What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (25 page)

The third layer is
sexual preference
. What parts of the body and what situations turn you on? What scenes do you masturbate about? What is on your mind at the moment of orgasm? For most men, the most erotic parts of the body are the female face, breasts, buttocks, and legs. For most women, the preferred body parts are the male chest and shoulders, arms, buttocks, and face. Caressing a member of the opposite sex, seeing him or her naked, dancing, intimate conversation, subdued lighting, and music are common arousing situations.

But these are not—by any means—universal. Many people crave nonstandard objects and situations: Common ones are feet, hair, ears, the belly button; silken and rubbery textures, panties, stockings, jeans; peeping, flashing, receiving and inflicting pain. Animals, children, urine, and even an amputee’s stumps are rarer and more bizarre. Lust-murder and arranging one’s own death are the most erotic acts for the extremely rare person. If any of these are your turn-ons, forget the bizarreness of the object for a moment, and ask yourself this important question: “Does the object of my passion get in the way of an affectionate, erotic relationship between myself and another consenting human being?” When the panties or the pain become more important than your partner, you have crossed a line.

The fourth layer, the one next to the surface, is our
sex role
. Do you do what most men do or what most women do? Most people who feel they are male adopt male sex roles, and most females adopt female roles. But we know of the separate existence of sex roles by the not-uncommon dissociations of identity and role. For example, some women become truck drivers—dominant, aggressive, and tough. Some men become nurses—caring, gentle, and compassionate. The term
sex role
makes role sound arbitrary, a mere costume that can be shed at will and easily replaced with one more suitable to the moment. In this view, sex roles are creations of fashion: The macho male and bimbo female stereotypes are just accidents of the way Americans now happen to be raised. And as accidents of socialization, they can be changed simply by altering the way we raise our children or by some other act of will. We shall see if this is really so or if this is just ideological fantasy.

The surface layer is
sexual performance
, how adequately you perform when you are with a suitable person in a suitable erotic setting. Normal performance consists of arousal and orgasm. Do you have problems in either of these areas? Frigidity and impotence (what pejorative words!) are common problems, as are premature ejaculation for men and absence of orgasm for women.

I have ordered your erotic life into five layers for one basic purpose—to answer the questions of what changes and how easily it changes. Lack of change, I believe, corresponds to
depth;
the deeper the layer, the harder it is to change. (This is a preview of the global theory I will put forward in
chapter 15
.) My theory of sex is that transsexuality is a problem at the identity level and simply will not change; sexual orientation, the next deepest layer, very strongly resists change; sexual preference, once acquired, is strong, but some change can be wrought; sex role can change quite a bit, but change is by no means as easy as feminist ideologues contend, nor as difficult as antifeminists would like; correcting sexual performance is painful, but because performance problems are at the surface layer, you should be very hopeful that they will change.

Layer I: Sexual Identity and Transsexuality: What Are You?

Transsexuals are biologically normal. An average transsexual man has a penis in good working order, 46XY chromosomes, hair on his face and body, lots of testosterone, and a deep voice. An average transsexual woman has a vagina, working ovaries, 46XX chromosomes, breasts, and all the rest of the female physical features. Transsexuals are physically indistinguishable from average men or women. Yet psychologically, they are as abnormal as anyone can be. By the three major criteria of abnormality—irrationality, suffering, and maladaptiveness—transsexuals top the chart. They believe—irrationally, it seems—that they are trapped in the body of the wrong sex. They are miserable: depressed, suicidal, and self-mutilating—some try to cut off their sex organs. They almost never marry or reproduce.

Transsexuals have had their “wrong sex” belief for as long as they can remember. And they are doomed to have it for the rest of their lives. Every kind of psychotherapy has been tried on transsexuals. So rare is any success that the single clear case in the archives of successful change calibrates just how intractable this problem is.
²

John was born in
1952
and always thought of himself as a girl. He was the baby of the family, frail and delicate beside his tomboy older sister. When he was four, he started to wear makeup and was delighted when his sister started school because she got lots of new clothes for him to dress up in. [Transsexuals always cross-dress. But they are transvestites only by a technicality. A transvestite male wears women’s clothes to get turned on sexually; a transsexual male wears them because he believes he is a woman.]

John envied his mother and sister, and loathed his maleness. He went to school, but did badly. Isolated and lonely, he occupied himself with
cooking and housekeeping. As a teenager, he read about transsexualism and about the important discoveries being made at the Johns Hopkins Medical School. He took estrogen and felt tranquil and calm for the first time in his life. He was also delighted that he no longer got erections. He took a job at a fried-chicken stand and started to save up for sex-change surgery. It was at this time that he was seen by a psychiatric team and formally diagnosed as a transsexual
.

He took the name “Judy” and began to live as a woman, preparing for surgery. He passed well as a woman, and with hormone treatment wore bikinis to the beach. Just as surgery was to begin, Judy disappeared
.

Several months later, Judy reappeared at the chicken stand. But not as Judy
—
as John. When he subsequently presented himself to the psychiatric team, he wore a three-piece suit and short hair, had clipped fingernails, and strutted manfully. He related his story enthusiastically:

On his way to surgery, he kept a promise to the stand owner to check in with a local physician who was a member of a fundamentalist religion (John was a lapsed Baptist with no religious interest). The physician told John that he could make it as a woman, but that his real problem was possession by evil spirits. The physician performed a three-hour exorcism with prayers, exhortations, incantations, and the laying-on of hands. John fainted several times, but when it was over, the physician said he had removed twenty-two evil spirits, and John was free of the delusion of being a woman for the first time in his life. He was followed closely for the next two and a half years by the psychiatric team and was clearly male
—
psychologically as well as physically. He did well in his job, was promoted, and was looking forward to marrying
—
a woman
.

