BRIEF
COMMUNICATIONS
these are sex-influenced genetic differences is a question for further research. The possibility that psychiatric disturbance could manifest as multiple somatic symptoms in females is important clinically in the diagnosis and management of childhood and adolescent “medical” and behavioral problems.
3.
5.
7.
try
126:534-549,
1975
2. Cadoret RJ, Cunningham adoptees from psychiatrically Temperament, hyperactive. ables. J Pediatr 87:301-306.
Male BY
L,
Loftus R, et al: Studies of disturbed biological parents: II. antisocial, and developmental van1975
Transsexuals
EDWARD
M.
in the
LEVINE,
PHENOMENON
1318
is Professor, Ill. 60626.
of transsexualism has recently attention. It has been incorporated on various aspects of human sexual Department
Am J Psychiatry
Guze
SB:
The
III. Familial Br J Psychiatry Children Grown
426, 1962 PurtelI JJ, Robins pects of hysteria.
and 8.
156 control
Siegel
multifactorial
model
of
relationship between socio127:23-32, 1975 Up. Baltimore, Williams &
K: Education, 1970
5:
E, Cohen A quantitative
subjects.
a study 1972
of their
10. Crowe
RR:
ME:
Health
and
Behav-
Observations on clinical asstudy of 50 hysteria patients 146:962-969, 1951 for the Behavioral Sciences.
JAMA
Nonparametric
Statistics
New York, McGraw-Hill 9. Crowe RR: The adopted arrest
Book Co. 1956 offspring of women records.
Personal
Arch
Gen
communication,
criminal
Psychiatry
offenders: 27:600-609,
December
1975
Subculture
behavior and has been the subject vision panel and interview shows years.
/33:i
of Sociology,
i November ,
Loyola
1976
Universi-
However,
most
of
what
of a number of teleover the past few is discussed
or
por-
trayed about transsexualism is restricted in content and perspective, largely because of the nature of the group of transsexuals about whom most is known. The great majority of men whose transsexual identity has
been
confirmed
been
unknown
cians These
and others individuals
are employed attire
and
by
as such
psychiatric
to anyone
whose seem
assistance to lead
in a variety sex
roles
and
diagnosis
but they ordinary
of occupations general
social
the
have
diagnosti-
have sought. lives-they
where
their
behavior
are
male. In addition, their lives seem to differ little, if at all, from those of others in the heterosexual communities in which they live. Indeed, when they decide to become full-time, cross-dressing transsexuals, their social
acquaintances
are
no inkling that this ered or was even characteristically deviants, including sexuals, and are they might fairly class
Dr. Levine ty, Chicago,
T,
PH.D.
,
THE
Reich
Wilkins Co. 1965 Rutter M, Tizard J, Whitmore ior. New York, Longman,
Homosexual
The author describes 20 male transsexuals who differ f rom most discussed in professional studies and from those in media portrayals in that they live in the male homosexual subculture . Furthermore interviews with these individuals indicated that transsexuals are no more sexually or socially homogeneous than heterosexuals or homosexuals. In general, these men entered the homosexual subculture in their teens; they knew they were not heterosexual and therefore assumed they must be homosexual. As their gender identity crystallized, homosexual activity became repugnant and they rejected and were rejected by male homosexuals. Being unable to attract heterosexual men, they sought bisexualpartners in afutile effort to confirm their identity asfemales. The author suggests that in addition to efforts to help transsexuals shift their gender identity, psychiatrists should emphasize prevention ofthis psychopathologic symptom.
