1997 - Jafari PDF

A DESCRIPTIVE STUDY OF MALE TO FEMALE
TRANSSEXUALISM:
THE PREVALENCE AND USE OF DISSOCIATIVE EXPERIENCES
A Dissertation
Presented to the Faculty o f
The California School o f Professional Psychology at Alameda
In Partial Fulfillment
o f the Requirements o f the Degree
Doctor o f Philosophy
By
Mariam Jafari
June 1997
R e p r o d u c e d with p e r m issio n o f th e co p y r ig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

UMI Number: 9734269
Copyright 1997 by
Jafari, Mariam
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R e p r o d u c e d with p e r m issio n o f th e co p y rig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .
A DESCRIPTIVE STUDY OF MALE TO FEMALE
TRANSSEXUALISM:
This dissertation, by Mariam Jafari,

has been approved by the committee members
signed below who recommend that it be
accepted by the faculty o f the California
School o f Professional Psychology at Alameda
in partial fulfillment o f requirements for the
degree o f
DOCTOR OF PHILOSOPHY
Dissertation Committee:
Abbot Bronstein, Ph.D.

Chairperson
Ali Chavoshian, Ph.D.
Alan Swope, Ph.D.

© Copyright by Mariam Jafari. 1997
All Rights Reserved
iii
1
ABSTRACT
A DESCRIPTIVE STUDY OF MALE TO FEMALE TRANSSEXUALISM:
MARIAM JAFARI
California School o f Professional Psychology at Alameda
The transsexuals' account o f alienation and detachment from their biological
gender, in particular from their genitals, is analogous to reports o f individuals with
depersonalization experiences. Depersonalization is a subcategory o f the defense o f
dissociation. In this study the prevalence o f dissociative experiences o f Male to Female
transsexuals was evaluated and compared to the prevalence o f dissociative experiences in
a control group o f males and females.
The study group consisted o f twenty-seven male to female transsexuals. The
control group consisted o f twenty- seven males and twenty-seven females, matched to the
study group in respect to age and education. The participants' ages ranged from twenty-
one to sixty-five.
The Dissociative Experiences Scale (DES) and the Questionnaire for Experiences
o f dissociation (QED) were used to assess dissociative experiences. A statistically
significant difference was identified comparing the mean DES score o f the group o f MF-
R e p r o d u c e d w ith p e r m issio n o f th e co p y rig h t o w n er . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .
transsexuals with the entire control group, consisting o f twenty-seven males and twenty-
seven females (T = 2.5; P = 0.2).
Forty-one percent o f the transsexual participants compared to seventeen percent of
the control group scored at or above the cutoff score o f fifteen on the DES. This
difference was statistically significant (p = .02). Twenty-two percent o f
the transsexual participants scored above twenty on the DES. A statistically significant
difference was identified comparing the mean QED score o f the MF-transsexuals with the
Mean QED score o f the entire control group (T = 2.5; P = .01).
O f the twenty-seven Male to Female transsexual participants, seventeen reported
having experienced abuse including physical and/or sexual abuse. Ten participants did
not report any abuse. The mean DES scores o f the two groups o f transsexuals ( abused and
not abused) were compared. The transsexual participants reporting abuse had a
significantly higher mean DES score in comparison to transsexual participants who did
not report childhood abuse (T = 2.6; p < .01).
In addition to this data, information on family history and personal meanings o f
femininity and masculinity are presented in a qualitative data analysis and the etiology o f
transsexualism is reconsidered.
Further research is suggested to evaluate the occurrence o f dissociation in
transsexualism and. in general, in the etiology o f gender disorders.
R e p r o d u c e d w ith p e r m is s io n o f th e co p y rig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

Dedicated
to
Djamschid and Heidelore
Acknowledgments
First and foremost. I would like to thank the transsexual participants who were
willing to share their invaluable personal experiences, which made this research project
possible.
I am most grateful to my dissertation committee. My chairperson. Dr. Abbot
Bronstein whose breadth o f knowledge in analytical theories greatly inspired my
thinking. Dr. Alan Swope whose careful reading and scholarly advise brought clarity in
my conceptualizations. I would like to thank Dr. Ali Chavoshian whose comprehension
and encouragement were essential to the completion o f this study.
I extend my sincere thanks to a number o f professionals who familiarized me with
the transsexual community. In particular, I would like to thank Ms. Judy Van Maasdam
who generously shared her tremendous expertise and clinical experience. I am grateful to
Mary Monihan and Stefanie Eng who introduced m y study to the transsexual community.
I am indebted to my friend and mentor Mary Canedy Burt who gave me the
opportunity to work in her unique center for em otionally disturbed children, where I
directly witness and understand the outcome o f young children's traumatic experiences.
I am thankful to Coronet Galloway for teaching me the SPSS and to Dr. Bruce
Cooper for sharing his time and expertise in statistics. A number o f my friends played an
important part in the difficult process o f research. I am particularly grateful to my friend
JoAn Cabello for her valuable editorial advise, and to my friend Wiebke for her
continuous support during the data collection.
R e p r o d u c e d w ith p e r m issio n o f th e co p y rig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .
I would like to extend my thanks to my family, in particular my parents
Djamschid and Heidelore who created an environment which allowed me to take risks
ask questions early on. To my brother Mohammad for his relentless encouragement and
to my mother Homeira and my father Amir for their love and financial support.

Table o f Contents
Page
Dedication...................................................................................................................................iv
Acknowledgments......................................................................................................................v
List o f Tables............................................................................................................................viii
I. INTRODUCTION...........................................................................................................I
II. BACKGROUND.............................................................................................................4
III. METHOD........................................................................................................................ 42
IV. RESULTS........................................................................................................................ 45
V. DISCUSSION................................................................................................................. 69
References..................................................................................................................................... 82
Appendix A: Dissociative Experiences Scale...................................................................... 91
Appendix B: Questionnaire for Experiences o f Dissociation........................................... 98
Appendix C: Personal History Questionnaire.....................................................................101
vii
List o f Tables
Page
1. DES scores: original Data.............................................................................................. 35
2. Age range........................................................................................................................... 46
3. Education........................................................................................................................... 47
4. Mean- DES scores...........................................................................................................48
5. Mean- DES scores o f abused vs.not abused
transsexual participants................................................................................................. 50
6. Gender transition.............................................................................................................. 51
7. Mean- DES scores and phaseso f gender transition..................................................53
8. Onset................................................................................................................................... 55
9. Cross-dressing.................................................................................................................. 56
10. Psychiatric and treatment history................................................................................. 63
11. Alcohol and Drug use......................................................................................................64
12. Relationship to parents....................................................................................................66
13. Abuse experiences........................................................................................................... 68
viii
1
INTRODUCTION
The following study investigates the prevalence o f dissociative experiences o f
male to female transsexuals. Transsexuals have the conviction that they belong to the
opposite gender and feel imprisoned in their bodies. This experience is accompanied by
an intense suffering, with only hope to alleviate the pain envisioned in the sex change.
The transsexual's belief is described as non-delusional (Pauly. 1969, Person & Ovesey,
1974a). These men and women are aware o f their physical endowment, but sense that
their biological sex is inconsistent with their true gender. Some researchers emphasize
that the belief is not based on a lack o f reality testing (Sorensen and Hertoft. 1982) and
distinguish transsexuals from schizophrenics with chaotic sexual identities.
Although transsexuals are cognizant o f their biological gender, they have a sense
o f repulsion or alienation towards their gender insignia and the attached symbols to the
point that the irreversible sex transformation becomes an ultimate goal aspired with
urgent insistence.
The transsexuals' account o f alienation and detachment from their biological
gender, in particular from their genitals, is analogous to reports o f individuals with
depersonalization experiences. Depersonalization, considered as an ego defense
mechanism in psychoanalytical theory, has been described as a sense o f detachment from
one's body, thoughts, feelings and actions (Simeon & Hollander. 1993). Bodily changes
with numbness are reported and "the sensation that a part o f the se lf or the whole self has
changed; or that a given part is no longer experienced as belonging to the person"
(Stamm, 1962, p. 763). In depersonalized states although reality testing is intact the sense
o f reality is diminished. Feelings o f distance and strangeness prevail and reality is sensed
as grey and lifeless (Shapiro. 1975).
Depersonalization is a subcategory o f the defense o f dissociation. According to
most investigators, incidents o f dissociation appear in minor and major
psychopathological forms. Gabbard (1994) views the primary function o f dissociation as
protection against overwhelming stimuli. Spiegel and Cardena (1991) defined
dissociation as "a structured separation o f mental processes <e.g. thoughts, emotions,
conations, memory, and identity) that are ordinarily integrated" (p. 367). Bernstein and
Putnam (1986) emphasize that the different forms o f dissociation are conceptualized as
occurring along a continuum. Pathological dissociative reactions are characterized by a
disruption in the individual’s sense o f identity and disturbances o f memory.
The question that arises is: Do transsexual individuals display a greater prevalence
o f dissociative symptoms in comparison to the normal population, and is the prevalence
o f dissociative experiences in transsexuals similar, in extent, to individuals with
pathological forms o f dissociation?
The condition o f transsexualism in real and mythological persons has been
depicted for thousands o f years with examples from early Greek. Hindu and Muslim
cultures (Bullough. 1976). In (1902), Krafft-Ebing diagnosed individuals who believed
they had changed sex as "metamorphosis sexualis paranoia". Cauldwell (1949)
introduced the term "psychopathia transsexualis" and Benjamin (1966) who was the first
who used the term transsexual became the advocate for the transsexual plight.
The controversy among the medical community increased when sex conversion
surgery became popularized. The psychological explanation tor the surgical procedures
was based on studies with intersexed individuals, e.g. hermaphrodites. The results o f
these studies led to the assumption that socialization and not biology is the dominant
factor in the development o f core gender identity (Edgorton. ICnorr. and Callison. 1970).
Surgery as treatment o f choice became increasingly accepted by well known medical
schools and hospitals. Opponents o f the surgical procedures described the transsexual's
plea for surgery as an appeal for mutilation (Cappon. 1970 1 and critiqued surgery as a
drastic nonsolution (Restak, 1979) which did not alter the transsexual's distorted sense o f
self. Derogatis. Meyer and Vazquez (1978) point out the theoretical controversy in
relation to this phenomenon and distinguish two major schools. One school o f thought
perceives that one's gender is different from one's anatomical sex as a defensive
maneuver invoked to ease gender discomfort. The other school believes that the condition
o f transsexualism occurs naturally. Any psychopathology is regarded as predominantly
reactive in nature to the primary gender incongruity. Parallel to the opposing theoretical
conceptions, different ideas about treatment have been developed with considerable
disagreement regarding the treatment o f choice.
In the literature on transsexualism there is a lack o f systematic studies which
elucidate the etiology o f transsexualism. In spite o f the similarity o f the experiences o f
transsexual individuals with the accounts o f individuals with experiences of
depersonalization and dissociation there are no systematic studies on the prevalence o f
4
dissociative symptoms in transsexual individuals.
The following study will investigate the prevalence and severity o f dissociative
experiences and the occurrence o f early experiences o f abuse in male o f female
transsexual individuals. The etiology o f male to female transsexualism will be
reconsidered using descriptive data and theories on the concept o f dissociation. The
literature review will encompass theories on the etiology o f transsexualism including
clinical studies, theories and research on the phenomenon o f depersonalization and
dissociation. The emphasis will be on psychodynamic theories and perspectives.
BACKGROUND
Transsexualism
The term transsexualism was coined by Claudwell four decades ago. Since then a
number o f definitions have been presented in the literature. The broadest definitions
stress the request for sex transformation surgery (Ovesey & Person. 1973), other
definitions emphasize the incongruity between the biological sex and gender identity
(Feinbloom, 1976). The variety and range o f different definitions reflect the gemeral
controversy on this subject.
In DSM-IV. transsexualism is subsumed under the general category o f gender
identity disorders. The DSM-IV emphasizes the strong and consistent cross-gender
identification and the desire to live and pass as the other sex. The sense o f
5
inappropriateness in o f one's biological sex is coupled with the urge to get rid o f primary
and secondary sex characteristics. Transsexualism is distinguished from physical intersex
conditions and from schizophrenics with cross gender delusions.
Brown (1990) points out that the vast majority o f patients with gender dysphoria
does not display physical anomalies and the coexistence o f transsexualism and
schizophrenia has been observed to be a rather rare phenomenon. Patients with a
borderline personality disorder may display gender dysphoria as part o f their general
pathology.
In the last years a number o f authors conceptualized gender dysphoria as a
subgroup o f the wider category o f borderline personality disorder. (Arndt. 1991:
Lothstein, 1979).
The condition o f transsexualism is distinguished from transvestism which is
according to the DSM-IV (1994) defined as "fetishistic cross dressing by heterosexual
male". "Fetishism" is referred to sexually arousing fantasies, sexual urges and behaviors
involving cross-dressing". Transvestic fetishism is primarily considered as a sexual
disorder and distinguished from gender identity disorders. Transvestic individuals might
develop gender dysphoria in consequence to situational stress.
Researchers have reported similarities in the psychosexual histories o f transvestite
and transsexual patients. Some authors regard the distinction between transsexuals and
transvestites on the basis o f fetishistic cross dressing as too simplistic (Brown. 1990:
R e p r o d u c e d w ith p e r m issio n o f th e co p y r ig h t o w n er . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

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Person and Ovesey, 1978: Buhrich. N.. McConaghy N.. 19 —T'l. Honig and Kenna (1974)
believe that transsexualism is always preceded by transvestism or accompanied by
cross-gender fetishism although the condition itself is not rooted in an aberrant erotic
preference.
Arndt (1990) introduces the term "standard transsexual” to settle the disagreement
around primary or true transsexuals.
This standard male transsexual is one who claims a iifelong conviction o f being
female, while acknowledging that he is a biological male. Thus, he is not
delusional. Generally, cross dressing was not sexually arousing, ruling out
fetishistic transvestites; it simply felt right... He has difficulty living as a man and
believes he would be better adjusted in the opposite gender role. He may be
passing as a female on his own and can do this convincingly. Ultimately, he
desires sex reassignment surgery (p. 123).
The com plex issues which emerge in the differential diagnosis reflect the controversy in
regard to the etiology o f transsexualism. In the following chapter the etiological theories
on transsexualism w ill be reviewed.
Etiology o f Transsexualism
The phenomenon o f transsexualism has been elucidated from different
perspectives including "psychogenic" and "biogenic" theories. Meyer (1982)
distinguishes three hypotheses in reference to the etiology o f transsexualism; the
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7
"biological/ imprint hypothesis", the "non conflictual identity hypothesis" and the
"conflictual defense hypothesis" (p. 390).
The Biological/Imprint Hypotheses
The idea o f a biological determinant in the development o f gender and erotic
orientation has a long history and has been discussed as early as 1894 (Krafft-Ebing,
1894). Benjamin (1966), who first introduced the term "transsexualism", postulates a
neuroanatomical center for gender identity which becom es disordered in the case o f
transsexual individuals.
The modification o f sexual behavior in rodents and other lower mammals, using
hormones administered at a critical period, led some investigators to the hypothesis that
hormonal changes predispose to changes in sexual behavior in humans. These research
findings have been criticized for their reliance on animal findings and their disregard for
the importance o f the affective system in the higher mammals (Honig & Kenna. 1974:
Meyer. 1982). Prenatal hormonal changes have been observed to cause tomboyish
behavior in girls or effeminate behavior in boys, but in neither group was there a clear
indication o f gender abnormality (Ehrhardt. Epstein. & Money. 1968: Ehrhardt. Evers &
Money, 1968; Yalom, Green & Fisk 1973). Some researchers assume a prenatal influence
o f H-Y antigen in the development of transsexualism. H -Y antigen affects the sexual
center in the hypothalamus. Domer (1988), who researched the H-Y antigen in
transsexuals, found different results in homosexual in comparison to heterosexual and

