was overtly seductive in nature. The son responded to this overt seduction on the part of his mother by open hostility as he moved into the adolescent phase of development. Both mothers during the latency phase of their sons' development tended to overlook misbehavior and open rebelliousness on the part of their sons in an attempt to demonstrate their love. Both mothers were indulgent and overprotective and related to their sons in an immature manner tinged with seductiveness and alternating fearfulness. Some people might classify these boys as fetishists. LITERATURE REVIEW The psychoanalytic formulation of adult transvestism is discussed by Fenichel (1953), Friedemann (1966), Friedman (1959), Friend et al. (1954), Segal (1965), and many others. Reports on adolescent transvestites are few in number. Shankel and Carr (1956) report a case history of an adolescent who dressed in women's clothing and partially strangled himself by hanging on several occasions. Bakwin and Bakwin (1966) comment, in line with this, on the number of accidental deaths by hanging of adolescent boys dressed in female clothing. Liakos (1967) reports a brief case history of a family with two transvestite sons and a transvestite father. Stoller (1967) describes several patterns of hostile interaction between the mother, wife, or other significant female figure and the adult male transvestite. He notes the woman's hostility but not the dependent or symbiotic-like relationship which we observed in the adolescent transvestites in our study. The case of a 5-year-old transvestic boy described in detail by Littin et al. (1.956) provides data which illustrate how the behavior of the mother particularly encouraged and fostered her son's cross-dressing. A few reports on other sexual deviancies describe family patterns. Rickles (1942) discusses the development of exhibitionism within the context of the exhibitionist's relationship with his mother. He provides a convincing description of the specific interaction which occurs within the exhibitionist's family in relationship to this symptom complex. Macht and Mack (1968) describe both family patterns and the fantasies and dreams of fire-setters. They stress the highly overdetermined nature of this phenomenon and convincingly relate it to specific family interactions. Shoor et al. (1966) describe characteristics of adolescent child molesters but do not provide
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adequate enough descriptions of family interactions so as to enable one to delineate specific family patterns in relationship to this symptom complex. The same is true of the work of Mohr (1962) concerning pedophilics. The family patterns noted both by Rickles and by Macht and Mack are significantly different from those reported here. DISCUSSION Until recently, the dynamics of transvestism was formulated in individual intrapsychic terms. And within this framework the predominant emphasis was on the sexual nature of this syndrome. The observations reported in this paper reveal this syndrome to be both intra- and interpsychic, and we feel that an appreciation of the family patterns of interaction enriches the understanding of this syndrome. The relationship between mother and daughter is qualitatively different than that between mother and son. In the former, the mother is seen as being both warm and giving, whereas in the latter she is hostile and rejecting. The son has to learn to cope with this hostility in order to gain security and gratification. He discovers that his mother is less angry and more accepting of him when he dresses in female clothing. Crossdressing behavior then may begin primarily as nongenital behavior and only later on become eroticized. As such, it has implications of identification with the favored sister and with the aggressive mother. Although we have emphasized the mother-daughter mother-son relationship as being central to this syndrome, the role of the father is also important. The father is not a strong, adequate masculine figure for identification. Rather, the adolescent's model for masculine identification is distant, weak, and helpless. Thus the family interactional pattern determining this syndrome is quadrangular, involving mother, sister, adolescent transvestite, and father. These patterns are significantly different not only from those of other crossdressers but also from those of the exhibitionist and the fire-setter. In the case of the exhibitionist, the father is absent and the mother relates to this boy as though the sight of his penis alone brings her joy (Rickles, 1942). Her control of the exhibitionist lacks the hostility we observe in the mother of the transvestite. In the fire-setter, there are emotional links around fires related to the father or a father figure (Macht and Mack, 1968). Of central importance is the absence of the father during the fire-setting, with the behavior representing a cry for help of the overburdened adolescent. The absence of the father also carries with it feelings of abandonment and rage. Much of the burden of the adolescent involves a close relationship with the mother, who expects her son or daughter to meet many of the mother's sexual and dependency needs. An extension of this work is necessary before our findings can be generalized to all adolescent transvestites. Analysis of observations of adolescent transvestites not brought for psychiatric care might yield different results. Our finding that transvestism seems to be the result of collusion between mother and son is in apparent contrast to the history given by many adult transvestites who recall cross-dressing secretively in adolescence and who uniformly find transvestism sexually stimulating (Stoller, personal communication). While the adults' recollections of their feelings during adolescence are notoriously distorted, this disparity between recollections of
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a d u l t transvestites a n d o u r findings m a y also be a result o f some selective f a c t o r in o u r sample. Nonetheless, we feel t h a t direct o b s e r v a t i o n o f the f a m i l y is an exceedingly i m p o r t a n t m e t h o d for gaining m o r e u n d e r s t a n d i n g o f sexual deviations.
ACKNOWLEDGMENTS W e wish to express o u r a p p r e c i a t i o n to Drs. E l e a n o r Steele a n d R o b e r t Stoller, who r e a d an earlier d r a f t a n d c o n t r i b u t e d m a n y helpful c o m m e n t s a n d suggestions which are i n c o r p o r a t e d herein.
REFERENCES Bakwin, H., and Bakwin, R. (1966). Clinical Manifestations of Behavior Disorders in Children, W. B. Saunders, New York. Fenichel, O. (1953). The psychology of transvestism (1930). In Collected Papers, Vol. 1, W. W. Norton & Co., New York. Friedemann, M. (1966). Reflection on two cases of male transvestism. Amer. J. Psychotherap. 20: 270--283. Friedman, P. (1959). Transvestism. In Arieti, S. (ed.), American Handbook of Psychiatry, Vol. II, Basic Books, New York. Friend, M., Schiddel, L., Kline, B., and Dunaeff, D. (1954). Observations on development of transvestism in boys. Amer. J. Orthopsyehiat. 24: 563-575. Liakos, A. (1967). Familial transvestism. Brit. J. Psychiat. 113: 49-51. Littin, E., Griffin, N., and Johnson, A. (1956). Parental influence in unusual sexual behavior in children. PsychoanaL Quart. 25: 37-55. Macht, L., and Mack, J. (1968). The firesetter syndrome. Psychiatry 32: 277-289. Mohr, J. (1962). The pedophilias: Their clinical, social and legal implications. Canad. Psychiat. Ass. J. 7: 255-260. Rickles, N. (1942). Exhibitionism. J. Nerv. Ment. Dis. 95: 11-17. Segal, M. (1965). Transvestism as an impulse and as a defense. Int. J. Psychoanal. 46: 209-217. Shankel, W., and Carr, A. (1956). Transvestism and hanging episodes in a male adolescent. Psychiat. Quart. 30: 478-493. Shoor, N., Speed, M., and Bartlett, C. (1966). The syndrome of the adolescent child molester. Amer. J. Psychiat. 122(7): 783-790. Stoller, R. (1967). Transvestite's women. Amer. J. Psychiat. 124(3): 333-339. Stoller, R. (1968). Sex and Gender, Science House, New York.
