This study investigated why more males than females complain of dissatisfaction with their anatomical sex (gender dysphoria). New referrals to a university gender identity clinic were dichotomously classified as heterosexual or homosexual. There were 73 heterosexual and 52 homosexual males; 1 heterosexual and 71 homosexual females. The average heterosexual male was 8 years older at inception than the homosexual groups. The heterosexual males reported that their first cross-gender wishes occurred around the time they first cross-dressed, whereas the homosexual groups reported that cross-gender wishes preceded cross-dressing by 3-4 years. Some history of fetishistic arousal was acknowledged by over 80% of the heterosexual males, compared to fewer than 10% of homosexual males and no homosexual females. The results suggest that males are not differentially susceptible to gender dysphoria per se, but rather that they are differentially susceptible to one of the predisposing conditions, namely, fetishistic transvestism.

This study investigated whether heterosexual males are more likely to regret sex reassignment surgery than homosexual males or females. Subjects were 111 postoperative transsexuals who had been surgically reassigned for at least one year, representing a follow-up rate of 84.1%. Subjects' feelings about surgery were assessed with self-administered questionnaires. None of the 61 homosexual females or 36 homosexual males consciously regretted surgery, compared to 4 of the 14 heterosexual males: a significant difference. This finding suggests that heterosexual applicants for sex reassignment should be evaluated with particular caution, although a heterosexual preference is not an absolute contraindication for surgery.

This study showed that the "socially desirable" presentation for a heterosexual male gender dysphoric is one that emphasizes traits and behaviors characteristic of "classic" transsexualism. Fifty-one homosexual and 64 heterosexual adult male gender patients were administered the Crowne-Marlowe (1964) Social Desirability Scale as well as eight questionnaire measures that tapped various features of the clinical history commonly given great weight in differential diagnosis. The tendency for a heterosexual subject to describe himself in terms of moral excellence or admirable personal qualities was significantly correlated with scores in the "transsexual" direction on all eight sexological measures; for the homosexual subjects, only one correlation was significant. It is argued that the patients most motivated to create a favorable impression on the examiner are likely to be those most anxious to obtain approval for sex reassignment surgery. Because, in this population, the socially desirable presentation is "feminine," it is possible that the differences in the histories produced by transvestites and heterosexual transsexuals are exaggerated to an unknown degree by the motivation of the latter to obtain approval for this operation. The findings do not diminish the important distinction between these groups, but they do suggest caution in interpreting the self-report data that have been used in comparing them.

This study examined the relationship, in a sample of male-to-female transsexuals, between psychological and social adjustment, on the one hand, and gender reorientation (approximation of the status of the opposite biological sex), on the other. Three gender reorientation variables were studied: exogenous female hormones, vaginoplasty, and social feminization (adoption of the female gender role at home and in the transsexual's social life and the procurement of documents indicating the female sex). These three gender reorientation variables plus age were employed as predictor variables in a series of multiple regression analyses. Five stepwise regression analyses were carried out, one for each of five criterion variables (depression, tension, involvement with a male partner, cohabitation with a male partner, and the MMPI Lie Scale). There was a statistically significant negative correlation between depression and social feminization and between tension and social feminization, and a significant positive correlation between cohabitation with a male partner and vaginoplasty. Neither the MMPI Lie Scale nor the simple fact of having been "involved" with a male partner at some point during the past year correlated significantly with any of the predictor variables. These results indicate that gender reorientation is associated with better psychological and social adjustment in male-to-female transsexuals.

Study 1 examined the relation of gender reorientation (approximation of the status of the opposite biological sex) to psychological adjustment in gender dysphorics. Three patient groups were studied in multiple regression analyses, with psychological symptoms as criteria and measures of three roughly sequential components of gender reorientation (role changes, document changes, and physical changes), age, and education as predictors. Psychological complaints correlated negatively with the earliest phase of reorientation for females and with the later phases for males. Age and education bore little relation to current symptoms. Results suggest psychological improvement accompanies gender reorientation in both male and female gender dysphorics; the greatest degree of improvement is seen earlier in the process for females. Subjects in Study 2 were postoperative transsexuals at least 1 year after surgery. Follow-up rate was 77.5% for all patients meeting the 1-year criterion. Satisfaction with surgery was high, and psychosocial adjustment was acceptable for the majority. Results of both studies support the rationale for clinical intervention in aid of gender reorientation in selected cases.The term gender dysphoria (Fisk, 1973) refers to discontent with one's biological sex, the desire to possess the body of the opposite sex, and also to be regarded by others as a member of the opposite sex. Transsexualism may be defined as extreme gender dysphoria that has persisted without fluctuations for a considerable time-2 years, according to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association, 1980). In practice, it is sometimes difficult to decide whether a given patient's gender dysphoria is severe or persistent enough to be labeled transsexualism.The diagnostic criteria for transsexualism in the DSM-III do not require that the individual share the normal sexual interests of the opposite biological sex. All or virtually all fetnale-to-male transsexuals are sexually attracted to females (which makes them homosexual, in the ordinary sense of the word). Male-to-female transsexuals, however, may be homosexual (attracted to males) or hetero-Requests for reprints should be sent to Ray Blanchard,