8
bisexual transsexuals. In a critical review on the etiology c : transsexualism. Arndt (1991)
reports conflicting findings in regard to the existence o f H-Y antigen abnormalities in
transsexuals.
As opposed to the pure biological theories, the "imprint hypothesis" emphasizes
the primacy o f psychological factors in gender development. Based on studies with
intersexed individuals. Money and the Hampsons (19571 concluded that sex assignment
and rearing are the determining factors in the development o f gender identity. According
to Money and Ehrhardt (1972) the acquisition o f gender identity' is rooted in a process
analogous to imprinting. Gender formation occurs during a critical period in the first three
years o f life. Once gender identity is established it becomes increasingly resistant to
change. The authors compare the formation o f gender with the acquisition o f native
language. According to the biological/imprint theories mental contents and conflicts are
an outcome o f the dissonance among "brain set. imprint and somatotype" (Meyer. 1982).
Psychotherapy is considered as ineffective and surgery is viewed as a rehabilitative
measure. Imprinting is according to Money, a critical mechanism in the development o f
transsexualism. The imprint is based on "detrimental social experience". (Money &
Gaskin. 1970-1971). Meyer (1982) challenges this explanation questioning what is
considered a sufficiently detrimental experience leading to the cross gender identification.
Similar to Money, Stoller (1968) employs the concept o f imprinting in his theory o f
transsexualism. The feminine gender identity o f the transsexual is. according to Stoller.

9
the result o f unconflicted, identity formation (Stoller. 1968 in Meyer. 1982).
The Non-conflictual Identity Hypothesis
Stoller (1968) differentiates male transsexualism from other gender aberrations.
Stoller. (1980) describes male transsexuals as the most feminine o f all males. Male
transsexualism is as opposed to the perversions an "identity per se" (Stoller. 1975), a
clear-cut entity with a specific clinical picture and typical dynamics and etiology. The
condition is the result o f a nonconflictual "nonmental" learning process comparable to
imprinting. This process is caused by the blissful symbiotic relationship between mother
and son. The outcome is the son's primary fem ale identification which is according to the
author not the result o f an active process, but a process in which something "is impressed
upon the malleable infant's unresisting proto psyche and unfinished CNS" (Stoller,
1975b).
Stoller hypothesizes that transsexualism occurs in a certain type o f family
constellation. The mother felt unwanted in her early life. She is chronically depressed and
has a: strong bisexual disposition. The boy child is regarded as the solution for the
mother's lifelong hopelessness. She discourages her son's masculinity and feeds and
cultivates his femininity at the earliest stages o f his development (Stoller. 1975). In this
relationship the male child becomes the "phallus" o f his mother. The father is either
absent and/or distant or passive and does not counteract the "excessively blissful"
mother/infant symbiosis. This type o f relationship produces a profound disturbance in the

boy's body ego: he has no impetus toward separation and differentiation from the
mother's female body. There is no experience o f an oedipai comlict and castration anxiety
and the developmental solution differs greatly from that worked out by either the normal
individual or those who turn to perversion.
As opposed to boys where this condition develops around the age o f one or two.
in girls this condition does not develop until later, around three or four. The development
o f female transsexualism is similar to the development o f homosexuality and is according
to Stoller (1975 b). a "defense against trauma; a depressed mother unable to love and care
for her infant" (p. 242). While in the case o f boys there is a complete absence o f trauma
and conflict.
Stoller’s idea o f non-conflictual development o f male transsexualism has evoked
much controversy. He has been criticized for not taking into account theories o f
separation and individuation, thereby neglecting the importance o f defensive operations
and compromises o f the patient in the evolution o f their transsexualism (Lothstein. 1979).
Mahler (1975. in Volkan. 1979) challenges the idea that transsexuality ever develops
without conflict or severe trauma. She argues that the "excessively blissful", sym biotic
mother infant relationship begins to abate beyond the fifth month o f life. The child
experiences a maturational push to go beyond this phase in order to achieve further
differentiation o f self and object presentations and the attuned mother allows the child to
separate. Any disruption o f this forward movement creates conflict. Stoller portrays the

11
mother infant relationship as a blissful unity, but indicates that the mothers o f male
transsexuals are characterized by psychopathology. The assumption o f a blissful mother-
son relationship is puzzling considering the profound depression in the mothers, who also
have "the most powerful penis envy" (Stoller, 1975. p. 41).
Stoller's idea o f imprinting has been reviewed by several authors. According to
Ovesey and Person (1973) there is no evidence o f imprinting in man in the biological
sense, as there is in animals. Gender identity in transsexuals is not unambiguous but
confused. Volkan (1979) questions Stoller’s ideas o f imprinting in the development o f
gender identity which implies that gender development is not effected by affective or
conflictual processes. Volkan critiques Stoller, in that Stoller does not seem to consider
"gender identity as part o f a gradually developing ego identity" (Volkan, 1979, p. 195). In
relation to the notion o f imprinting, Mitchell (1976) questions "If it is the mother’s
unconscious with which we are dealing, then why should this be 'genderized'-the
unconscious o f men and women is neither masculine nor feminine but bisexual" (p.358).
Mitchell (1976) points out that Stoller views gender identity as "part o f o n eself but does
not include other parts o f the self in his conceptualization which are based on the laws o f
imprinting.
The nonconflictual hypotheses seems to operate in a libidinal framework not
explicating the vicissitudes o f aggression. Stoller's original ideas on the condition o f
transsexualism initiated a broad theoretical discussion on this issue. Several investigators
12
regarded conflict and defense as pivotal in the etiology o f transsexualism. In the
following chapter these theories w ill be reviewed.
The Conflict/Defense Hypotheses
Socarides (1988) disagrees with Stoller's ideas on the etiology o f transsexualism.
The condition is. according to Socarides (1988) not a clinical entity but a secondary
elaboration o f pre-existing conditions such as transvestitism or homosexuality.
According to Socarides (1970). transsexualism as well as transvestitism can be
conceived in a unitary theory o f perversion. Sexual perversions originate in the
pre-oedipal period especially between eighteen months and three years (Socarides, 1970).
The individual who has been unable to pass through the symbiotic and
separation-individuation phases, attempts to resolve his overwhelming anxiety by
developing the perverse condition. "Sexual perversion serves the repression o f a pivotal
nuclear complex: the urge to regress to a pre-oedipal fixation in which there is a desire for
and dread o f merging with the mother in order to reinstate the primitive mother-child
unity" (Socarides. 1970. p. 347).
In transvestitism the individual strives to attain the femininity o f the mother and
sister through cross-dressing. He retains the phallus, though disguised behind a feminine
attire. The transsexual individual attempts to satisfy his yearning for femininity through
radical elimination o f all signs o f his anatomical gender.
According to Socarides (1988) sexual perversions including transsexualism can
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13
emanate from different lev els o f organization. The same transsexual phenomenology
might be related to different structures arising from oedipal or pre-oedipal sources or
from schizophrenic processes.
Similar to Socarides. Person and Ovesey (1974a) disagree with Stoller's idea o f
the transsexual's conflict-free female gender identity. Transsexualism, transvestism and
effeminate homosexuality originate in different stages along a developmental gradient.
Distortion o f gender and sex in the three conditions are rooted in the pre-oedipal period
and are the results o f different modes o f handling separation anxiety at progressive levels
o f maturation. In male transsexualism, the child attempts to allay separation anxiety with
a reparative fantasy o f symbiotic fusion with the mother. The result is an ambiguity o f
gender identity (Person & Ovesey 19 7 4 a ). The ambiguity o f gender identity disrupts the
gender role development and development o f sexuality leading to a frequently observed
asexuality in primary transsexuals. This development begins before the child is three
years old and has established a core gender identity. Person and Ovesey (1 9 7 4 a ) perceive
sex reassignment as the transsexual's attempt to alleviate separation anxiety by acting out
the unconscious fantasy surgically to become symbolically his mother. Person and
Ovesey (1974b ) indicate that in effeminate homosexuality and transvestism there is little
ambiguity in regard to the core gender identity but the gender role is significantly
disturbed. These individuals who do not resort to symbiotic fusion allay their anxiety
resorting to transitional and part objects. These mechanisms become available further
along the developmental gradient. Person and O vesey (1 9 7 4 a . 1974b ) differentiate
between primary and secondary transsexuals. In primary transsexuals the wash for a
transsexual resolution is persistent and progressive. They are primarily asexual and have
no significant episodes o f homosexuality or heterosexuality. In the secondary group the
transsexuals are effeminate homosexuals or transvestites. Their transsexual resolution is
often a result o f a stressful life situation occurring after a sustained time o f active
homosexuality or transvestism. In this group the transsexual impulse is transitory and
fluctuating, but it may eventually become insistent and consequently develop into a
transsexual syndrome. Person & Ovesey suggest (1 9 7 4 a ), that the majority o f
transsexuals are not psychotic. Since "the patient is presented with medical evidence, that
the condition does in fact exist, his subsequent b elief that he is a woman does not fulfill
the criteria for classification as a delusion" (Person & Ovesey, 1974a, p. 18).
The primary transsexual exhibits little sexual interest and masturbation is
performed mechanically, without much pleasure with vague heterosexual fantasies and in
a "rather dissociated way". The repugnance o f the male insignia develops mostly in
adolescence and progresses gradually. Cross-dressing leads to a sensation which Person
and Ovesey's patients describe as a feeling o f comfort, relief and warmth. In comparison
to primary transsexuals transvestites' core gender identity is more firmly male.
Although Person & Ovesey propose separation anxiety and fusion fantasies as the
central psychological problems among transsexuals they recognize that neither "is
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15
specific to transsexualism, and hence cannot explain transsexualism in any etiologic
sense" (Person & Ovesey. 1974 b. p. 189). The authors point out that separation anxiety
and fusion fantasies are prominent in many psychiatric disorders, particularly in the range
o f borderline disorders. The significant difference between transsexuals and other
borderline patients is the association between the fusion fantasy and the ambiguous
gender identity. Person and Ovesey (1 974a ) see a myriad o f unanswered questions in the
etiology o f transsexualism such as whether the fusion fantasy disrupts core gender
identi'.y or whether the ambiguity arises from another source and consequently influences
the evolution o f the fusion fantasy.
In agreement with Person & Ovesey (1974a). Volkan (1979) subsumes
transsexualism in the range o f borderline disorders. Volkan (1979) applies the theory o f
internalized object relations to male and female transsexuals and points out that the
phenomenon o f transsexualism is based on an object relations conflict. According to
Volkan (1979) transsexuals display an incessant search for perfection seeking plastic
surgery continuously for different body parts. Based on clinical observation he interprets
the search for perfection as a "search to be uncontaminated by aggression" (Volkan. 1979.
p.201). Rorschach test results (Volkan and Berent. 1976) suggest that the male
transsexual views his penis as a "symbol for evil", as bad and aggressive. The mother is
idealized and is seen as the source o f goodness and purity. The male transsexual aspires
to fuse with his mother's idealized femininity and rejects the malign masculinity which is
16
symbolized by the penis. "The male transsexual seeks to unite nis 'all good' self
representations with his 'all good' mother representations to become him self a perfect
woman; at the same time he dreads merging with the 'all bad’ mother representation, and
keeps that representation as well as his own 'all bad' self representation primitively split.
This takes place at a level at which self-and object images or representations are
differentiated except in regard to genital body parts" (Volkan. 1979. p. 205). Using
primitive splitting the transsexual tends to externalize the all bad" object representations
to other people. The world is seen as full o f dangerous and frustrating forces. Anything
that blocks his search for perfection is seen as a threat to his regressive hope o f merging
with the 'all good' mother.
In regard to the transsexual's ability to build mature relationships. Volkan (1979)
states that the transsexual's relationship with his/her partner is a "part-object" relationship
(Klein. 1946). The transsexual uses his or her partner to reinforce the "all good"
constellation which he or she is trying to maintain. Volkan (1979) emphasizes that
transsexuals display a general search for perfection, a perfection not only in respect for
the body parts but also in respect to a more generalized s e lf concept. The transsexual's
need to have all traces o f his or her anatomical gender effaced is according to Volkan an
unconscious attempt to destroy untamed aggression. "What is called 'sex reassignment
surgery' might as w ell be called 'aggression reassignment surgery'" (Volkan. 1979. p.
201). Volkan (1979) elaborates on Stoller's idea regarding the transsexual's feminine core

gender identity. He assumes that the patient includes in this fem uune core only the 'good'
and idealized se lf images, and attempts to protect the "core" from destructive aggression.
As Person and Ovesey (1974a) have noted the questions in regard to the specific
etiology o f transsexualism are still unanswered. Volkan attempts :o delineate the specific
factors in the development o f the transsexual. He postulates that se lf and object
representations are differentiated with exception to the genital body parts. The penis is
seen as the symbol o f all evil. When the penis is regarded as the symbol for evil, why is
the transsexual not able to eliminate the penis in symbolic ways? Volkan's observation o f
the transsexual's continuous pursuit o f plastic surgery for different body parts suggests
that the aggression is extended from the genitals onto the w hole body o f the transsexual.
Volkan does not clarify why the transsexual, regarding his penis, the symbol o f maleness,
as "all bad" and evil, has often a strong wish for a "heterosexual" relationship with a man.
In agreement with Person & Ovesey (1974a) and Volkan <1979). Meyer (1982)
views gender pathology as an outcome o f early relationships o f the symbiotic and
separation individuation phases. Gender identity is "part o f a hierarchical series beginning
with archaic body ego. early body image, and primitive selfhess" (Mever. 1982. p. 413).
He views gender identity not as a primary phenomenon but rather as a tertiary
phenomenon. The author sees transsexualism as closely linked to perversions. The
difference to perversions is considered related to the extent o f sym bolic capacities. As
opposed to the perverse individual who can make use o f sym bolic representations, the
transsexual has to retreat to concrete restitution in order to repair the idea o f the damaged
mother. The transsexual attempts to convert the fantasy into reality with the quest for sex
reassignment. According to Meyer (1982) the quest for sex reassignment serves defensive
and expressive functions and is a compromise formation. Meyer does not clarify why the
transsexual attempts to concretely repair the idea o f the damaged mother by damaging
himself.
Meyer's (1982) notion that gender identity is not a primary phenomenon is in
accordance with Lothstein's (1988) position that gender development can be only
understood as part o f the nuclear self-development. Lothstein (1988) critiques the
common use and examination o f the concept o f core gender identity which does not make
any reference to the development o f the nuclear self. Lothstein (1988) employs the
theoretical concepts o f Self Psychology (Kohut. 1977, Kohut, 1984) to elucidate the
development o f gender identity disturbances. According to Kohut "the se lf arises thus as
the result o f an interplay between the newborn's innate equipment and the selective
.. ^ponses o f the self-objects through which certain potentialities are encouraged in their
development while others remain unencouraged or even are actively discouraged" (Kohut
& W o lf 1978, p.416). Lothstein (1988) postulates that self-object failures may lead to
"severe disorders in gender-self or gender-identity functioning" (p.214). The early gender
self experience is created by the mother figure. Her empathic mirroring and her response
to the child's body and developing body image, has a crucial impact on the gender self
R e p r o d u c e d with p e r m issio n o f th e co p y r ig h t o w n e r . F urth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