caught the public’s in college courses
CR,
6. Perley M, Guze SB: Hysteria-the stability and usefulness of clinical criteria. A quantitative study based on a follow-up penod of six to eight years in 39 patients. N EngI J Med 266:42 1-
REFERENCES
I. Cunningham L, Cadoret RJ. Loftus, R, et al: Studies of adoptees from psychiatrically disturbed biological parents: psychiatric conditions in childhood and adolescence. Br J Psychia-
Cloninger
disease transmission: pathy and hysteria. 4. Robins L: Deviant
people,
shocked
because
they
have
had
metamorphosis was being considpossible. Such male transsexuals avoid contact with other sexual other male transsexuals and homonot involved in prostitution. Thus be depicted as “straight” middle-
a description
stated in the literature. There are, however, other
that
is either
psychiatrically
implied
confirmed
or
BRIEF
male transsexuals whose life-styles contrast markedly with the majority of those about whom we have information. The discussion that follows, which is an extension of previous research (1 2), is based on interviews with 20 transsexuals1 who live in the male homosexual subculture; the transsexuals’ homosexual acquaintances were also interviewed. These interviews indicated that there are increasing numbers of male transsexuals who live in this subculture and whose problems and life-styles are much like those ofthe men ,
in this
sample,
who
stated
that
they
knew
many
others
like themselves. The information gained about certain key aspects of the lives of the individuals in this sample provides an added dimension to our knowledge about transsexualism, if only because it indicates that transsexuals are no more socially or sexually homogeneous a group than are other sexual deviants or heterosexuals. Much of the literature on male transsexuals has focused on their more obvious problems and tensions and has emphasized ways in which they can and should be assisted. One of these methods is sexchange surgery, which is intended to provide a more effective adjustment to the transsexual gender and psychosocial identity. Sensitivity to and familiarity with the transsexuals’ plight are translated, quite understandably, into a genuine professional desire to alleviate their problems when at all feasible. This
outlook
has
been
supplemented
in recent
years
by the appearance on television shows of male transsexuals who have changed gender. Characteristically, these programs do not raise questions about the etiology of transsexualism, much less discuss the question of whether or not it is a psychopathologic symptom. This is due, in part, to the assumption that viewers would be bored by time-consuming technical explanations.
Inasmuch
gramming maintain
es,
as
are and
rather
boost
than
considerations, viance will
those
always
in charge
looking their
social
audience
novel ratings,
responsibility
that dictate presented
be
of television
for
unmistakably
as
men
‘I should
note that there
mine the individuals’
accuracy claims
were subsequently to be some basis noses.
no
matter
or mental
how
to
it is financ-
health
how topics on sexual to an impressionable
dience. Understanding of and sympathy sexualism on the part ofthe public and are increasing. One impression that from media presentations is that there male transsexual. However, there are who are six feet tall and taller, weigh more, and have body configurations are in modifying and tone of voice.
pro-
subjects
deau-
toward transof professionals is easily drawn is an “average” transsexual men 200 pounds and that stamp them successful
they
their bodies, apparel, mannerisms, Will such tragic figures really conis no way in which
of the psychiatric of transsexuality.
approved for their
the sociologist
diagnoses that However,
for sex-change claims and the
surgery. correctness
COMMUNICATIONS
vince anyone, particularly the heterosexual men they so desperately wish to attract, that they are females? Of course it is important to attempt to assist transsexuals in solving their problems; it is, however, equally important to recognize that transsexualism is a psychopathologic symptom and that appropriate attention and concern should be given to its prevention (3). It is from this perspective that I will examine certain aspects of the interpersonal relationships of male transsexuals in the homosexual subculture that add psychological problems to their already burdened lives.
TRANSSEXUALS:
THE
HOMOSEXUAL
PHASE
The transsexuals in this sample went through two transitional phases. The first was during their late teens when they were introduced to the male homosexual subculture by homosexuals who befriended them at a time when they assumed that they “must” be homosexual, since they knew they were not heterosexual. A factor that “confirmed” this belief was that all of them had been involved in homosexual relations, although they were invariably passive and never actively pursued a homosexual partner. The second phase involved their complete detachment from homosexuals, their new relationships, and the problems this change entailed. Entering the male homosexual subculture provided these men with an enormous sense of relief from the tensions
they
had
suffered
from
“homosexuality” from parents severing their relations with their permanently into areas near bars clusively
to male
sexual
having
to hide
their
and friends.2 Upon families, they moved that cater almost ex-
deviants.
However,
as
their
sense ofgender identity began to crystallize, they gradually realized that they were not homosexuals, and hornosexual activity had become repulsive to them. Consequently, their once close personal relationships with male homosexuals grew cool and distant. As they withdrew from these relationships, the homosexuals they had been close to began to view them as “women” and, therefore, as sexually repugnant. Furthermore, the transsexuals had become cornpetitors with the homosexuals for male bisexual partners for sex and, to a lesser extent, for companionship. The homosexuals became openly depreciating of and insulting toward the transsexuals and vilified them in their
comments
during
interviews.
(Competition
among male heterosexuals for partners is less intense because they are less driven by sexual and personality compulsions, and because their lives are more generally governed by social norms that effectively mitigate any hostilities they may have toward perceived cornpetitors.)
can deter-
confirmed these two individuals
so there seems of the diag-
2Field
research
indicated
that
female-to-male
variably patronize lesbian bars, sex-role segregation that sharply heterosexual sex-role trends.