Sex change
. Psychotherapy changes sexual identity rarely, if ever.
³
The only thing that reliably works is to change the body to conform to the unshakable sexual identity. This is why sex-change operations were developed. Once a headline-making novelty, these operations are now routine. Tens of thousands have been done. Once the patient convinces the diagnosticians that his or her transsexual identity is unshakable, the long process of changing the body to conform begins. In the more common male-to-female (MF) case, the person first lives for a few months in the female role, changing his name, and dressing and acting like a woman. Hormonal treatment is begun, and breasts grow, the voice changes, and facial hair disappears. Surgery itself is then undertaken. The testicles are removed and the penis is cut off—though its skin is preserved to line the new vagina, making pleasurable intercourse and even orgasm possible.

In the female-to-male (FM) transformations, hormone treatment and multiple surgery (breast removal, ovary removal, and, ultimately, the construction of a penis) are done over several years. The penis cannot naturally become erect, however, and prosthetic devices must be used for intercourse.

As radical as surgery is, long-term follow-up of hundreds of patients suggests that while far from ideal, it is the treatment of choice. Most patients are much happier and adapt fairly well to their new lives, living comfortably in their new bodies, dating, having intercourse, and marrying. Any children, of course, are adopted, since no surgery can transplant viable internal sex organs. Those patients who do poorly psychologically are the ones who have had the poorest surgical results.
⁴

The origin of sexual identity
. Of the entire nosology, transsexualism is the deepest disorder. I know of no other psychological problem so intractable. We do not know how to change the psyche to conform to the body, so as a last resort we change the body to conform to the psyche. The depth of this disorder reflects the fact that sexual identity is the core layer of sexuality, and perhaps the very core of all of human personality.

Why is sexual identity so deep? I want to go well beyond the data to present a theory of the origin of sexual identity. My speculation is that most of sexual identity—both normal and transsexual—comes from an unknown hormonal process in the second to fourth months of pregnancy.

I start with a simplified version of how a fetus becomes male or female. The embryo has both potentials. Very early, both sets of internal organs—male and female—are present. The fetus would always go on to become female but for the next, crucial step: Two masculinizing hormones are secreted from the male fetus’s testes. The female internal organs then wither, the male internal organs grow, and the external male organs develop. In the absence of the masculinizing hormones at this stage, the male internal organs wither, and female internal and external organs develop. All this happens roughly at the end of the first trimester.
⁵

I want to speculate that there is something else happening at this stage: The masculinizing hormones have a psychological effect. They produce male sexual identity (or, in their absence, female sexual identity). They also guide the development of the corresponding sexual organs, but this is a separate process. In this theory, sexual identity is present in the fetus. There is no way of asking a fetus if he feels like a male or a female, however, so this is not an easy theory to test. But there are four startling “experiments of nature” in which sexual identity is dissociated from sexual organs—all of which support my thesis.

You already know about two of them: MF transsexuals and FM transsexuals. In this theory, some as-yet-unknown disruption of the sexual-identity phase, but not the organ-development phase, takes place. For the MF transsexual, the psychological phase of masculinization does not occur, but the other phase—the masculinization of the sexual organs—goes normally. For the FM transsexual, the psychological phase goes awry, and masculinization occurs; the other phase—feminization of the sexual organs—goes normally, and herein may lie the tragedy.

There are two mirror-image conditions that show remarkable parallels to the two transsexualisms and that are much better understood—the
adrenogenital syndrome (AGS)
and the
androgen-insensitivity syndrome (AIS)
. They may be the key to understanding transsexualism.

The adrenogenital syndrome has a profound effect on the 46XX fetus (a chromosomally normal female): It bathes her in masculinizing hormones. As a result, she is born with the internal organs of a female (since they were differentiated before the bath), but she is also born with what seems to be a penis and scrotum. The penis and scrotum look convincing, but they are actually an enormously enlarged and penile-shaped (foreskin and all) clitoris. The scrotum contains no testicles. Many AGSs are declared boys and raised as boys. Since the hormonal bath continues, their voice deepens, and face and body hair sprout at puberty. These AGSs
grow up as normal men
. They feel like they are male, they pursue women romantically, they have intercourse as men, and they become good husbands and fathers (by adoption or artificial insemination). There is a complete absence of bisexual fantasy or action. In contrast, when an AGS is surgically feminized and then reared as a girl, as sometimes happens, problems often ensue: She may feel and act like a man; bisexual fantasy and action are common.
⁶

In my theory, AGSs reared as males are “first cousins” of FM transsexuals. Both are 46XX fetuses who are masculinized psychologically. But the transsexual misses the next phase—the masculinization of her external organs. She is therefore born psychologically male but with a vagina, and so is declared and raised as a girl. Her life is a constant misery thereafter. It gets even worse after puberty, because unlike her AGS cousin, she sprouts breasts and has periods. Her AGS cousin is psychologically male, but was fortunate enough also to be born with the appearance of a penis and scrotum and so is declared a boy. His life works out because what everyone thinks he is (by virtue of the appearance of a penis at birth and, later, by his deep voice and facial hair) is the same as he thinks he is—a man.