system. In relation to the gender dysphoria in boys Lothstein (1988), postulates, that the
mothers display deep fear and hatred o f men. These mothers regard masculinity as
dangerous and bad. This ideas are communicated to the boy who in an attempt o f self
preservation succumbs, to the mother's wish constructing an "as if' feminine
self-experience. Failures in empathy and self-object functioning in relation to the child's
emerging gender s e lf lead to a diffuse and fragmented self experience. Mother and boy's
extended closeness appears ambivalent and is, according to Lothstein. rooted in conflict
rather then in a blissful symbiotic relationship. The boy's femininity is the only path to
survive the mother's abhorrence o f maleness. He dreads and rejects his maleness and
constructs a faulty gender self-structure with an "as-if' feminine self-experience.
Lothstein's (1979) broad clinical study with 125 gender dysphoric individuals
illuminates and broadens the theoretical postulations o f other investigators.
Lothstein's patients presented severe narcissistic character pathology and restricted
defenses, such as splitting denial, omnipotence, projection and projective identification.
They had endured chaotic, unpredictable and traumatic experiences o f loss and
abandonment with mothers who were overly stimulating or alternatively withdrawn and
distant. These experiences led to intense separation anxiety and a desperate longing to
fuse and reunite with the mother.
Most patients in Lothstein's (1979) study were isolated, exhibiting feelings o f
emptiness. In periods o f stress the magical idea emerged that satisfying relationships

20
would be attained through sex change. For some patients the rigid identification with the
opposite sex was a way to achieve a certain continuity and structure and a shielding
against a lapse into a damaging state o f emptiness. Some patients abhorred their bodies,
others expressed primarily gender envy. Others displayed both phenomena. The patients
who loathed their body displayed more anxiety, impulsivity. self mutilative behaviors and
suicidality. They maintained the idea that by getting rid o f their maleness they achieved a
state o f inner peace and tranquility. Lothstein (1979) states that "...many male
transsexuals focused their aggressive conflict on their genitals, and experienced a dualism
in their personalities between a male destructive element and a female constructive
element" (p. 226). Those patients who mainly displayed gender envy longed for
acceptance and fulfillment o f their dependency needs. Females were regarded as
recipients o f affection, admiration and love. Many transsexuals had experienced a recent
death and exhibited fear o f dying. The metamorphosis into the opposite sex appeared as a
solution o f mortality. Lothstein's clinical observations are broad and thorough and a basis
for more systematic investigations. There is a lack o f clarification in regard to the extent
o f the various phenomena. There is also a lack o f distinction in regard to the different
forms o f gender dysphoria.
Summary
The review o f the literature on the etiology o f transsexualism demonstrates the
advances in the theories on severe gender dysphoria. It also portrays the profound
R e p r o d u c e d w ith p e r m issio n o f th e co p y r ig h t o w n e r. F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

21
controversy among the investigators who see the transsexual's condition as rooted in
conflict and those who understand this phenomenon as the outcome o f a non-conflictual
learning process embedded in a blissful relationship. The conflict-free theory assumes
that female gender identity is stable in the male to female transsexual, the conflict defense
theory postulates the development o f ambiguous or confused gender identity. According
to the conflict-defense theories sex reassignment can be regarded as an attempt to resolve
gender ambiguity. Many authors agree that separation anxiety and fusion fantasy are
central psychological problems in the development o f transsexualism and transvestism.
Person and Ovesey (1974a, 1974b) see the gender and sexual distortions in both
condition as ways o f handling separation anxiety on different levels o f maturation.
Lothstein (1979), who delineates gender development in the framework o f se lf
development, emphasizes the importance o f cross-gender identification for the child's
emotional survival. The so called "synthetic female identity" appears to be the a desperate
attempt to escape the damaging emptiness and establish a tenuous continuity and
integration. Lothstein points out that "Many therapists who tried to change the gender
identifications o f the transsexual patient back to the original biological sex ... failed to
realize that there might be nothing to go back to" (Lothstein. 1979, p. 230).
Most o f the theories on transsexualism are based on observations and clinical
findings. There is a lack o f systematic research to help clarify some o f the conflicting
ideas on the phenomenon. As mentioned in the introduction, the transsexual's experience

22
o f "occupying" the wrong body and alienation from his/her biological gender is
comparable to reports o f patients with symptoms o f depersonalization. In the next chapter
some ideas and clinical observations will be reported which suggest the presence o f
depersonalization and general dissociative experiences in male to female transsexual
individuals.
Dissociation and Transsexualism
Transsexuals feel entrapped in their bodies and experience their biological sex as
a cruel mistake o f nature. Some loathe their genitals, others perceive their male organs
with indifference, and their main concern is to possess female genitals. The transsexual's
desire to convert his/her biological sex can become a "sole preoccupation" in his/her life.
In som e cases the urge leads to se lf mutilation and self-castration. Self-mutilation is
described as a way to convince the surgeons o f the sincerity of their quest and as a way to
obtain sex reassignment surgery. Some investigators report that 3 to 18 percent distraught
transsexual individuals who had engaged in genital mutilation (Pauly. 1965. Pauly 1968;
Hoopes. Knorr & Wolf, 1968). Although the self-mutilative act seems impulsive, there is
evidence o f premeditation. This leads to the idea that se lf mutilation must have been
preceded "by a long history o f repudiation and dissociation o f the genital organs from the
body image" (Arndt. 1991. p. 126). Guze (1968) indicates that the penis o f the male to
female transsexual becomes "reified and is assumed to be almost a separate entity"
(p. 172). The author (1968) assumes that depersonalization processes seem to be in action.

23
The notion o f dissociative mechanisms is indicated in Money and Pimrose's study (1969)
with 14 male to female transsexuals. The authors indicate, 'a dissociative quality to the
male transsexual's disengagement o f genitopelvic erotic functioning and his engagement
o f feminine imagery-content, while having sexual relations' (p. 125). In their visual
fantasy the transsexuals disregarded their male organs and replaced them with female
genitals. Money and Pimrose (1969) noted that the strong dissociative mechanisms may
be basic for the understanding o f the phenomenon o f transsexualism. Later Money (1986)
indicated that child abuse and dissociation could be o f etiological importance in
transsexualism. In a single case study Schwartz (1988) linked multiple personality and
transsexualism to extensive child abuse experiences. Holly Devor (1994) in an initial
discussion on "transsexualism, dissociation and child abuse", speculated that "in some
cases, transsexualism maybe an adaptive extreme dissociative survival symptom to severe
child abuse" (Devor, 1994. p. 49).
The transsexual's experience o f his/her biological gender, the reports o f se lf
mutilation, the dissociative quality o f the his/her fantasy life and the general idea o f
gender ambiguity or confusion raises the question on the prevalence o f depersonalization
and dissociative experiences in transsexual individuals.
The Following chapters will review theories and research on depersonalization
and dissociation. The emphasis o f the theoretical review will be on psychodynamic
theories on depersonalization and dissociation.
24
Depersonalization
The depersonalization phenomenon has been explored from various theoretical
perspectives and it has been postulated that depersonalization occurs on different levels o f
functioning. Transient depersonalization experiences can occur in normal individuals
facing new situations. Severe and long lasting depersonalization experiences have been
observed in different psychopathological states. The following review w ill focus on
psychodynamic conceptualization on the phenomenon o f depersonalization.
Definition
Freud (1936) delineated depersonalization as an individual's feeling "that a piece
o f his own self is strange to him". As opposed to depersonalization in derealization this
sensation o f strangeness is linked to outer reality. The positive counterparts to
depersonalization and derealization are according to Freud '"fausse reconnaissance', 'deja
vu', 'deja raconte'. etc.. illusions in which w e seek to accept something as belonging to
our ego (Freud.1936. p. 245). A similar definition is proposed by Stamm (1962) who
subsumes under the term o f depersonalization "all those states in which the individual
becomes aware o f changes in himself, bodily or mental or both, that lead to feelings o f
strangeness in himself. In such cases there is an alteration in the ego with a split into a
part which feels estranged and one which carries on the observer's role" (p. 762).
Subjective Experience
Depersonalization is reported as a feeling o f detachment from one own's body,
R e p r o d u c e d with p e r m issio n o f th e co p y rig h t o w n e r . F urth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .
thoughts, feelings and actions. (Simeon and Hollander. 199? i. Arlow (1966) describes a
patient who reports o f the sensation o f having two selves. One part o f the two selves is
experienced as objective and detached, observing the other pan in action. The sensation
o f change and strangeness is at times associated with parts o f the s e lf at other times with
the whole s e lf (Stamm. 1962).
In depersonalized states the awareness o f the s e lf or the body as a whole or parts
o f the body is intensified. Bizarre bodily changes with numbness or deadness in different
parts or in the whole body are reported (Stamm. 1962). These experiences commonly
generate unpleasant feelings o f unrealness and at times lead to anxiety.
Winnicott (1971) discusses a patient who reports that as a child, while playing
with other children, she often watched herself playing as if watching someone else. She
lived in her daydreams which remained isolated from reality. When her attention was on
her fantasies she described herself as dissociated with as if she was not be in her own skin
(Winnicott, 1971).
Psvchodvnamic Interpretation
Nunberg (1924) links depersonalization to the trauma o f a sudden loss o f a love
object. Libido is withdrawn from the external world and shifted to the ego. Fedem (1928)
agrees with Nunberg (1924) in regard to the occurrence o f trauma. A s opposed to
Nunberg (1924) he points out that the cathexes o f the ego is not heightened but rather
R e p r o d u c e d w ith p e r m issio n o f th e co p y r ig h t o w n er . F urth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

26
diminished. This leads to a loss o f ego boundaries.
Arlow (1966) conceives depersonalization and dereaiization in the context o f
regression o f ego functioning. Stamm (1962) relates depersonalization to regression to a
primitive oral state o f consciousness, a regression to "an eariy. undifferentiated ego state"
underlying both daydreaming and depersonalization (Stamm. 1962).
Depersonalization has been described as an affective state defensively used by the
ego against painful conflictual impulses or affects. These affects and impulses are
themselves the result o f intrasystemic or intersystemic conflicts. Arlow (1966) and
Jacobson (1959) emphasize the intrasystemic conflict within the ego. Feelings o f
depersonalization emerge when one identity is disavowed and unacceptable to the other
(Jacobson. 1959). Arlow (1966) accentuates that depersonalization is the result o f
conflicted poorly integrated partial identifications. Depersonalization may occasionally
emerge when the ego is unable to master internal or external dangers. In the case o f
external dangers, as in the case o f trauma, instant depersonalization becomes adaptive.
Internal dangers can lead to the disturbance o f the sense o f reality. Internal dangers are
denied in fantasy and displaced into the external world. Consequently the perception o f
the external world is colored by the representatives o f internal dangers and consequently
repudiated (Arlow, 1966). The depersonalized feeling tone placates the anxiety ridden
ego. and the danger is sensed as unreal. Arlow's distinction o f internal and external
dangers seems to be too definite. The distinction becomes unclear in the case o f severely
27
traumatized individuals whose initial adaptive reaction becomes maladaptive and whose
sense o f reality becomes disturbed in the way which Arlow relates to internal dangers.
Frances. Sacks & Aronoff. (1977) point out the close theoretical and clinical
relationship between the affect o f depersonalization and the concept o f self. In agreement
with other investigators they postulate that individuals are subject to depersonalization on
different levels o f functioning. They suggest "two complementary models o f
depersonalization: one as a defense o f the ego against painful stimuli arising from within
the self: the other, as a signal affect denoting the disruption o f self-constancy" (Frances.
Sacks & Aronoff. 1977. p. 325). The first model is mainly applicable to individuals,
functioning on a neurotic level, the latter is more prominent in individuals functioning on
a psychotic or borderline level. The individual is susceptible to depersonalization when
the ego is limited in the capacity to form a stable relationship with a well-balanced and
integrated self. Depending on the developmental level, and the formation o f self,
object-constancy. or se lf object differentiation, specific vulnerabilities can be detected.
Schizophrenics, borderline, narcissistic and neurotics display different susceptibilities to
the affect o f depersonalization. The emergence and awareness o f split o ff self-fragments
may lead in borderline patients to depersonalization and in narcissistic patients a break in
the self-object relationship may evoke the affect o f depersonalization.
Depersonalization ranges from transient experiences to abnormal, recurrent and
prolonged states and may be found in different degrees o f intensity and duration in certain

28
ego states that are in the normal range as well as in psychotic conditions.
Depersonalization and Sense o f Reality
Shapiro (1975) regards depersonalization and unusual uses o f daydreaming as
manifestations o f disturbances which occur in relation to reality and regards the
relationship between daydreaming and depersonalization in the context o f the
development o f the sense o f reality (p. 10). According to Shapiro (1978) reality sense
develops during the stage o f primary narcissism which he compares with Winnicott's
"stage o f illusion". In this phase everything pleasurable is regarded as real, alive and
vivid.
In depersonalization the sense o f reality is disturbed. The world is not experienced
as animated and vivid, but as grey and lifeless. Although the actual ability to test reality is
intact, the sense o f reality is marred by feelings o f strangeness and unrealness. In
daydreaming on the other hand the knowledge o f reality is temporarily relinquished, but
the sense o f reality is enhanced. The use o f daydreams though is not always enhancing
the sense o f reality (Shapiro, 1975). Unusual fantasies can be used in a manner similar to
depersonalization to dissociate from reality. This process is according to Shapiro
prominent in Winnicott's patient who experienced reality only in a dissociated fantasy
life. The ability for normal daydreaming is disrupted when reality and fantasy are
insufficiently differentiated. This may occur when the sensation for reality is not attached
to both fantasy and reality. Winnicott (1971) links the creative use o f fantasy to a