AmfPsychiatry
thereby contrasts
133:li,
transsexuals
maintaining with many
November
/976
almost
a pattern contemporary
in-
of
1319
BRIEF
COMMUNICATIONS
Transsexuals are often receiving estrogen and are therefore less driven by sexual impulses. However, their consuming need to prove that they are women leads them to search constantly for a heterosexual male who, in their minds, is the only person who can confirm their identity as women. However, they can not attract such individuals and are, therefore, obliged to turn to bisexual men. The transsexuals in this sample had been or, when interviewed, were involved in prostitution-unlike, it should be recalled, most of the transsexuals who have been described in the literature. All of them said they did this in order to supplement their incomes, since they had, for a variety of reasons, quit theirjobs (or in the case of a few of the youngest, had never been gainfully employed) and were dependent on welfare. None of them was happy about having resorted to prostitution, and their major source of satisfaction (aside from the income) was deceiving heterosexual males into assurning
they
were
RELATIONSHIPS
consorting
WITH
with
females.
BISEXUALS
Sooner or later, these transsexuals found a male bisexual lover to decrease their intense loneliness and in an ill-disguised and futile effort to prove that they could attract and keep the attentions of a “heterosexual” male. However, it was common knowledge that their lovers were bisexual. What was less generally known, however, was that some ofthese bisexuals frequently prevailed on their transsexual “mistresses” to resort to prostitution to supplement their incomes, for most of the bisexuals were not employed full time or held low-paying jobs. That the transsexuals yielded to this manipulation was evidence of their extreme dependency on the bisexuals for companionship and sex, which was heightened by the fact that the bisexuals were invariably dominant in these relationships. In addition, the bisexual partner alone could maintain the facade of female heterosexuality that the transsexuals so desperately wanted. As might be suspected, the living arrangements of the transsexuals and their bisexual lovers were set up chiefly to suit the convenience and whims of the bisexuals who offered no assistance in taking care of household tasks and generally felt free to come and go and spend money as they wished. These situations were not merely a contemporary reflection ofrnore traditional living arrangements of heterosexual couples; they clearly expressed the unquestioned dominance of the bisexuals, whose domineering personalities, not simply the preferences and needs of lovers, took priority over all other considerations. It is no exaggeration to say that these bisexuals were examples of male chau,
vinism
The riddled
ships 1320
at its
lives with
with
worst.
ofthe
transsexual
unpleasant
homosexual Am J Psychiatry
men
in this sample
experiences
in their
acquaintances
and
i33:/
/ November ,
were
relation-
with 1976
bisex-
ual lovers. They were depreciated and degraded by other sexual deviants, which they had not anticipated and which counteracted the personal gains they felt they had achieved in being able to live openly as transsexuals.
Informal
comments
during
one
of the
inter-
view sessions indicated that professional and public acceptance of male transsexuals will not cause their personal problems to vanish. These problems stem from their
male
anatomies
from
their
alities
(3, 4).
and
clearly
INTERPERSONAl.
sense
of female
weak,
gender
dependent
PROBLEMS
AMONG
and
person-
MALE
TRANSSEXUALS
The
personality
disturbances
ofthese
men
had a con-
siderable effect on their social relationships with other transsexuals. It was assumed that individuals whose lives are so beset with difficulties would be particularly sensitive and sympathetic toward others like themselves. Surprisingly, the opposite proved to be the case. They did not seek each other out as roommates
in order to share expenses and gain companionship and commiseration; in fact, they very rarely invited other transsexuals to their apartments. Aside from meeting other transsexuals in homosexual bars, their social
life
was
meager.
The underlying reason deep-seated emotional pressed
in
their
for this insecurity,
deprecatory
seemed to be their which was ex-
comments
about
other
transsexuals. Those interviewed mate the number of transsexuals ranged from 75 to 500) and then they knew personally. At this
were asked to estiin Chicago (estimates were asked how many point, they said they
really
they
doubted
that
the
others
knew
were
truly
transsexuals. They criticized them for their lack of femininity, which they believed manifestly established transsexuality, or expressed their underlying resentment by casually suggesting that they were attempting to “pass” as transsexuals but were actually “drag queens.” Inasmuch as they could not have known (except
in cases
of close
personal
acquaintances)
whether
these individuals had been as transsexuals, it was clear to shore up their emotional
psychiatrically confirmed that they were attempting insecurities by denying or
raising ens.
the
serious
doubts
about
transsexualism
of oth-
COMMENT
There ceptability suit in
is reason
to suggest
of various forms more transsexuals
that
increased
social
of sexual deviance recognizing their
ac-
will retrans-
sexuality earlier, seeking to openly establish it sooner, and more casually adopting the life-style appropriate to their transformation in gender identity. Given this possibility, it is appropriate to ask if it is not now time to shift the emphasis from a responsible
BRIEF
professional desire to help while not abandoning this tion to the psychopathologic sexualism
and
REFERENCES
transsexuals to one which, perspective, directs attencharacter of trans-
encourages
improved
parenting
I. Levine
and anatomical changes from male to female.
in order
bility
can be most
Problems
in transsexuals’ Obviously, this
effectively
assumed
in the
transiresponsi-
C, Mihailovic
of
M: Male
transsexuals.
to female:
Archives
of
the
Sexual
role
Behavior
1975
2.
