42

AMERICAN JOURNAL OF PSYCHOTHERAPY

tioning to form the transvestitic pattern in later life. This psycho- logical conditioning takes place long before the age of 12 or 13 when the principal attitudes are generally well established. His desire for sexual contacts is usually low, more often hetero- than homo- sexual. He is miserable when dressed as a man and immediately comfortable and relaxed in the clothes of a female. He has become an expert in cosmetic make-up, yet is occasionally in social or legal difficulties. He assumes a female first name and wants to be re- ferred to as "she." He is usually introverted, non-aggressive, and his peculiarity hardly interferes with a smooth functioning of so- ciety. His conflict results from social pressure and legal prohibi- tion. In fighting his peculiarity he sometimes over-emphazises masculinity and becomes known as a "tough guy." In one case the over-compensation took the form of the patient having his en- tire body tattooed. Here masochism may have entered.

More than anything else the psychogenetic transvestite wants to see a change in the existing restrictive laws, so that he can lead a woman's life. He does not want to be changed but wants society's attitude toward him to change, again revealing narcissistic ten- dencies. Treatment is therefore rarely attempted. But if so it would be principally psychoanalytic. Endocrine therapy is rarely indicated. Only if there are signs of hypogonadism, masculiniza- tion may be attempted with testosterone. Simultaneously, a be- lated reenforcement of the maturing process with chorionic gonado- tropin would be logical.

2. The intermediate type. His symptoms and problems are fundamentally the same as in type #1, but decidedly more pro- nounced. Therefore, he inclines at times toward transsexualism, but is at other times content, with merely dressing and acting as a woman. He wavers between homo- and heterosexual desires usually according to chance meetings. He can be a very disturbed person. His masturbation fantasies are narcissistic and he visualizes him- self functioning as a woman.

The gonads are usually within normal limits, but may incline toward underdevelopment suggesting a psycho-sexual infantilism. Skeletal measurements sometimes are of eunuchoid character. He rates low in masculinity and rather high in femininity on the re- spective M.F. scale. There may be more or less feminine markings in his physical make-up, for in ance vide hips, breast development, female hair distribution, etc. Adverse childhood influences, often