29
successful "disillusion". The ability to have an enriching fantasy life is based on the
development o f reality testing and the successful differentiation o f fantasy and objective
reality. Shapiro (1975) points out that even when fantasy and objective reality are
accurately differentiated, the sense o f reality connected to reality- and/or fantasy may be
disturbed. As mentioned above dissociation encompasses experiences o f
depersonalization. The following chapter w ill examine perspectives on the concept o f
dissociation.
Dissociation
Dissociation is generally regarded as existing along a continuum, encompassing
transient experiences in ordinary Iife-events to profound experiences in minor and major
psychopathology. The concept o f dissociation was introduced by Pierre Janet (1889) and
extended by Morton Prince (1909).
Janet (1889) regarded dissociation as related to the lack o f binding energy caused
by life stresses, trauma, hereditary' factors, innate factors or an interaction among them.
According to Janet.(1889) lack o f energy leads to deficient psychical synthesis
(integration) and to the splitting o f the consciousness. Experiences become split o ff but
continue to have a mental existence as fixed ideas or alter identities not integrated in long
term memory or the person's identity.
Freud pointed out "that the splitting o f the contents o f consciousness is the
consequence o f voluntary act on the part o f the patient: that is to say it is instituted by an
30
effort o f will, the motive o f which is discemable" (Freud, 1894/1963. p.69). Janet viewed
Freud's conceptualizations as legitimate ideas which could coexist with his theory
(Erderlyi. 1994). As opposed to Freud who emphasized that the mental processes are
active in hysteric phenomena. Janet regarded the mental processes as passive (Gabbard,
1994).
Newer conceptualizations accentuate the disruption o f integrative functions in
pathological dissociation (Nemiah. 1980; West. 1967). West (1967) has defined
dissociation as a "state o f experience or behavior where dissociation produces a
discemable alteration in the person's thoughts, feelings and actions, so that for a period o f
time certain information is not associated or integrated with other information as it
normally would be" (West, 1967, p. 890). According to Nemiah (1980) pathological
dissociation involves a substantial alteration is the sense o f identity and Bernstein and
Putnam (1986) underlined the disturbance in the individual's sense o f s e lf as one o f the
main two characteristics o f all dissociative disorder.
The lack o f integration in pathological dissociation is also emphasized by Spiegel
& Cardena (1991), who conclude that dissociation “can be thought o f as a structured
separation o f mental processes (e.g thoughts, emotions, conation, memory, and identity)
that are ordinarily integrated" (p. 367). Two or more mental contents are divided to an
extent that the individual is unable to link different contents and eventually alternates
between contradictory experiences.
31
Some authors underline the positive functions o f dissociation. Dissociation is a
capacity which enables the individual to screen out stimuli or irrelevant information and
protects the ego from overstimulation, enhancing the ego's capacity for integration.
(Kihlstrom & Hoyt. 1990; Young, 1988). In pathological forms though, dissociation
becom es a disabling defense which disrupts integrative functions o f the ego. The
continuity o f experience, memory and identity is an achievement, a continuous
construction built on dissociation and association (Spiegel & Cardena. 1991).
Dissociation is a defensive process which has similarities as well as differences
from defenses such as repression, splitting and denial (Tilman. Nash &Lemer, 1994).
Gabbard (in Young, 1988) clarifies the distinction between dissociation and repression
underlining the actuality o f parallel consciousness in dissociation. According to Gabbard
(in Young 1988) repression defends against forbidden internal wishes whereas
dissociation defends against external traumatic experiences. Singer and Sincoff (1990)
point out that in repression the ideas are pushed in the unconscious whereas, in the
process o f dissociation the link between different ideas is broken down. According to
Lemer (in Gabbard 1994) the two concepts, dissociation and splitting, have similarities
and differences. In both phenomena mental contents are compartmentalized and
separated. Both phenomena are used to defend against unpleasant affects and experiences
and can cause a discontinuity in the sense o f self. Gabbard (1994) regards the difference
between splitting and dissociation to the extent in which ego functions are disrupted.

Based on Kemberg's (1975) conceptualizations on splitting. Gabbard (1994) postulates
that in splitting, impulse control and the ability to tolerate anxiety and frustration are
impaired. In dissociation, on the other hand, memory and consciousness are affected
(Gabbard. 1994).
Some authors emphasize that in dissociative processes the self is separated from
its’ own experience. Parts o f the self are expelled to a 'not me' domain. This mechanism is
regarded as a defense against unbearable experiences which impinge upon consciousness
but are not integrated in the sense o f self (Spiegel & Cardena. 1991). This
conceptualization o f dissociation is similar to Frances. Sacks and Aronoffrs thoughts on
depersonalization "as a signal affect denoting the disruption o f self-constancy" (Frances.
Sacks, Aronoff, 1977, p. 325).
The main difference between dissociation and splitting appears to be related to the
fact that dissociation is a broader concept. In contrast to the concept o f splitting where
only maladaptive mechanisms are emphasized, dissociation encompasses adaptive
processes which are necessary for normal functioning, as well as mechanisms which lead
to incapacitating disintegration. Tilman, Nash and Lemer (1994) emphasize that in
contrast to splitting where object and self representations are polarized into "good" and
"bad", in dissociation a variety o f segment are divided which can't be categorized as good
or bad.
Investigators have attempted to distinguish normal from pathological forms o f

dissociation. Based on the idea that dissociation occurs along a continuum. Bernstein and
Putnam (1986) developed a scale in order to quantify dissociahve experiences and to
have a valid and reliable instrument which allows the screening o f individual with major
dissociative symptomatology.
The Assessment o f Dissociation
The Dissociative Experiences Scale (DES) is a se lf administered questionnaire
and currently the most widely used and extensively researched screening instrument. The
DES permits to examine the frequency o f experiences such as absorption, imaginative
involvement, gaps in awareness, amnestic experiences, depersonalization and
derealization. The DES has 28 items, with scores ranging from 0 to 100. The score o f 0
indicates that the participant never has the experience represented in the item and the
score of 100 indicates that the participant always has the experience described in the item.
The total DES score is the average o f all 28 item scores. Test-retest reliability for the
DES ranges from .84 to .96 (Bernstein & Putnam. 1986: Frischholz, Sachs. Brown &
Hopkins, 1990). Split-half reliability ranges from .83 to .93 (Bernstein & Putnam 1986;
Pitblado & Sanders. 1991). High test-retest and internal reliability have been found for
clinical and nonclinical population and a Cronbach's Alpha o f .95 has been reported
(Frischholz et al.. 1990).
Construct validity o f the DES has been established and replicated in several
studies (Bernstein & Putnam. 1986; Carlson. Putnam & Ross. 1993).

34
Dissociative Experiences and the Generai Population
Bernstein and Putnam (1986) found a Median DES score o f 11 for 34 normal
adults. In a larger sample with 573 adults from a non clinical population Carlson. Putnam
& Ross. (1993) found a mean DES score 8.6 with SD-10.0. Ross. Joshi and Currie (1990)
examined the frequency o f dissociative experiences with a stratified cluster sample o f
1.055 men and women over 18 years old. The median score o f the entire sample was 7
and the mean was 10.8. There was no significant correlation between overall DES score
and sex. nor a significant correlation between DES score and any o f the demographic
variables. In both sexes the DES scores declined significantly with age.
Dissociative Continuum
Bernstein and Putnam (1986) investigated the number and frequency o f
dissociative experiences in different populations and discerned a steady progression in the
DES scores, with the lowest scores in the normal group, and the highest in the group o f
individuals with the diagnosis o f multiple personality disorder. Table 1 show s the number
and Median Score o f items endorsed among different populations in Bernstein and
Putnam's (1986) study.
35
Table 1
DES scores: original data
Group Median No. Median DES Score
Normal Subjects 11 11
Phobic anxiety 11 18
Agoraphobics 13 23
Adolescents 18 24
Schizophrenics 18 30
Posttraumatic stress 22 39
disorder
Multiple personality 28 58
Prevalence o f Dissociative Disorders
In comparison to non-clinical subjects, psychiatric patients, endorse more DES
items and they endorse them at a higher rate. These results had been found in the initial
study of Bernstein and Putnam (1986) and have been replicated and confirmed by newer
studies with increasing reports on the high frequency o f dissociative disorders among
36
psychiatric patients. Saxe, van der Kolk. Berkowitz. Chinman. et al. (1993), found in a
study with 110 psychiatric patients that 15% o f the patients scored above 25 on the
Dissociative Experiences Scale and 100% o f this group met the DSM-III criteria for
dissociative disorders.
Chu and D ill (1990) found that 24 % o f 103 psychiatric inpatients displayed
median DES scores, which were at the level o f or higher then the median scores o f
patients with posttraumatic stress disorder. The investigators indicate that in the past,
dissociative disorders might have been underdiagnosed among psychiatric patients.
Dissociative symptoms could have been confounded with psychotic symptoms. Scores
over 30 are according to Ross. Anderson. Fleischer & Norton (1991) always indicative of
a DSM-III diagnosis o f MPD. In this study, in addition to the DES, which is a screening
instrument a diagnostic instrument was employed.
In a large multicenter study with 1051 participants the concurrent validity o f the
DES was assessed (Carlson, et al., 1993). The goal was to evaluate the DES' capacity to
predict multiple personality disorder among general psychiatric patients. A cutoff score of
30 yielded a sensitivity rate o f 76% and a specificity rate o f 85% (Carlson, et al., 1993).
Most patients who had scores higher then 30 on the DES and were not classified as MPD.
had a diagnosis o f dissociative disorder other than multiple personality disorder (43%). or
posttraumatic stress disorder (42%).
According to Steinberg, Rounsaville. Cicchetti. (1991). who evaluated the utility
37
o f the DES in detecting patients with dissociative disorders. "DES cutoff score o f 15-20
yields good to excellent sensitivity and specificity as a screening instrument" (p. 1050).
The researchers point out that the false negative diagnosis for dissociative disorders rises
when a cutoff greater then 20 is used on the DES. This study was critiqued by Carlson et.
al. (1993) for the relatively low number o f subjects (N-36).
There is a general agreement among investigators that the DES is a good
screening test for high levels o f dissociation and should not be considered as a diagnostic
instrument.
Dissociation and Trauma
Janet. Prince and Freud in his early theoretical work (in Erderlyi. 1994), regarded
the occurrence o f actual traumatic events as essential in the development o f dissociative
symptoms. More recent research indicates a close connection between traumatic events
and dissociative symptoms.
Despite methodological problems related to the retrospective nature o f the
research based on self report there is an agreement among researchers that there is strong
evidence suggesting that dissociative phenomenology is connected to traumatic events.
Although the occurrence o f abuse is prevalent in various psychiatric disorders,
dissociative symptomatology is reported as a distinctive and frequent outcome o f early
abuse. Investigators have indicated histories o f abuse in 57% to 75% o f the general
psychiatric population and in 72% to 98% o f patients with dissociative symptomatology

38
(Steinberg, Rounsaville. Cicchetti, 1991).
Chu and Dill (1990), who employed the DES with 98 female psychiatric patients
found higher levels o f dissociative experiences as measured by the DES among patients
with a history o f physical and sexual abuse.
According to Coon, Bowman, Pellow & Schneider (1989) study on the prevalence
o f abuse in various clinical populations. 100% with the diagnosis o f atypical dissociative
disorder and 82% with the diagnosis o f psychogenic amnesia reported childhood abuse
and neglect. Saxe. Van der kolk. Berkowitz, et al. (1993) indicate that in a group o f
patients with high scores on the Dissociative Experiences Scale, reported higher incidents
o f childhood trauma and disruptions in parental care.
Questionnaire o f Experiences o f Dissociation
Based on the idea that dissociation is occurs along a continuum, an alternative
scale to the DES was developed and tested on the general population. The Questionnaire
o f Experiences o f Dissociation (QED) has 26 true/false items. The items are rooted in the
clinical literature on "classical hysterics, on dissociative and multiple personality
disorders, and dissociative experiences elicited by temporal lobe epilepsy. The scale was
used with a large group o f normal subjects and has a reliability' o f .77. Normals
demonstrated a mean o f 9.92 and a standard deviation o f 4.28.. a group o f patients with
somatization disorder ("Briquet hysterics") had a mean o f 13.9 and a small group o f
multiple personality patients (N-3) an average score o f 24.6 was reported. The score has

39
not been further validated on clinical population. The QED is suggested as a
complementary test to the DES. since the item contents do not overlap with the DES. and
the true and false response form is different from the DES' frequency gradient
responding.
The following chapter will integrate ideas on the etiology o f transsexualism and
theories o f depersonalization and dissociation which lead to the hypotheses o f the present
study.
The Present Study
The present study is focused on m ale to female transsexuals. Transsexuals often
describe the feeling o f being entrapped in their bodies, which they often experience as not
belonging to themselves. Male to female transsexuals reject their anatomical gender, and
despise the insignia o f their masculinity. "The self-loathing is focused on the male
insignia, thereby preserving a modicum o f s e lf esteem for the fantasized other self, that is
the 'female' self' (Person & Ovesev, p. 16). Clinical studies report that transsexuals feel
estranged, anxious and depressed. Transsexuals report o f having been lonely as children,
alienated and immersed in their own thoughts. They report that as children they attempted
to engage in boy's activities but with a "sense o f distaste" (Person & Ovesey, 1974a, p.
12), feeling estranged and detached from their actions. After adopting a woman's role the
transsexuals experience considerable relief and ease and report dramatic changes in their
well-being.
40
In regard to their sexuality, it is indicated that transsexuals have little or no sexual
interest (Person & Ovesey, 1974a, p. 15). Masturbation is performed with either no
fantasy at all. or with vague homosexual fantasies. Money and Pimrose (1968) detect a
"dissociative quality to the male transsexual's disengagement o f genitopelvic functioning
and his engagement o f feminine imagery-content, while having sexual relations" (p. 125).
The transsexual's conviction o f being a woman entrapped in a male body is not
based on a lack o f reality testing. The transsexual is aware o f his physical endowment,
but regards it as a cruel mistake o f nature. The descriptions seem based on a disturbance
in the sense o f reality then in reality testing. A s indicated in the literature review,
depersonalization is a disturbance in the sense o f reality. The subjective experience o f
depersonalization is described as a feeling o f detachment, or as a sensation that a part or
the whole s e lf has changed or does not belong to the person (Stamm. 1962). These
descriptions are analogous to the transsexual's sense o f alienation from their male
characteristics.
As noted above, depersonalization, derealization and identity confusion are
dissociative symptoms. The notion o f the transsexual's gender ambiguity (Person &
Ovesey, 1974a), the report on their dissociative fantasies. (Money & Pimrose. 1969) and
the transsexuals' account o f experiences o f alienation vis-a-vis their biological gender,
raise the question o f the prevalence o f dissociative symptomatology in transsexuals.
Dissociative symptomatology has been reported as a distinctive and frequent outcome o f