Levine E, Grunewald D, Shaiova C: Behavioral differences as symptomatic of differences in emotional conflict among male transsexuals. Archives of Sexual Behavior 5:81-86, 1976
3.
Socarides
C: The
desire
for
sexual
transformation:
a psychiatric
evaluation. Am J Psychiatry 125:125-131, 1969 4. Person E, Ovesey L: The transsexual syndrome Psychother 28:4-20, 1974
by psychiatrists.
Differential
E, Shaiova
transformation 4:173-185,
to avoid the development of transsexualism. What I am suggesting is that as much emphasis be placed on prevention as on procedures designed to facilitate social tions
COMMUNICATIONS
Diagnosis
of Narcolepsy
in males.
Am J
Versus
Schizophrenia BY BRUCE
SHAPIRO,
M.D.,
AND
HENRY
SPITZ,
M.D.
from wakefulness EEG pattern quency. Stage ized by 12-14 a transition to
The authors discuss the problems of accurately diagnosing narcolepsy when patients manifest the auxiliary symptoms ofthis disorder, i.e. cataplexy, hypnagogic hallucinations, and sleep paralysis, which often seem to indicate a psychiatric diagnosis. They conclude that misdiagnosis ofnarcolepsy can be avoided ifclinicians are aware that this illness can simulate a psychiatric disorder and ifthey give careful attention to the history ofthe patient’s illness. ,
slow
waves
slow waves 90 minutes
THE
standing
20 years disorders
PAST
of sleep
the recognition have received
and underincreased at-
of
1-2
than
Hz,
with
stage
this series movements
IV).
eye
cept along
for the extraocular with numerous other
the
pattern
similar
commonly
III
showing
70 to
is interrupted hypotonia
by (ex-
of stage
to REM
I sleep.
stage
This
is
of sleep,
which
NREM
stages
occurs
with
with
increasing
sleep
sleep. In some persons the length, order, regularity, relationship to wakefulness of these various stages
or de-
viates
re-
normally
difference simply
proceeds
between to the
in various
wakefulness
difference
stages,
and
between
day
sleep and
and
that
is not
the
akin
night.
Thus
the
series
ing
still
the
frequency healthy
the
during
adult
of central
the
is engaged
nervous
mysterious
significantly
in a rather
system
one-third
from
the
of
statistical
corn-
changes
life
that
norm.
durwe
call
One
suIting
has
Narcolepsy (“sleep attacks”) is a disorder of the sleep-wake cycle characterized clinically by the sudden, often irresistible urge to sleep. Gelineau (5) first named the disorder in 1880, and a classic description
,
been
The authors N.Y. , where
established
(4)
that
are both with New York Dr. Shapiro is Instructor
Assistant Professor of Psychiatry. Dr. trist, Veterans Administration Hospital,
print requests 10510.
to Dr.
Shapiro
at P0
disorder
night.
It is now known that EEG tracings of “normal” human sleep are characterized by four nonrapid eye movement (NREM) and one rapid eye movement (REM) stages. With the aid of electroencephalography electrooculography and electrornyography it ,
sleep
among
muscles), changes and
tention in the psychiatric literature. The major impetus for this development was the electroencephalographic elucidation of man’s sleeping state. Aserinsky (1), Kleitman (2), Dernent (3), and others revealed that
plicated
regularity
fewer
every
and respiratory physiological
to that
referred some
stage
Approximately
of sleep events and generalized
rapid
an EEG OVER
to stage I sleep, characterized by an of relatively low voltage and mixed freI sleep is followed by stage II (characterHz sleep spindles), which in turn makes stages III and IV (both characterized by
NARCOLEPSY
AND
is narcolepsy.
ITS
AUXILIARY
SYMPTOMS
,
the
healthy
adult
shifts
Medical College, New York, of Psychiatry and Dr. Spitz is Shapiro is also Staff PsychiaMontrose, N.Y. Address re-
Box
307,
Scarborough,
N.Y.
was
written
by
Daniels
in
1934
excellent clinical descriptions have appeared (7-9). The work Am J Psychiatry
i33:i
(6).