41
early abuse raising the question o f traumatic experiences in MF transsexuals.
This writer assumes that the transsexual might attempt to allay identity confusion
and painful feelings o f deadness evoked through depersonalization, by establishing a
"synthetic" female identity. Early failures in the mother infant relationship might have led
to a disturbance in the sense o f reality which are defended against with the fantasy o f
belonging to the female gender. These fantasies might have been perpetuated and
sustained by the fantasies o f the caregivers and are imbued with a greater reality sense
then the actual reality. The transsexual individual might attempt to defend against severe
dissociative experiences by adopting the female gender role. This endeavor might not
resolve but ameliorate the dissociative symptomatology. The research questions which
ensue from this summary are as follows:
Main Hypotheses
(1) MF-transsexual females w ill display higher frequency o f dissociative experiences
in comparison with non-clinical populations o f men and women.
(2) The frequency o f MF-transsexual female's dissociative experiences will be
equivalent to that o f individuals with dissociative disorders (as determined in other
studies).
Additional questions to be explored:
(3) Dissociative Experiences decrease when MF-transsexual females begin to live as
females.
R e p r o d u c e d w ith p e r m is s io n o f th e c o p y r ig h t o w n e r . F u rth er r ep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

42
(4) MF-transsexual participants who had early experiences ot' trauma dissociative
experiences in comparison to the transsexual participants who do not report
traumatic experiences.
METHOD
The primary group o f interest in this study were m ale to female transsexuals. A
total o f thirty-one self-defined male to female transsexuals participated in the study. From
the thirty-one transsexuals in the study group twenty seven fulfilled the requirement for
participation. Two participants who described themselves as transvestites and one who
reported being bom a hermaphrodite were not included in the study group. The remaining
twenty seven were biological males who had the sense and or conviction that they were
bom with the wrong sex and belong to the female gender. Participants had a history o f
cross gender wishes and all but one participant had the desire to engage in sex
transformation procedure (hormonal and/or surgical) or were in the process o f hormonal
therapy. The majority o f the participants had not yet undergone any irreversible surgical
procedures. The group o f participants ranged from individuals who were still living in the
male role to those who have been living as females over ten years. All participants were
required to be in individual psychotherapy and/or in a support group.
The study groups age ranged was between 21 and 65. Transsexual participants
were recruited through psychotherapists and counselors who are known to work with
gender dysphoric individuals, flyers posted at clinics who specialized in gender dysphoria
43
issues through flyers posted in gender identity clinics, bulletin boards and magazines
which focused on gender issues.
The control group consisted o f 27 males and 27 females (non-clinical population).
The control group consisted o f individuals interested in participating in a study on gender
identity. The participants o f the control group were recruited through information flyers
in a variety o f Bay Area public places (eg. libraries, coffee shops). This group was
matched to the study group in respect to age and education.
Dissociative experiences were evaluated with the Dissociative Experiences Scale
(DES) (Bernstein & Putnam, 1986) and the Questionnaire for Experiences o f Dissociation
(QED) (Riley, 1988). Both questionnaires were completed by participants o f the study
group o f MF-transsexual women and the participants o f the control group.
The DES scale is a 28-item visual analogue self-report measure that evaluates
dissociative experiences. Dissociation is defined as the lack o f integration o f thoughts,
feelings and experiences into the stream o f consciousness (Carlson, 1993). The DES
score is an index for the overall number and frequency o f the different types o f
dissociative experiences. The items explore the frequency o f experiences such as
amnestic experiences, gaps in awareness, depersonalization, derealization, absorption,
and imaginative involvement. Experiences which happen under the influence o f alcohol
or drugs are not included.
The QED is a standardized se lf report scale with 26. true and false items. The

44
QED items do not overlap with the DES items.
In addition to the DES and QED. the MF-transsexual women com pleted a
questionnaire (Personal History Questionnaire), which explored personal data, family
history, current and past relationships, sexual and cross gender history, and memories o f
physical and sexual abuse. This questionnaire is designed by the writer in adaptation to
the “Social. Sexual. Economic & Psychological Adjustment Questionnaire” from the
Gender dysphoria clinic in Stanford (Dixen, Maadever. Van Maasdam & Edwards. 1984).
This questionnaire incorporates som e questions from the “Life Experiences
Questionnaire" (Bryer, Nelson. Miller & Krol. 1987) and the “Physical Maltreatment
Scale" (Briere & Runtz. 1988).
The following statistical hypothesis were tested in the quantitative data analysis.
1. The mean DES score o f the MF-transsexual participants will be significantly higher the
mean DES score o f the control group o f nonclinical population o f males and females.
2. The MF-female transsexuals' mean QED scores will be significantly higher then the
mean QED score o f the control group.
3. The mean DES score o f the MF-transsexual females will not significantly differ from
the mean DES score o f patients with dissociative disorders: Mean: 37.15+18.24. (The
mean DES score was established by Steinberg. Rounsaville & Ciccetti. (1991).
4. The mean DES score o f the participants who report traumatic childhood experiences
will be significantly higher then the DES score o f the participants who do not report

45
traumatic experiences.
5. The mean DES score o f the MF-transsexuals who begin to iive as females will be
significantly lower then the one who switch gender roles.
Methods o f data Analysis
Scores for each item o f the DES are "determined by measuring the subject's slash
mark to the nearest 5mm from the left hand anchor point o f the 100-mm line. The score
for the entire scale is an average o f the 28 item scores and will be referred to as the DES
score. A cutoff score o f 15 and 20 will be employed find the percentage o f individuals
who show dissociative experiences in the range o f individuals with dissociative disorders.
The statistical data analysis will be presented in the following chapter. In addition
to the quantitative analysis, data on background information about the transsexual
participants including demographic data, current and past relationships, family history,
cross gender history, idiosyncratic meaning about femininity and masculinity were
qualitatively analyzed and presented in form o f descriptive statistics. In case the DES
score o f the MF-transsexual participants is normally distributed parametric statistics will
be employed.
RESULTS
All except one male to female participant reported having the sensation and/or
conviction o f being a women in a male body. The participant who gave a negative
response to this question was included in the study since she reported a sensation and

46
conviction o f being female, and had been living e x c lu s iv e ly as a female since two years
and is undergoing hormonal therapy.
The age o f the MF transsexual participants ranged from 21 to 66 (see table 2).
A total o f 26% had a high school or lower degree, 37% had some college education. 15%
had a college degree and 22% had begun accomplished graduate studies (see table 3).
The control group consisted o f 27 men and 27 wom en who were matched by age
and education to the study group o f 27 MF-transsexuals.
Table 2
Age range
MF transsexuals Ctrl Female Ctrl Male
N N N
Age range
20-29 6 6 6
30-39 6 6 6
40-49 10 10 10
50-59 4 4 4
60-65 1 1 1
47
Table 3
Education
MF transsexuals Ctrl Female Ctrl Male
N N N
Education
HS or less 6% 26% 26%
Some coll. 37% 37% 37%
College 15% 15% 15%
Grad. Stud 22% 22% 22%
1. The mean DES scores o f the different groups is shown in Table 4. Multiple comparison
test for unequal variances was performed to compare the group o f MF transsexuals with
the control groups with mean DES scores as dependent variable. The homogeneity o f
variance was tested with the Levee test. A statistically significant difference was
identified comparing the mean DES score o f the group o f MF-transsexuals with the
whole control group, consisting o f 27 males and 27 females (T=2.5; P= 0.02). A
statistically significant difference was found comparing the mean DES scores o f the

48
group o f MF-transsexuals with both the control group o f females (T= 2.7: p=.01) and
with the control group o f males (T= 2.0: p= 05).
Table 4
Mean DES-scores
N Mean-DES
MF transsexuals 27 15
Control group 54 8
2. O f the 27 MF-transsexual participants. 25 completed the Q.E.D. All the participants o f
the control group (N=54) completed the Q.E.D.. Multiple comparison test for equal
variances was used to compare the mean Q.E.D. score o f the MF transsexuals with the
mean Q.E.D. scores o f the control groups. The homogeneity o f variance was tested with
the Levee test. A statistically significant difference was identified comparing the mean
Q.E.D. score o f the MF-transsexuals with the Mean Q.E.D. score o f the whole control
group consisting o f 27 males and 27 females (T=2.5; P=.01).
3. It was hypothesized that the mean DES score o f the MF-transsexuals will not differ
significantly from the mean DES score o f individuals with dissociative disorder. This

49
hypotheses was not confirmed. A contingency analysis was performed to identify the
proportion o f transsexuals scoring at and above 15 on the DES. Forty one percent o f the
transsexual participants compared to 17% o f the control group scored at or above the
cutoff score o f 15. This difference was statistically significant ip=.02). Twenty two
percent o f the transsexual participants scored above 20 on the DES. The cutoff score o f
15-20 has been established by Sternberg, Rounsaville & Ciccnetti, (1991)
4. O f the 27 participants. 17 reported having experienced abuse including physical and/or
sexual abuse. Ten participants did not report any abuse. The prevalence o f abuse was
based on affirmative responses to question 5.12 and 5.13 o f the Personal History
Questionnaire. (Appendix C). In addition to these data, responses to questions such as
first sexual experience were examined. Participants who reported childhood sexual
experiences with an adult were included in the category o f participants with abuse
history. The mean DES scores o f the two groups o f transsexuals (abused and not abused)
were compared with a t-test for independent samples and unequal variances (see table 5).
The transsexual participants who reported abuse had a significantly higher mean DES
score in comparison to transsexual participants who did not report childhood abuse.

50
Table 5
Mean DES scores o f abused vs. not abused transsexual participants
MF- TS participants
History o f
Abuse N DES SD T
(mean)
17 18.81 14.603
2.65*
no 10 8.44 5.263
*p < .01
5. The mean DES score o f the group o f transsexual participants who were switching
gender roles was compared with the mean DES score o f the group o f transsexuals w-ho
were exclusively living as females with a t-test for independent samples, (see table 6)
There was no statistically significant difference in the mean DES scores o f the tw o group
o f transsexuals.
51
Table 6
Gender transition
MF transsexual participants
N Mean
Gender role
switching roles 9 14.4
exclusively female 18 15.2
Following this analysis the groups were divided into four groups. The first group
consisted o f transsexuals who reported switching gender roles but they were still living
exclusively in the male role. The second group reported switching gender roles but they
had started to live "mostly" in the female role, the third group lived "exclusively" in the
female role, less then one year and the fourth group lived exclusively in the female role,
more then one year. One-way analysis o f variance on ranks followed by Tukey-B test,
showed that the mean DES score o f the second and third group were statistically
significant (p=.05). The mean DES score o f the group o f transsexuals who have been

living more then one year in the female role was statistically higher then the mean DES
score o f the group o f transsexuals who had begun to live in the female role. Although
there were no other statistically significant differences in the mean D E S scores o f
transsexuals in different stages o f their transition, there is an obvious trend in the data.
The mean DES score o f transsexuals who still lived mostly as males is twenty two. The
mean DES score decreases drastically (mean DES= 4) in transsexuals who started to live
as females but still switch gender roles. The mean DES scores seem to increase in
transsexuals who are farther in their transition who had been living exclusively as
females, (see table 7)
53
Table 7
Mean DES score and phases o f gender transition
MF transsexuals
N Mean DES
Gender roles
1) switching mostly male 5 22
2) switching mostly female 4 4
3) exclusively female 5 15
< then one year
4) exclusively female 13 15
> then one vear
Qualitative Results
From the twenty-seven Male to Female transsexuals who participated in the study
twenty-two were Caucasians, one African American, one Asian American, one Puerto
Rican, and one Biracial. One participant did not report her ethnicity.
Ten transsexual participants reported being currently in a relationship. O f the ten.
50% had a relationship with a man and 50% with a relationship with a woman. Sixteen
participants were currently not in a relationship and one person did not respond to this

question. Seventeen participants reported they had been married or are still married and
twelve indicated that they have children.
History o f gender dvsphoria
The majority o f the transsexual participants (70%) reported having had a wish to
"be a girl" in early childhood, before the age o f six. One participant did not agree with the
question which implied the "wish to be a girl" and corrected it to the "inclination to be a
girl". The participants reported they had the "conviction to be a girl" at a later age. O f the
24 participants 46% had the conviction in their adolescence or had as young adults (see
table 8).
55
Table: 8
Onset
MF transsexuals
N=24
Wish to be a girl Conviction to be girl
Age % %
0-6 70% 41%
7-12 8% 11%
12-20 19% 16%
20+ 4% 30%
One participant who reported having had the conviction at the age o f forty
reported:
I knew very early (at the age o f five) I wasn't comfortable as a boy. but it took
much longer (It wasn’t until I was 20 years old) to realize I would feel more
natural as a girl and still longer to act on it (I was 45 years old)".
One transsexual woman who began to live exclusively as a women in her early 40s
stated:
"I consider m yself to have two birthdays. One when I was bom and one when I
came out o f the closet, the latter is when I began to live. If I hadn't came out when
56
I did, I would be probably be dead by now."
Cross-dressing
Twenty-three participants reported their age at w hich they first cross dressed in
private. The majority began to cross-dress in their early childhood (six years and less).
Public cross-dressing began at a later age. A ll participants responded to this question. The
majority cross dressed in public as adolescents (49%) and young adults (37%) (see table:
9)
Table 9
Cross-dressing
MF-transsexuals
Private Cross-dressing Public Cross-dressing
N=23 N =27
Age % %
0-6 52% 11%
6-12 18% 3%
12-20 22% 49%
20+ 8% 37%
57
O f the 25 transsexuals who responded to the question. 'Describe your experience
when you first cross-dressed?". seventy six% emphasized a sense o f "completeness",
accompanied by a general sense o f well-being, comfort, peace and calmness.
"It felt overwhelmingly good and complete (#8)": "I felt natural, whole, complete
and had a general sense o f well being (#10) ;"I felt at ease, in touch with myself,
physical and mental well being (#15)". "...a feeling o f being whole and at ease
(# 20 )".
Several participant expressed an overwhelming feeling o f happiness and related it to the
harmony o f the physical with the mental experience. "I became so emotional, cried. I was
so happy that my inside matched my outside (#10)". Four participants mentioned erotic
feelings in addition to the general sense o f well-being with feeling natural and complete
(#11)". Only one participant emphasized exclusively erotic feelings as a result o f her first
experience dressing in female clothing; "it was exciting and felt erotic (#12)".
Sex Transformation Surgery
Nineteen participants had not had any transformation surgery, and eight o f the
participants have begun the surgery, including breast implants facial work and one person
bilateral orchidectomy. Twenty five participants reported that they planned having the
surgery and two denied planning to have sex reassignment surgery.
The majority o f the transsexual participants saw a sense o f "completion" and
"harmony" as the essential change which transformation surgery would bring in their