Recently
and literature ofHishakawa
I November ,
/976
several
reviews and asso1321
COMMUNICATIONS
these are sex-influenced genetic differences is a question for further research. The possibility that psychiatric disturbance could manifest as multiple somatic symptoms in females is important clinically in the diagnosis and management of childhood and adolescent “medical” and behavioral problems.
3.
5.
7.
try
126:534-549,
1975
2. Cadoret RJ, Cunningham adoptees from psychiatrically Temperament, hyperactive. ables. J Pediatr 87:301-306.
Male BY
L,
Loftus R, et al: Studies of disturbed biological parents: II. antisocial, and developmental van1975
Transsexuals
EDWARD
M.
in the
LEVINE,
PHENOMENON
1318
is Professor, Ill. 60626.
of transsexualism has recently attention. It has been incorporated on various aspects of human sexual Department
Am J Psychiatry
Guze
SB:
The
III. Familial Br J Psychiatry Children Grown
426, 1962 PurtelI JJ, Robins pects of hysteria.
and 8.
156 control
Siegel
multifactorial
model
of
relationship between socio127:23-32, 1975 Up. Baltimore, Williams &
K: Education, 1970
5:
E, Cohen A quantitative
subjects.
a study 1972
of their
10. Crowe
RR:
ME:
Health
and
Behav-
Observations on clinical asstudy of 50 hysteria patients 146:962-969, 1951 for the Behavioral Sciences.
JAMA
Nonparametric
Statistics
New York, McGraw-Hill 9. Crowe RR: The adopted arrest
Book Co. 1956 offspring of women records.
Personal
Arch
Gen
communication,
criminal
Psychiatry
offenders: 27:600-609,
December
1975
Subculture
behavior and has been the subject vision panel and interview shows years.
/33:i
of Sociology,
i November ,
Loyola
1976
Universi-
However,
most
of
what
of a number of teleover the past few is discussed
or
por-
trayed about transsexualism is restricted in content and perspective, largely because of the nature of the group of transsexuals about whom most is known. The great majority of men whose transsexual identity has
been
confirmed
been
unknown
cians These
and others individuals
are employed attire
and
by
as such
psychiatric
to anyone
whose seem
assistance to lead
in a variety sex
roles
and
diagnosis
but they ordinary
of occupations general
social
the
have
diagnosti-
have sought. lives-they
where
their
behavior
are
male. In addition, their lives seem to differ little, if at all, from those of others in the heterosexual communities in which they live. Indeed, when they decide to become full-time, cross-dressing transsexuals, their social
acquaintances
are
no inkling that this ered or was even characteristically deviants, including sexuals, and are they might fairly class
Dr. Levine ty, Chicago,
T,
PH.D.
,
THE
Reich
Wilkins Co. 1965 Rutter M, Tizard J, Whitmore ior. New York, Longman,
Homosexual
The author describes 20 male transsexuals who differ f rom most discussed in professional studies and from those in media portrayals in that they live in the male homosexual subculture . Furthermore interviews with these individuals indicated that transsexuals are no more sexually or socially homogeneous than heterosexuals or homosexuals. In general, these men entered the homosexual subculture in their teens; they knew they were not heterosexual and therefore assumed they must be homosexual. As their gender identity crystallized, homosexual activity became repugnant and they rejected and were rejected by male homosexuals. Being unable to attract heterosexual men, they sought bisexualpartners in afutile effort to confirm their identity asfemales. The author suggests that in addition to efforts to help transsexuals shift their gender identity, psychiatrists should emphasize prevention ofthis psychopathologic symptom.