58
lives. O f the 24 participants who agreed that surgery will make a change in their lives, the
majority (60%) accentuated the sense o f completion and harmony between the "physical
and mental" leading to a "richer" and more satisfying life and general happiness.
Yes I want to align the mental and the physical (#3 i. ...remove o f being in a
physical half state (#22). SRS will correct my sense o f self, physically not
mentally (#13). I will have a greater feeling o f completeness, with mind and body
congruity (#5). My body will be more in harmony with my mind, ease my
emotional life, sensual life too. I will have a simpler life too. better intimacy and
social life in general (15).
One participant corrected the term SRS and suggested instead "Gender Confirmation
Surgery","... as it is only clarifying and bringing into congruity that which does not fit
the rest o f being." (#27). Two participants saw in the SRS a mean to get rid o f their
despised phallus.
I want the surgery so I can get rid o f the thing that I hated all my life (#9). This
ugly phallus will be reconstructed into a vagina, so I can live and function as I
desire (#13).
Six participants desired a more fulfilling relationship with a man. "To be heterosexual
instead o f homosexual" (#29).
"What does it mean to be a woman?"
The question about the meaning to be a woman invoked a variety o f responses. O f
59
the 27 transsexual participants twenty-two elaborated on this question, the remaining five
either did not respond or stated that they were not sure.
The majority o f the participants (n=8) stated in their response the perception that women
are endowed with the ability to give and/or receive em otions, warmth and comfort.
Women are described as "soft and vulnerable" (n=3). As a women one is "able to show
and share emotions and feelings and able to be cuddled, heid and comforted (#8)". To be
a women means "being tender emotionally, being matemai in my feelings for my
children...(#14)"; "caring, considerate, nurturing, soft vulnerable (#27)".
Three participants emphasized the personal meaning o f feeiing close and intimate with
other females, "it means that you feel connected to the in the most natural and instinctive
way, that you relate to women and feel as pan o f the femaie world (#15)". Four
participants' elaboration on the meaning o f being a woman focused on the sense o f
harmony and happiness "being close to me (#10)". "...to be happy in my own skin, to feel
good about what I am (#13). One transsexual commented on women's greater ability to
cope. Being a woman means to be "at ease and have a more refined ability to deal with
the world". Women are regarded by four participants as receiving admiration and
preferential treatment particularly by men. Four responses included the "beauty" and
"grace" of women.
Two respondents focused on the social construction o f femininity and one participant
criticized the stereotypical way o f perceiving women emphasizing women's "strength and

60
power".
"What does it mean to be a man?"
From the twenty seven transsexual participants, twenty three responded to this
question. Seven participants mentioned not knowing what it means to be a man.
explaining that they did not have the experience.
"I don't know; never did (#21)". "I honestly could not tell you, never was one.
guess not to be female (#15). "I don't know. I just know. I am not one. It almost
destroyed me trying to be one for everybody else, when I knew I was not a man.
(#14).
Three transsexuals highlighted their experiences living as males. "To be discordant and
unhappy, and always feeling awkward (#22). "...to be a man means to be half a person, an
image o f a person (#13)". Six responses focused on nuances o f aggression in their
concept o f manhood. To be a man means "Aggression, ego competition, leader, rough
and tumble (#3). "To be butch aggressive and strong (#29)". "It means to be aggressive
se lf centered and sloppy (#26). "To be butch and masculine in all actions (#23)". Five
participants described men in more positive terms in particular in their relationship to
women as "responsible caretakers, respecting women (#25)". One participant saw men as
subservient to women "To be a man means to a workhorse, and meaned labor to care for
women (#12)". Two participants emphasized the meaning as the comfort men feel in their
male role and one commented on the societal influence on the role o f men and women.
61
Difference between man and woman
In response to the question o f the main difference "between being a man and
woman" the majority o f the transsexuals (n=7) emphasized an emotional difference.
Women were regarded as being able to experience and express emotions. "The depth o f
emotions and feelings are stronger in women (#15)". "Internal make up. feelings.. (#15)".
Women "tend to have empathy and less need for ego struggles (#27)". They are
"vulnerable, vivacious, enthusiastic, sociable, expressive and caring (#28)". One
transsexual participant described her own experiences living as a man and as a woman:
"For me being a man was only going through the motions o f life. I performed this role for
several years, but as a woman I feel I can truly have a chance to experience life and feel
its' value to the fullest (#11)".
Sexual History
O f the 25 participants who responded to the question "In general how important a
part does sex play in your life?". 72% regarded sex as not important. 66% reported
involving their genitalia rarely or never in their sexual activities.
Psychiatric History
All participants were actively involved in psychotherapy and/or in a support
groups. Twenty three participants reported having individual psychotherapy. The
majority o f the participants saw the primary reasons for seeking therapy was their gender
transition, to find support and som eone to talk to or to relieve stress. Six participants also
62
reported depression manic depression and/or anxiety and panic attacks as their primary
reason to seek psychotherapy.
O f the 26 participants four reported having been hospitalized for depression,
suicidality and somatic pain. Eight o f the 27 participants reported suicide attempts, four
had multiple attempts. Three described "having been on the brink" o f attempting suicide
and sixteen participants had not attempted suicide. O f the twenty seven participants, nine
reported that they had attempted genital mutilation. One o f the nine participants had
removed his/her testicles. Another participant did not agree with the word mutilation and
replaced it with the word "correction".
The question about current medication was answered by 24 participants (see table 10).
Six participants conveyed they took psychotropic medication, mainly anti
depressants and/or anxiliotics. One person indicated taking Depakote for PTSD
symptoms. Twenty participants reported taking hormones. One o f the participants
explained the effect o f the hormone treatment, "they keep me emotionally stable, when I
run out o f my hormones, I have PMS like symptoms, irritability, and cry at anything
(28)".
63
Table 10
Psychiatric and treatment history
MF transsexuals
Yes NO
Hospitalization 4 22
(N=26)
Suicide attempts 8 19
(N=27)
Genital Mutilation 9 18
(N=27)
Individual Therapy 23 4
(N=27)
Psychotropic Medication 6 18
(N=24)
Hormones 20 4
(n=24)
From twenty five participants who responded to the question about drug and
64
alcohol use. 7 denied any use. 10 reported casual use o f m ainly alcohol and marijuana
five participants reported frequent use o f drugs and three w ere in recovery. One
participant reported having been drinking heavily up to the point when she started
hormone therapy.
Table 11
Alcohol and drug use
MF-transsexual
Alcohol and/or drug use
No use casual Frequent In recovery
7 10 5 5
Family History
All participants responded the questions inquiring about their family background.
The mothers o f twenty three participants were present when they were growing up. Four
participants had lost their mothers at an early age (less than 4 years old) due to death or
divorce. Fourteen participants elaborated on their relationship with their mothers. Three
reported having a close and loving relationship with their mother. "She was my biggest
65
supporter (#5)". One person who described her relationship as very close added that her
mother "was not demonstrative o f her affection". Four regarded their relationship to their
mother as normal and close. Nevertheless one o f the participants who saw her
relationship to her mother as close elaborated that there was not much communication
between them. Seven described their relationship as negative. "She was cold and distant. I
felt emotionally abandoned by her (#27)". "My mother preferred my sisters (#29)". "We
had the worst possible relationship (#4). The fathers o f thirteen o f the twenty seven
participants were present when they were growing up. O f these thirteen participants two
reported that their fathers were often absent. Fourteen participants lost their fathers in
their childhood due to death, divorce or abandonment. O f the eleven participants who
elaborated on their relationship with their father, the majority (N=8) reported that their
relationship was negative. "He was physically abusive (#17). "He used to go out o f his
way to embarrass me and ridicule me (#8). One participant who lost her "workaholic"
father when she was eight years old described having been afraid o f him but expressed
that "he was brilliant" and she loved and admired him. One participant described her
relationship with her father as normal, and two participants stated that they were close.
One o f the two indicated that her father "is also gay and loves women, men and
transsexuals (#23)".
Of the four participants who had stepmothers only one elaborated on the
relationship, reporting, "our relationship w as mostly sexual” (#4).

66
Nine participants mentioned growing up with stepfathers six elaborated on their
relationship . One participant described her relationship as fine" and five saw their
relationship as negative.
Table 12
Relationship to parents
Quality o f Relationship
No answer close normal negative
Mother (N =23) 10 3 4 7
Father (N=13) 2 2 1 8
Stepmother 2 O i l
(N=4)
Stepfather 3 0 1 5
(N=9)
From the Twenty five answered the question "When you were growing up, did
you experience violence among your parents?". Eleven described having experienced
violence. One participant expressed "I was raised with violence from all sides and all the
time. It is hard to point out the specifics (#12). The majority o f the respondents who
elaborated on this question indicated that father or stepfather initiated the physical
violence. "My father was beating up on my mom and my mom was shouting (#10)". "My
67
father would occasionally beat her up he had a terrible temper".
The participants were asked "Everyone gets into conflicts with other people and
sometimes this leads to physical blows such as hitting really hard, kicking, punching
throwing down etc. Did any o f the following people did thai to you?"
All MF transsexual participants responded to this question. Six reported having
experienced physical and emotional abuse by their mothers. One participant commented
"my mother: slapping, calling me names, using pointed piece o f soap roughly in my anus
angry about constipation; ostensibly washing out my mouth out with soap (27#)"..
Fifteen were mistreated by fathers and stepfather. "Father: frequent beatings, occasional
black eyes; bruises hitting with objects (#24)". Five participants elaborated on violent
treatment by siblings and six by acquaintances. One participant commented "Siblings
used to beat me up... slamming my head against the wall (=30)" (see table 13).

68
Table: 13
Abuse experiences
MF transsexual (N=27)
Physical Abuse Sexual Abuse
Mother 6 0
Stepmother 0 1
Father 12 1
Stepfather 3 0
Siblings 5 0
Acquaintance 6 3
Twenty six participants elaborated on the psychiatric history o f their parents.
Eleven described their father
having psychological problems such as alcoholism (n=3), manic depression (n=3), PTSD
(n =l), paranoid schizophrenic (n =l), obsessive compulsive (n = l), mild depression(n=l)
and repressed homosexual ( n = l). One participant stated "killing in wars is a
psychological problem". Only three mothers were mentioned as has having psychological
69
problems, one had severe depression, another mother minor depression, and one
participant described her mother as an "emotionally and physically abusive borderline.
DISCUSSION
The transsexual participants in this study were self-identified. Although the
participants' self-description corresponds with the general definition o f transsexualism
including the early onset, history o f cross-dressing, the desire to be the other sex. and the
urge for transformation surgery, most participants did not seem to have experienced an
unambiguous femininity in the course o f their lives. The majority attempted, at some
point, to live a heterosexual life. O f the twenty seven participants, seventeen had married
and twelve had fathered children. These participants did not fit the category o f "true
transsexuals" who according to Stoller have a non-conflicted progressive femininity.
Although they cannot be categorized as "primary transsexuals.'* who according to Person
and Ovesey, have no significant episodes o f heterosexuality or homosexuality, the
majority o f the participants reported experiences which conform to Person and Ovesey's
description o f primary transsexuals such as early childhood fantasies o f belonging to the
female gender and having the sensation o f warmth and comfort following cross-dressing
and relative asexuality. The participants in this group can be defined as standard
transsexuals (Arndt, 1991).
The control group consisted o f males and females who responded to a flyer

70
requesting participants for a psychological study on gender identity. Consequently it can
be assumed that the control group was not a random group of the population, but
consisted o f individuals who were interested in these themes. Experiences o f abuse were
not explored among the control group since the research questions requiring a control
group did not focus on abuse experiences.
The mean DES scores o f the control group in this study were similar to mean DES
scores o f the non-clinical population in other studies. The results o f this study indicate
that the majority o f the MF-transsexual participants have dissociative experiences which
are significantly higher than the experiences o f the non-clinical population. The fact that
nearly half o f the MF-transsexual participants scored above 15 on the DES suggests that
dissociative symptoms might have been overlooked in the MF-transsexual population.
Although the DES is a screening instrument and not a diagnostic instrument, researchers
have demonstrated that high scores on the DES are suggestive o f dissociative disorders.
As mentioned above, the DES is a screening instrument and a more detailed
diagnostic method should be used to further evaluate the prevalence o f dissociative
disorders among transsexuals and in general, among gender dysphoric individuals.
The number o f abused individuals among the MF-transsexual participants is
striking. Sixty three percent had experienced physical and/or sexual abuse. The
questionnaire in this study did not directly inquire about emotional abuse although
several participants implied in their data that they were not only physically, but also
R e p r o d u c e d w ith p e r m issio n o f th e c o p y r ig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

71
emotionally abused. Including questions about emotionai abuse might have yielded more
information about early traumatic experiences.
Taking into consideration that patients who suffer from amnesia and often might
not recall abuse experiences suggests that the results might have been an underestimation
o f true prevalence o f abuse among MF-transsexuals. A study using qualitative methods in
particular clinical interviews might generate more detailed and useful information about
early traumatic experiences. Although some authors have mentioned that child abuse
experiences might be a contributing factor in the etiology o f transsexualism (Schwartz
1988; Lothstein, 1979, M oney, 1986), the experiences o f childhood trauma has been
neglected in the research and etiological consideration on MF-transsexualism. The
occurrence o f child abuse has been reported in female to male transsexualism (Devor,
1994, Lothstein, 1983, Pauly, 1974).
In the present study the individuals who reported traumatic experiences had
significantly higher dissociative experiences in comparison to the transsexuals who did
not recall any experiences o f abuse. These results confirm many other studies which
associate dissociation with trauma.
In interpreting these data it should also be considered that the DES is a scale with
many limitations. The DES, as well as the QED, is very transparent and can be feigned in
either direction (Steinberg, 1997). Some o f the MF-transsexual participants expressed
concern that the questions in the DES inquired about "insanity". Doubts and suspicion
72
about the specific purpose o f this study might have skewed the responses, particularly
since the concept o f dissociation was not mentioned to the participants with the idea that
preconceptions on dissociation might distort the responses. There is also a possibility that
many individuals who recalled and reported experiences o f trauma were also less guarded
revealing their dissociative experiences. The association o f trauma and high DES scores
in this study might have been partly based on covariates which were not controlled.
The responses to the personal history questionnaire yielded more detailed
information about early childhood experiences o f the MF transsexuals. The idea o f a
"close intimate relationship" with the mother was not the experience o f the majority o f
the MF participants. Six participants revealed they have been physically abused by their
mothers and one participant described his relationship with his stepmother as "mainly
sexual". Fifty percent o f the MF transsexuals who elaborated on their relationship with
their mothers described their relationship as negative. Some o f those who described their
relationship as close or normal mentioned that there was "no communication." or in one
case as mother is portrayed as not "demonstrative in her affection". These descriptions do
not concur with Stoller’s ideas o f an "excessive blissful" relationship between the
transsexual and his mother. The depiction o f the mothers in the study group can be
compared to Person and Ovesey's observation that mothers provide dutifully routine care
but are rather distant and separation seems to arise from the lack o f empathic mirroring.
Similarly, Lothstein (1977) depicted the mothers as overly stimulating or alternately