caught the public’s in college courses
CR,
6. Perley M, Guze SB: Hysteria-the stability and usefulness of clinical criteria. A quantitative study based on a follow-up penod of six to eight years in 39 patients. N EngI J Med 266:42 1-
REFERENCES
I. Cunningham L, Cadoret RJ. Loftus, R, et al: Studies of adoptees from psychiatrically disturbed biological parents: psychiatric conditions in childhood and adolescence. Br J Psychia-
Cloninger
disease transmission: pathy and hysteria. 4. Robins L: Deviant
people,
shocked
because
they
have
had
metamorphosis was being considpossible. Such male transsexuals avoid contact with other sexual other male transsexuals and homonot involved in prostitution. Thus be depicted as “straight” middle-
a description
stated in the literature. There are, however, other
that
is either
psychiatrically
implied
confirmed
or
BRIEF
male transsexuals whose life-styles contrast markedly with the majority of those about whom we have information. The discussion that follows, which is an extension of previous research (1 2), is based on interviews with 20 transsexuals1 who live in the male homosexual subculture; the transsexuals’ homosexual acquaintances were also interviewed. These interviews indicated that there are increasing numbers of male transsexuals who live in this subculture and whose problems and life-styles are much like those ofthe men ,
in this
sample,
who
stated
that
they
knew
many
others
like themselves. The information gained about certain key aspects of the lives of the individuals in this sample provides an added dimension to our knowledge about transsexualism, if only because it indicates that transsexuals are no more socially or sexually homogeneous a group than are other sexual deviants or heterosexuals. Much of the literature on male transsexuals has focused on their more obvious problems and tensions and has emphasized ways in which they can and should be assisted. One of these methods is sexchange surgery, which is intended to provide a more effective adjustment to the transsexual gender and psychosocial identity. Sensitivity to and familiarity with the transsexuals’ plight are translated, quite understandably, into a genuine professional desire to alleviate their problems when at all feasible. This
outlook
has
been
supplemented
in recent
years
by the appearance on television shows of male transsexuals who have changed gender. Characteristically, these programs do not raise questions about the etiology of transsexualism, much less discuss the question of whether or not it is a psychopathologic symptom. This is due, in part, to the assumption that viewers would be bored by time-consuming technical explanations.
Inasmuch
gramming maintain
es,
as
are and
rather
boost
than
considerations, viance will
those
always
in charge
looking their
social
audience
novel ratings,
responsibility
that dictate presented
be
of television
for
unmistakably
as
men
‘I should
note that there
mine the individuals’
accuracy claims
were subsequently to be some basis noses.
no
matter
or mental
how
to
it is financ-
health
how topics on sexual to an impressionable
dience. Understanding of and sympathy sexualism on the part ofthe public and are increasing. One impression that from media presentations is that there male transsexual. However, there are who are six feet tall and taller, weigh more, and have body configurations are in modifying and tone of voice.
pro-
subjects
deau-
toward transof professionals is easily drawn is an “average” transsexual men 200 pounds and that stamp them successful
they
their bodies, apparel, mannerisms, Will such tragic figures really conis no way in which
of the psychiatric of transsexuality.
approved for their
the sociologist
diagnoses that However,
for sex-change claims and the
surgery. correctness
COMMUNICATIONS
vince anyone, particularly the heterosexual men they so desperately wish to attract, that they are females? Of course it is important to attempt to assist transsexuals in solving their problems; it is, however, equally important to recognize that transsexualism is a psychopathologic symptom and that appropriate attention and concern should be given to its prevention (3). It is from this perspective that I will examine certain aspects of the interpersonal relationships of male transsexuals in the homosexual subculture that add psychological problems to their already burdened lives.
TRANSSEXUALS:
THE
HOMOSEXUAL
PHASE
The transsexuals in this sample went through two transitional phases. The first was during their late teens when they were introduced to the male homosexual subculture by homosexuals who befriended them at a time when they assumed that they “must” be homosexual, since they knew they were not heterosexual. A factor that “confirmed” this belief was that all of them had been involved in homosexual relations, although they were invariably passive and never actively pursued a homosexual partner. The second phase involved their complete detachment from homosexuals, their new relationships, and the problems this change entailed. Entering the male homosexual subculture provided these men with an enormous sense of relief from the tensions
they
had
suffered
from
“homosexuality” from parents severing their relations with their permanently into areas near bars clusively
to male
sexual
having
to hide
their
and friends.2 Upon families, they moved that cater almost ex-
deviants.
However,
as
their
sense ofgender identity began to crystallize, they gradually realized that they were not homosexuals, and hornosexual activity had become repulsive to them. Consequently, their once close personal relationships with male homosexuals grew cool and distant. As they withdrew from these relationships, the homosexuals they had been close to began to view them as “women” and, therefore, as sexually repugnant. Furthermore, the transsexuals had become cornpetitors with the homosexuals for male bisexual partners for sex and, to a lesser extent, for companionship. The homosexuals became openly depreciating of and insulting toward the transsexuals and vilified them in their
comments
during
interviews.
(Competition
among male heterosexuals for partners is less intense because they are less driven by sexual and personality compulsions, and because their lives are more generally governed by social norms that effectively mitigate any hostilities they may have toward perceived cornpetitors.)
can deter-
confirmed these two individuals
so there seems of the diag-
2Field
research
indicated
that
female-to-male
variably patronize lesbian bars, sex-role segregation that sharply heterosexual sex-role trends.