73
withdrawn and distant. O f the twenty seven participants, thirteen grew up with fathers
and nine with stepfathers. The majority describe their relationship with fathers and
stepfathers as either not existent or negative. A large number o f the fathers were
physically and emotionally abusive and some had psychological problems.
The MF-transsexual participants' conception o f masculinity appeared to be shaped
by fathers who were erratic, violent and had a history o f out o f control behaviors. Most
researchers have emphasized the physical or psychological absence o f the fathers
(Freund. Langevin. Zajac. and Steiner. 1974; Stoller, 1976). A few studies describe the
transsexuals' hatred toward their fathers (Weitzman. Shamoian. and G olosow . 1971;
Wojdowski & Terbor. 1976). The responses to the question "what does it mean to be a
man?", showed that a number o f transsexuals denied having a concept o f maleness.
Several participants connected maleness with aggression and egoism. The few positive
meanings o f manhood were given in close association with women. For example one
participant described:" To be a man means to be a responsible caretaker and respecting
women...".
The dread o f maleness seems to be not only rooted in mother's abhorrence o f
maleness as Lothstein (1988) points out, but also in the actual traumatic experiences by
abusive fathers. The data in the personal history questionnaire indicate that the majority
o f the MF-transsexuals had early traumatic experiences. A s Bronstein (1992) pointed out
the experience o f trauma seems not only to be rooted in actual experiences o f abuse but in

74
a general environment where parents are not attuned to the child's needs and can not
contain the child's internal states.
This is unlike the trauma resulting from physical causes. Instead, it is a trauma
that ensues from the infant's unremitting experience o f being psychically
unprotected and can end in a pervasive sense o f disorganization. When coupled
with physical beatings or other real events, the effects are even more likely to
be pathological (Bronstein, 1992, p.255).
Despite the attempts o f leading a heterosexual life the majority o f the transsexual
participants in this study recalled having the wish to be a girl at an early age. (0-6 years
old). The "conviction" o f being female in a male body arose at a later age in most part.
These results are comparable with other studies. Lutz. Roback. and Hart (1984) reported
that two-thirds o f transsexuals had the feeling they were female at the age o f five.
According to Sorensen and Hertoft (1982) the wish to be a girl turns into fantasies o f
actually being female in adolescence. Siomopoulos (1974) regards this change from a
wish to the b elief o f being female as a shift from gender disorder to a delusional idea
which is based the "illogical deduction" that, "I am sexually attracted to males: A female
is sexually attracted to males; Therefore, I am a female" (p.57). This idea does not answer
the fact that many male to female transsexuals continue to feel attracted to women and
become "lesbians" after the gender transition. Person and Ovesey (1974b) clarify that the
wish turns into a conviction when the gender dysphoric individual is offered a "medical

75
vehicle" for his fantasy, "...since the patient is presented with medical evidence that the
condition does in fact exist, his subsequent belief that he :s a woman does not fulfill the
criteria for classification as a delusion" (Person & O v esey . p. 17-18).
The majority in this study group recalled cross-dressing in their childhood. Fifty
two percent before the age o f six and 18% before the age twelve. Reports about cross
dressing among transsexuals are inconsistent. Some report that all screened transsexuals
recalled the urge to cross dress before puberty, (Lutz. Roback and Hart. 1984). Others
found a low prevalence o f cross-dressing among transsexuals at an early age before the
age o f six.
Although there were no clear significant differences between the DES scores o f
the transsexuals who switch gender roles and those who live exclusively as females some
interesting trends in surfaced based on the different phases o f gender transition. The
dissociative experiences were highest among those transsexuals who were m ostly living
as males. The DES scores decreased considerably in transsexuals who had started to live
mostly as females, and increase again to the mean score o f 15 in transsexuals who have
been living as females for a longer period o f time.
These result should be interpreted with caution since it is based on small samples
and should be reevaluated with a larger study group. Nevertheless the trends indicates
that the assumed female identity provides relief from dissociative experiences, but only to
the individuals who are in the beginning o f gender transition. The dissociative
76
experiences seem to reemerge in the later stages o f gender transition. It is possible that
the dissociative experiences decrease with the initial enthusiasm about gender transition
and reemerge when the transsexuals begin to face the various barriers on the way to
surgery and complete gender transition. A comparative study o f pre- and post-operative
transsexuals with a larger study group could clarify these questions.
The majority o f the participants aspired to have surgery with the hope o f acquiring
a harmony between the "physical and mental" in order to live a more satisfying life. This
longing for congruity is connected to a fuller and happier life with rewarding
heterosexual relationships and overall, more intimate relationships with others. The
phallus signifies "the physical half state" and the attainment o f a complete female identity
through a female body which promises an integrated sense o f self. One participant
explained that "my body will be more in harmony with my mind, ease my emotional life,
sensual life too." The experiences o f being in a "physical half state" and desire to attain
"state o f comfort" is so intense that a number o f MF-transsexual participants had
attempted suicide, or genital injury.
These phenomenological descriptions can be understood in the framework o f
Winnicott's (1958) ideas on the mind's development and it's relation to the "psyche-
soma". Health is according to Winnicott (1958) rooted in the "continuity o f being", which
constitutes the self. In a process o f a healthy development the psyche and soma develop
in a mutual interrelationship. Psyche means "the imaginative elaboration o f the somatic

77
parts, feelings, and functions, that is. o f physical aliveness (p.244). In early development
the infant is in need o f a perfect environment which assures the continuity o f existence.
Gradually, the perfect environment which needs to be absolute in early development
becomes relative. The ordinary good mother is "good enough", and the mental activity o f
the infant turns a good enough environment into a perfect environment. In a healthy
development the mind does not usurp the environmental functions. But in an environment
where impingements, e.g overstimulation or trauma, disturb the continuity o f being, the
mental functioning becomes overactive replacing the maternal functions. The mind
disrupts the intimate relationship o f the "psyche-soma". which is a relationship giving the
individual a feeling o f aliveness. The result is a "mind psyche" which is removed from
the soma. The psyche disconnected from the sensorium. depleted o f aliveness. is a
strained and frail entity, under the constant threat o f breakdown. The individual in this
condition longs for "the return to the dependent psyche-soma. which forms the only place
to live from", (p. 247) The individual in this condition is constantly longing for someone
or something who can bring the early perfect environment into reality. The transsexual
participants' wish to "align the physical and the mental" in order to "ease the emotional
life", and "be more in harmony with" the mind, in order to achieve congruity and
happiness is an attempt to supply their being with a sense o f aliveness. These attempts
seem to illustrate the results o f early separation o f psyche-soma and disruption o f the
development o f the self. These ideas are comparable to other conceptualizations on

78
pathological dissociation which postulate the compartmen:alization o f mental contents.
Winnicott elucidates the process in its complexity, its' infantile origins, including the
mother child dyad, the anxiety and agony which are experienced with pathological forms
o f dissociation, and the urge to end the state which is depleted o f aliveness. The early
disruption o f the psyche from its' sensorium disturbs the development o f the sense o f
reality. Disturbances in the sense o f reality are accompanied by feelings o f strangeness.
Reality is not experienced as vivid and animated but as grey and lifeless. (Shapiro. 1975).
Male to female transsexuals seem to associate this state o f agonizing deadness with their
biological gender. As one participant eloquently describ ed :" To be a man means to an be
an image or a shadow o f a person". The body, in particular its' signs o f maleness are
despised and experienced as the cause for the tormenting reelings o f deadness and
meaninglessness. The phallus does not seem to be a "symbol of aggression" as Volkan
(1979) describes, but is rather depleted o f symbolic value and meaning. The phallus is
seen as the cause o f separation from a more animated sense of reality. According to
Shapiro (1975), in depersonalization although reality testing is intact the sense o f reality
is disturbed and marred by feelings o f strangeness. Daydreams on the other hand are
reality enhancing. The individual attempts to overcome feelings o f deadness occurring in
depersonalization with the use o f reality enhancing daydreams. Shapiro (1975) points out
that the use o f daydreams though is not always enhancing the sense o f reality. Unusual
fantasies can be used in a manner similar to depersonalization to dissociate from reality.

79
In the case o f transsexuals the idea o f femaleness seem to entail the hope for an enhanced
sense o f reality.
The MF transsexual's ideas on femaleness focus on the emotional life on women,
on their "softness" and "vulnerability", their ability to receive care and admiration and
tend to others. To be a women means "to be close to me": it means "that you feel
connected" and have a more refined ability to deal with the world. As postulated by
Person & Ovesey the transsexual attempts to allay separation-anxiety by resorting to the
"reparative fantasy o f symbiotic fusion with the mother." Using Winnicott's
conceptualizations the transsexual's longing for the female body and identity can be
interpreted as the desire to recreate the early mother infant relationship where psyche and
soma exist in mutual interrelation undisrupted by excessive impingements.
According to Winnicott, (1971) early maternal failure leads to the void in the
intermediate area where during transient maternal absence the infant can create an
illusion o f oneness with mother. In case o f early disillusionment, ideas o f oneness are not
available and the symbolic functions are disrupted, concrete means are utilized to create
an actual reality o f oneness, or as Lothstein indicates a longing for "fusion and unity"
with the mother. The transsexual desires to attain the soothing maternal functions
concretely by the reconstruction o f a female identity. The gradual development o f the
female body seem to confirm the "fantasy" o f oneness with the mother and leads to a
sense o f relief. As illustrated in the results some participants report that they become
80
irritable when they do not take female hormones, and one participants stated to have
given up her addiction to drugs beginning with her hormone treatment.
Based on Winnicott's ideas, Goldberg (1995) introduces two components in the
dissociative process. Initially the se lf is threatened by "impingements, trauma and
overstimulation." In order to control these dangers, the mind withdraws defensively from
its' sensorium. The mind, tom apart from it's source o f aliveness. experiences a new
threat. Feelings o f deadness prevail and reality is perceived as shallow and grey. The
individual attempts to overcome this state by "means o f a forced reconnection", which
"constitutes not an integration o f mind and psyche-soma but a pseudointegration".
(Goldberg, 1995). Pseudointegration, a forced non-symboiic connection o f mind and its
sensorium lacks the "fluid qualities o f integrated se lf experience" (p.497) and leads to
painful feelings inauthenticity.
Winnicott (1971) distinguishes between (dissociated) fantasies and imagination.
Imagination and dreams are used to creatively enrich the self in relation to reality.
Fantasies, on the other hand, rooted in dissociated mental activities have no symbolic
value. The MF transsexuals' relentless search for perfection seems to be related to
dissociated fantasies o f femaleness which appears to lack symbolic value and necessitates
others' constant confirmation. Instances where the transsexuals' femaleness is confirmed,
tenuous integration may be achieved, making reality tolerable. As Lothstein points out.
therapists should be careful in their attempt to change the gender identification o f the
81
transsexual back to the biological sex. since "there might be nothing to go back to"
(Lothstein. 199. p. 230).
The etiology o f transsexualism seems to be multidetermined by biological causes,
societal factors and family dynamics. This study's results indicate that dissociative
experiences might have been underestimated in the description and etiology o f
transsexualism. The results also indicate a connection between early traumatic
experiences and a high prevalence o f dissociation among transsexuals. Further research
with larger study groups and more extensive clinical methods are recommended to
evaluate the prevalence o f dissociation among the transsexual population and, in general,
among individuals with gender identity disorders. Research on gender dysphoria in
abused children could expand our knowledge o f general etiological questions. Knowledge
o f the occurrence and frequency o f dissociative experiences will have useful clinical
implications for the practitioner working with gender dysphoric clients.

82
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91
Appendix A
Dissociative Experiences Scaie
92
Dissociative Experiences Scaie
This questionnaire consists o f twenty-eight questions about experiences that you

may have in your daily life. We are interested in how often you have these experiences. It
is important, however that your answers show how often these experiences happen to you
when you are not under the influence o f alcohol or drugs. To answer the questions,
please determine to what degree the experience described in the question applies to you
and mark the line with a vertical slash at the appropriate piace as shown in the example
below.
Example:
0% 100%
1. Some people have the experience o f driving a car and suddenly realizing that they don't
remember what has happened during all or part o f the trip. Mark the line to show what
percentage o f the time this happens to you.
0% 100%
2. Some people find sometimes that they are listening to someone talk and they suddenly
realize that they did not hear part or all o f what was just said. Mark the line to show
what percentage o f the time this happens to you.
0% 100%
3. Some people have the experience o f finding themselves in a place and having no idea
how they got there. Mark the line to show what percentage o f the time this happens to
you.
0% 100%
4. Some people have the experience o f finding themselves dressed in clothes that they

93
don't remember putting on. Mark the line to show what percentage o f the time this
happens to you.
0% 100%
5. Some people have the experience o f finding new things in their belongings that they do
not remember buying. Mark the line to show what percentage o f the time this happens
to you.
0% 100%
6. Some people sometimes find that they are approached by people that they do not know
who call them by another name or insist that they have met them before. Mark the line
to show what percentage o f the time this happens to you.
0% 100%
7. Some people have sometimes the experience o f feeling as though they are standing
next to themselves or watching themselves do something and they actually see
themselves as if they were looking at another person. Mark the line to show what
0% 100%
8. Some people are told that they sometimes do not recognize friends or family members.
Mark the line to show what percentage o f the time this happens to you.
0% 100%
9. Some people find that they have no memory for some important events in their lives
(for example a wedding or graduation). Mark the line to show what percentage o f the
time this happens to you.
0% 100%
94
10. Some people have the experience o f being accused o f lying when they do not think
that they have lied. Mark the line to show what percentage o f the time this happens to
you.
0% 100%
1. Some people have the experience o f looking in a mirror and not recognizing
themselves. Mark the line to show what percentage o f the time this happens to you.
0% 100%
12. Some people have the experience o f feeling that other people, objects, and the world
around them are not real. Mark the line to show what percentage o f the time this
happens to you.
0% 100%
13. Some people have sometimes the experience o f feeling that their body does not seem
to belong to them. Mark the line to show what percentage o f the time this happens to
you.
0% 100%
14. Some people have the experience o f sometimes remembering a past event so vividly
that they feel as if they were reliving that event. Mark the line to show what
0% 100%
15. Some people have the experience o f not being sure whether things that they
95
remember happening really happened or whether they ust dreamed them. Mark the
line to show what percentage o f the time this happens to you.
0% 100%
16. Som e people have the experience o f being in a familiar piace but finding it strange
and unfamiliar. Mark the line to show what percentage o f the time this happens to
you.
0% 100%
17. Som e people find that when they are watching television or a m ovie they become so
absorbed in the story that they are unaware o f other events happening around them.
Mark the line to show what percentage o f the time this happens to you.
0% 100%
18. Some people sometimes find that they become so involved in a fantasy or
daydream that it feels as though it were really happening to them. Mark the line to
show what percentage o f the time this happens to you.
0% 100%
19. Some people find that they sometimes are able to ignore pain. Mark the line to show
what percentage o f the time this happens to you.
0% 100%
20. Some people find that they sometimes sit staring into space, thinking o f nothing, and
are not aware o f the passage o f time. Mark the line to show what percentage o f the
96
0% 100%
21. Some people sometimes find that when they are alone they talk out loud to
themselves. Mark the line to show what percentage o f the time this happens to you.
0% 100%
22 Some people find that in one situation they may act so differently compared with
another situation that they feel almost as if they were two different people. Mark the
line to show what percentage o f the time this happens to you.
0% 100%
23 Some people sometimes find that in certain situations they are able to do things with
amazing ease and spontaneity that would be usually difficult for them (for example,
sports work, social situations, etc.). Mark the line to show what percentage o f the
0% 100%
24. Some people sometimes find that they cannot remember whether they have done
something or just thought about doing that thing (for example not knowing whether
they have just mailed a letter or have just thought about mailing it). Mark the line to
show what percentage o f the time this happens to you.
0% 100%