AmfPsychiatry
thereby contrasts
133:li,
transsexuals
maintaining with many
November
/976
almost
a pattern contemporary
in-
of
1319
BRIEF
COMMUNICATIONS
Transsexuals are often receiving estrogen and are therefore less driven by sexual impulses. However, their consuming need to prove that they are women leads them to search constantly for a heterosexual male who, in their minds, is the only person who can confirm their identity as women. However, they can not attract such individuals and are, therefore, obliged to turn to bisexual men. The transsexuals in this sample had been or, when interviewed, were involved in prostitution-unlike, it should be recalled, most of the transsexuals who have been described in the literature. All of them said they did this in order to supplement their incomes, since they had, for a variety of reasons, quit theirjobs (or in the case of a few of the youngest, had never been gainfully employed) and were dependent on welfare. None of them was happy about having resorted to prostitution, and their major source of satisfaction (aside from the income) was deceiving heterosexual males into assurning
they
were
RELATIONSHIPS
consorting
WITH
with
females.
BISEXUALS
Sooner or later, these transsexuals found a male bisexual lover to decrease their intense loneliness and in an ill-disguised and futile effort to prove that they could attract and keep the attentions of a “heterosexual” male. However, it was common knowledge that their lovers were bisexual. What was less generally known, however, was that some ofthese bisexuals frequently prevailed on their transsexual “mistresses” to resort to prostitution to supplement their incomes, for most of the bisexuals were not employed full time or held low-paying jobs. That the transsexuals yielded to this manipulation was evidence of their extreme dependency on the bisexuals for companionship and sex, which was heightened by the fact that the bisexuals were invariably dominant in these relationships. In addition, the bisexual partner alone could maintain the facade of female heterosexuality that the transsexuals so desperately wanted. As might be suspected, the living arrangements of the transsexuals and their bisexual lovers were set up chiefly to suit the convenience and whims of the bisexuals who offered no assistance in taking care of household tasks and generally felt free to come and go and spend money as they wished. These situations were not merely a contemporary reflection ofrnore traditional living arrangements of heterosexual couples; they clearly expressed the unquestioned dominance of the bisexuals, whose domineering personalities, not simply the preferences and needs of lovers, took priority over all other considerations. It is no exaggeration to say that these bisexuals were examples of male chau,
vinism
The riddled
ships 1320
at its
lives with
with
worst.
ofthe
transsexual
unpleasant
homosexual Am J Psychiatry
men
in this sample
experiences
in their
acquaintances
and
i33:/
/ November ,
were
relation-
with 1976
bisex-
ual lovers. They were depreciated and degraded by other sexual deviants, which they had not anticipated and which counteracted the personal gains they felt they had achieved in being able to live openly as transsexuals.
Informal
comments
during
one
of the
inter-
view sessions indicated that professional and public acceptance of male transsexuals will not cause their personal problems to vanish. These problems stem from their
male
anatomies
from
their
alities
(3, 4).
and
clearly
INTERPERSONAl.
sense
of female
weak,
gender
dependent
PROBLEMS
AMONG
and
person-
MALE
TRANSSEXUALS
The
personality
disturbances
ofthese
men
had a con-
siderable effect on their social relationships with other transsexuals. It was assumed that individuals whose lives are so beset with difficulties would be particularly sensitive and sympathetic toward others like themselves. Surprisingly, the opposite proved to be the case. They did not seek each other out as roommates
in order to share expenses and gain companionship and commiseration; in fact, they very rarely invited other transsexuals to their apartments. Aside from meeting other transsexuals in homosexual bars, their social
life
was
meager.
The underlying reason deep-seated emotional pressed
in
their
for this insecurity,
deprecatory
seemed to be their which was ex-
comments
about
other
transsexuals. Those interviewed mate the number of transsexuals ranged from 75 to 500) and then they knew personally. At this
were asked to estiin Chicago (estimates were asked how many point, they said they
really
they
doubted
that
the
others
knew
were
truly
transsexuals. They criticized them for their lack of femininity, which they believed manifestly established transsexuality, or expressed their underlying resentment by casually suggesting that they were attempting to “pass” as transsexuals but were actually “drag queens.” Inasmuch as they could not have known (except
in cases
of close
personal
acquaintances)
whether
these individuals had been as transsexuals, it was clear to shore up their emotional
psychiatrically confirmed that they were attempting insecurities by denying or
raising ens.
the
serious
doubts
about
transsexualism
of oth-
COMMENT
There ceptability suit in
is reason
to suggest
of various forms more transsexuals
that
increased
social
of sexual deviance recognizing their
ac-
will retrans-
sexuality earlier, seeking to openly establish it sooner, and more casually adopting the life-style appropriate to their transformation in gender identity. Given this possibility, it is appropriate to ask if it is not now time to shift the emphasis from a responsible
BRIEF
professional desire to help while not abandoning this tion to the psychopathologic sexualism
and
REFERENCES
transsexuals to one which, perspective, directs attencharacter of trans-
encourages
improved
parenting
I. Levine
and anatomical changes from male to female.
in order
bility
can be most
Problems
in transsexuals’ Obviously, this
effectively
assumed
in the
transiresponsi-
C, Mihailovic
of
M: Male
transsexuals.
to female:
Archives
of
the
Sexual
role
Behavior
1975
2.