97
25. Some people find evidence that they have done things that they do not remember
doing. Mark the line to show the percentage o f the time this happens to you.
0% 100%
26. Some people sometimes find writings, drawings or notes among their belongings
that they must have done but cannot remember doing. Mark the line to show what
0% 100%
27. Some people sometimes find that they hear voices inside their head that tell them to
do things or comment on things that they are doing. Mark the line to show what
0% 100%
28. Some people sometimes feel as if they are looking at the world through a fog so that
people and objects appear far away or unclear. Mark the line to show what
0% 100%
98
Appendix B
Questionnaire for Experiences o f Dissociation
99
Questionnaire o f Experiences of Dissociation
This questionnaire consists o f twenty-six questions about experiences you may have in
your daily life. It is important that the experiences happen to you when you are not under
the influence o f alcohol or drugs. To answer the questions, please circle T (true) i f the
experience applies to you and F (false) if the experience does not apply to you.
True False
1 .1 often feel as if things were not real. T F
2. Occasionally. I feel like som eone else. T F
3. Sometimes my mind blocks, goes totally empty. T F
4 . 1 often wonder who I really am. T F
5. At one or more times. I found m yself staring

intently at m yself in the mirror as though
looking at a stranger. T F
6 . 1 often feel that I am removed from my thoughts

and actions. T F
7 . 1 rarely feel confused, like in a daze. T F
8 . 1 have had periods where I could not remember where

I had been the day (or days) before. T F
9. When I try to speak words. They don’t come out right. T F
1 0 . 1 have never come to without knowing where I was or how

I got there. T F
11. When I was growing up. people often said that I seemed to
be o f in a world o f my own. T F
12. Sometimes I feel like my body is undergoing a transformation. T F

100
13. Sometimes I feel as if there is someone inside o f

me directing my actions. T F
14. Sometimes times my limbs move on their own. T F
15. When I w as a child I rarely sat and daydreamed in school. T F
16. Sometimes I have problems understanding other's speech. T F
1 7 . 1 am rarely bothered by forgetting where I put things. T F
18. My mind has never gone blank on me. T F
1 9 . 1 have a rich and exciting fantasy life. T F
2 0 . 1 never find m yself staring o ff into space

without thinking o f anything. T F
21.1 daydream very little. T F
22. My soul som etim es leaves my body. T F
2 3 . 1 do not think I would be able to hypnotize myself. T F
24. When I was a child I never had imaginary companions. T F
2 5 . 1 have never gone into a trance, like hypnosis. T F
2 6 . 1 have never had periods o f deja vu. T F
101
Appendix C
Personal History Questionnaire
102
PERSONAL HISTORY QUESTIONNAIRE
The following questionnaire inquires personal and family history information. Please read
the questions carefully and write your answers in the indicated space. If you need more
space for your answers, please use the back page. If you do not remember or only vaguely
remember certain events and facts please indicate this in your response. If you do not feel
comfortable answering a question please indicate this and feel free to move on to the next
question. Thank you very much for your help and cooperation.
1. PERSONAL DATA
1.1. How old are y o u ? years
1.2. What is your ethnic background:
1.3. Are you currently in a relationship (romantic relationship)? yes no

Please indicate the gender o f your partner:
age gender (Male, Female. FM Male. MF Female)
1.4. Have you ever been married? yes

If yes. how old were you when you got married? years.
Duration o f marriage years
further information:
1.5. Are you currently married. yes no

How many times have you been married
Gender o f your spouse(s) and duration o f marriage:
1. Fem ale__ M a le M F/Fem ale___ FM/Male years
2. Fem ale__ M a le____ M F/Fem ale___FM/Male years
1.6. Do you have children:__ y e s ____no.

Biological: please indicate number____
age. sex 2 . ____age, sex 3 . ___a g e . sex
Adoptive/step/foster children: please indicate number____

age, sex; 2 . age, sex; 3 . age. sex.
103
2. Employment and Education History
2.1. Are you currently em p loyed yes. no

If yes please indicate the length o f time you have been employed?
years months
If no please indicate when you were employed last ?
years months ago.
2.2. In your employment are you still considered a male or a female.
2.3. If you have not yet begun cross-living, what are your vocational plans when you
do make the change?
2.4. At what age did you enter sch ool? age Please indicate how many years_____
you attended school and what is the highest grade you received:
3. Sexual and Genderal History
3.1. Age at which you first cross dressed?

_______ in public
_______ in private
3.2. Do you have the conviction/sensation o f being a woman in a male body?

yes no
If yes please answer the following questions
a) Age at which you first had the wish to be a girl?
years
b)Age at which you first had the conviction o f being a girl?
vears
3.3. Describe your experience when you first dressed in woman clothes?
3.4. How do you currently dress?

mostly as a man
mostly as a woman
exclusively_____ as a man
exclusively_____ as a woman
104
3.5. Have you ever attempted to live exclusively in the role o f choice?
yes no
If yes please indicate:
length o f tim e years months
Please indicate your success in passing as a wom an by circling one o f the choices.
1) I can always 2) most o f the time 3) some o f the time 4) rarely
5)n ever pass as a woman.
.6. Have you ever undergone (sex transformation) surgical procedures?

y e s ____ no
.7. Have you had any hormonal therapy? v e s ____no

.8 Do you plan to have sex reassignment surgery'? yes no
If yes what difference do you feel surgery will make in your life.
.9. What does it mean to be a woman?
10. What does it mean to be a man?
11. What do you feel is the most significant difference between being a man and
being a woman?
. 12. Describe your first sexual encounter?

Your a g e:______ years.
your partner's a g e :____ years.____ gender. Would you describe this experience as
positivee. o r ____ negative
Further information about your experience:
105
.13. In general how important a part does sex play in your life?
.14 Does your current sexual activity involve your genitalia?

never. rarely. at tim es, all the time.
4. Counseling/Therapy
4.1. Are you currently in therapy/counseling? yes. no. If yes. how long have
you been attending therapy or counseling? years month
If yes please describe briefly your primary reasons for seeking
therapy/counseling?
4.2. Have you been previously in therapy/counseling? yes . ___ no

If yes please indicate how long ago? . If yes please indicate the number o f
months and years you have been previously in therapy/counseling:
years._____months, frequency o f session per week
Please indicate the primary' reasons for seeking counseling therapy?
4.3. Have you ever been hospitalized for psychiatric problems?___ y e s .____no.
If yes how many times? for how long?_____
Please briefly indicate the reasons for your hospitalization?
4.4. Are you currently in a support group? yes. no
4.5. Please list your current medication and the condition for which they are
prescribed?
4.6. Have you ever attempted suicide?

yes, no
If yes how old were you ?_____
4.7. Have you ever attempted genital injury? yes. If yes how old were you?
years
4.8. Have you ever been involved in the use o f drugs? yes. no. Please indicate
the drugs you have used and the frequency o f the use.
106
Casual Frequent Addicted

Marijuana
Barbiturates
Amphetamine
Hallucinogens
Opiate
5.Family History
5.1. Please list the ages and sex o f all your brothers and
sisters in the order o f birth.
I. age sex 4.age sex
2.age sex 5.age sex
3.age sex 6.age sex
Please describe briefly your relationship with each o f
your siblings.(to whom were you closest.
with whom did you fight the most, with whom did you get
along)
Who were your parents' favorites?
5.2. Did your biological mother live with you when you were growing u p ? yes
no
If not how old were you when she stopped being present?
years old
(Check here if she was never present:_____ Why did she stopped being present:
separation or divorce illness (psychiatric or physical) death_____
other___________________________________________________________________
further information & please briefly comment on your relationship with her:
107
5.3. Did your biological father live with you while you were growing up?
yes no
If not how old were you when he stopped being present ? years old
(Check here i f he was never present:______ Why did he stopped being present:
separation or divorce illness (psychiatric or physical) death___
other________________________________________________________________
further information& please briefly comment on your relationship with him:
5.4. Did you ever have a stepmother or adoptive mother? yes no

If yes from what age to what age_____ ? If more then one. list your ages for each:
age___to age_____
age___to age_____
further information & please briefly comment on your relationship with her
(them).
5.5. Did you ever have a stepfather or adoptive father ? yes no____
If yes from what age to what age_____ ? If more then one. list your ages for each:
age___ to age_____
age___ to age_____
further information& please briefly comment on your relationship with him
(them).
5.6. Were you ever raised by any other adults? yes_____

no____
If yes. by whom____________________________________________
From what age to what age ?
If more then one, list your ages for each:
age____to age who age to age who age to
age by whom ______
(further information& please indicate your relationship with the person(s)
mentioned above.
108
5.7. Did any o f your parents or other caretakers had/have psychological problems?
yes. no.
Please specify which parent/caretaker Please describe the nature o f the problem:
5.8. Do your parents (step/foster parents) know about your decision to cross live?
yes no
If yes how do your parents feel about your decision to cross live?
Mother:
Father:
5.9. On average while growing up how much did you feel that your parents/ caretakers
loved and cared about you?
Father/stepfather/adoptive father etc.

Not at all very much
I 2 J 4
Mother/stepmother/adoptive mother etc.

Not at all very much
1 2 j 4
Further information:
5.10 How was the relationship between your parents?
5.11. When you were growing up did you experience violence between your parents?
yes no
If yes please give further information?

109
5.12. Everyone gets into conflicts with other people and

sometimes this leads to physical blows such as hitting really hard, kicking,
punching, throwing down, etc. Before (or after) you were 16. did any o f the
following people did that to you).
Father/stepfather/adoptive father etc. yes no It yes please indicate what
happened and how old you were: 109
Mother/stepmother/adoptive mother/ e tc . yes no

If yes please indicate what happened and how old you were:
siblings yes no
acquaintance/ friend:_____ y e s no
5.13. Before (or after) you were 16 years old, did any o f the people ever pressure you
into doing more sexually than you wanted to do (for example being pressured into
forced contact with the sexual parts o f your body or his/ her body? Did any o f the
following people do that to you?
Father/stepfather/adoptive father etc. yes no. If yes please indicate what

happened and how old you were:
Mother/stepmother/adoptive mother/ etc. yes no If yes please indicate
what happened and how old you were:
siblings yes no
acquaintance/ friend:__ y e s _____ no


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A DESCRIPTIVE STUDY OF MALE TO FEMALE

THE PREVALENCE AND USE OF DISSOCIATIVE EXPERIENCES

Presented to the Faculty o f

The California School o f Professional Psychology at Alameda

o f the Requirements o f the Degree

R e p r o d u c e d with p e r m issio n o f th e co p y r ig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

UMI Microform 9734269

This microform edition is protected against unauthorized

THE PREVALENCE AND USE OF DISSOCIATIVE EXPERIENCES

This dissertation, by Mariam Jafari,

Abbot Bronstein, Ph.D.

Ali Chavoshian, Ph.D.

Alan Swope, Ph.D.

R e p r o d u c e d with p e r m issio n o f th e co p y r ig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

A DESCRIPTIVE STUDY OF MALE TO FEMALE TRANSSEXUALISM:

THE PREVALENCE AND USE OF DISSOCIATIVE EXPERIENCES

California School o f Professional Psychology at Alameda

The transsexuals' account o f alienation and detachment from their biological

gender, in particular from their genitals, is analogous to reports o f individuals with

depersonalization experiences. Depersonalization is a subcategory o f the defense o f

dissociation. In this study the prevalence o f dissociative experiences o f Male to Female

transsexuals was evaluated and compared to the prevalence o f dissociative experiences in

a control group o f males and females.

The study group consisted o f twenty-seven male to female transsexuals. The

o f dissociation (QED) were used to assess dissociative experiences. A statistically

seven females (T = 2.5; P = 0.2).

Forty-one percent o f the transsexual participants compared to seventeen percent of

difference was statistically significant (p = .02). Twenty-two percent o f

Mean QED score o f the entire control group (T = 2.5; P = .01).

O f the twenty-seven Male to Female transsexual participants, seventeen reported

not report childhood abuse (T = 2.6; p < .01).

In addition to this data, information on family history and personal meanings o f

Further research is suggested to evaluate the occurrence o f dissociation in

transsexualism and. in general, in the etiology o f gender disorders.

R e p r o d u c e d w ith p e r m is s io n o f th e co p y rig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

I am most grateful to my dissertation committee. My chairperson. Dr. Abbot

Bronstein whose breadth o f knowledge in analytical theories greatly inspired my

my conceptualizations. I would like to thank Dr. Ali Chavoshian whose comprehension

and encouragement were essential to the completion o f this study.

I extend my sincere thanks to a number o f professionals who familiarized me with

important part in the difficult process o f research. I am particularly grateful to my friend

continuous support during the data collection.

R e p r o d u c e d with p e r m issio n o f th e co p y r ig h t o w n e r . F u rth er rep ro d u ctio n p roh ib ited w ith o u t p e r m issio n .

Appendix A: Dissociative Experiences Scale...................................................................... 91

Appendix B: Questionnaire for Experiences o f Dissociation........................................... 98

Appendix C: Personal History Questionnaire.....................................................................101

1. DES scores: original Data.............................................................................................. 35

4. Mean- DES scores...........................................................................................................48

5. Mean- DES scores o f abused vs.not abused

7. Mean- DES scores and phaseso f gender transition..................................................53

10. Psychiatric and treatment history................................................................................. 63

11. Alcohol and Drug use......................................................................................................64

12. Relationship to parents....................................................................................................66

13. Abuse experiences........................................................................................................... 68

The following study investigates the prevalence o f dissociative experiences o f

distinguish transsexuals from schizophrenics with chaotic sexual identities.

The transsexuals' account o f alienation and detachment from their biological

gender, in particular from their genitals, is analogous to reports o f individuals with

depersonalization experiences. Depersonalization, considered as an ego defense

mechanism in psychoanalytical theory, has been described as a sense o f detachment from

changed; or that a given part is no longer experienced as belonging to the person"

as grey and lifeless (Shapiro. 1975).

Depersonalization is a subcategory o f the defense o f dissociation. According to