Levine E, Grunewald D, Shaiova C: Behavioral differences as symptomatic of differences in emotional conflict among male transsexuals. Archives of Sexual Behavior 5:81-86, 1976
3.
Socarides
C: The
desire
for
sexual
transformation:
a psychiatric
evaluation. Am J Psychiatry 125:125-131, 1969 4. Person E, Ovesey L: The transsexual syndrome Psychother 28:4-20, 1974
by psychiatrists.
Differential
E, Shaiova
transformation 4:173-185,
to avoid the development of transsexualism. What I am suggesting is that as much emphasis be placed on prevention as on procedures designed to facilitate social tions
COMMUNICATIONS
Diagnosis
of Narcolepsy
in males.
Am J
Versus
Schizophrenia BY BRUCE
SHAPIRO,
M.D.,
AND
HENRY
SPITZ,
M.D.
from wakefulness EEG pattern quency. Stage ized by 12-14 a transition to
The authors discuss the problems of accurately diagnosing narcolepsy when patients manifest the auxiliary symptoms ofthis disorder, i.e. cataplexy, hypnagogic hallucinations, and sleep paralysis, which often seem to indicate a psychiatric diagnosis. They conclude that misdiagnosis ofnarcolepsy can be avoided ifclinicians are aware that this illness can simulate a psychiatric disorder and ifthey give careful attention to the history ofthe patient’s illness. ,
slow
waves
slow waves 90 minutes
THE
standing
20 years disorders
PAST
of sleep
the recognition have received
and underincreased at-
of
1-2
than
Hz,
with
stage
this series movements
IV).
eye
cept along
for the extraocular with numerous other
the
pattern
similar
commonly
III
showing
70 to
is interrupted hypotonia
by (ex-
of stage
to REM
I sleep.
stage
This
is
of sleep,
which
NREM
stages
occurs
with
with
increasing
sleep
sleep. In some persons the length, order, regularity, relationship to wakefulness of these various stages
or de-
viates
re-
normally
difference simply
proceeds
between to the
in various
wakefulness
difference
stages,
and
between
day
sleep and
and
that
is not
the
akin
night.
Thus
the
series
ing
still
the
frequency healthy
the
during
adult
of central
the
is engaged
nervous
mysterious
significantly
in a rather
system
one-third
from
the
of
statistical
corn-
changes
life
that
norm.
durwe
call
One
suIting
has
Narcolepsy (“sleep attacks”) is a disorder of the sleep-wake cycle characterized clinically by the sudden, often irresistible urge to sleep. Gelineau (5) first named the disorder in 1880, and a classic description
,
been
The authors N.Y. , where
established
(4)
that
are both with New York Dr. Shapiro is Instructor
Assistant Professor of Psychiatry. Dr. trist, Veterans Administration Hospital,
print requests 10510.
to Dr.
Shapiro
at P0
disorder
night.
It is now known that EEG tracings of “normal” human sleep are characterized by four nonrapid eye movement (NREM) and one rapid eye movement (REM) stages. With the aid of electroencephalography electrooculography and electrornyography it ,
sleep
among
muscles), changes and
tention in the psychiatric literature. The major impetus for this development was the electroencephalographic elucidation of man’s sleeping state. Aserinsky (1), Kleitman (2), Dernent (3), and others revealed that
plicated
regularity
fewer
every
and respiratory physiological
to that
referred some
stage
Approximately
of sleep events and generalized
rapid
an EEG OVER
to stage I sleep, characterized by an of relatively low voltage and mixed freI sleep is followed by stage II (characterHz sleep spindles), which in turn makes stages III and IV (both characterized by
NARCOLEPSY
AND
is narcolepsy.
ITS
AUXILIARY
SYMPTOMS
,
the
healthy
adult
shifts
Medical College, New York, of Psychiatry and Dr. Spitz is Shapiro is also Staff PsychiaMontrose, N.Y. Address re-
Box
307,
Scarborough,
N.Y.
was
written
by
Daniels
in
1934
excellent clinical descriptions have appeared (7-9). The work Am J Psychiatry
i33:i
(6).
Recently
and literature ofHishakawa
I November ,
/976
several
reviews and asso1321
