Categories of Gender Disorientation and Indecision, Male to Female
Group One: Low Intensity Transvestite
Gender Identity: Feminine identification only with acting out sexual fantasies. Gender Role: Normal Male. Cross-dressing intermittent and private. Eroticism: Genital-heightened arousal when cross-dressed. Biological Feminization: No desire. Conflicts: Guilt over normalcy, spousal disapproval. Desire for Re-assignment: Not considered. Treatment: Provide information and reassurance. Couples therapy. If impulses are ego-alien use behaviour modification, setting limits on cross-dressing sufficient to control guilt but enough to allow emotional relief.
Group Two: Medium Intensity Transvestite
Gender Identity: Appeal for Femininity may spill over into non-sexual life. Gender Role: Cross-dressing more pressured, fetishistic and exhibitionistic. Intermittent relapse of intense need to act on feminine impulses related to stress alternating with reduced desire. Eroticism: Genital-some breast. Biological Feminization: If impulses ego-alien may use spironolactone to reduce libido. Conflicts: Guilt and sexual performance anxiety, threatened masculinity fear of aging. Desire for Re-assignment: Fleeting under stress. Treatment: Insight-oriented psychotherapy to identify and modify sources of stress. Negotiate compromise in transvestitic behaviour such as dressing under male clothing.
Group Three: Transvestitic Transsexual
Gender Identity: Ambivalent gender identity. Value male sex organs but feel feminine. "She-Male" Gender Role: Dresses as much as possible depending on life circumstances. Dressing not necessarily sexual. Impulses often intensify with age and may crystalize into a transsexual picture. Eroticism: Genital and breast. Biological Feminization: Spironolactone for demasculinization + gynecomastia. Some may need hormones for emotional balance. Conflicts: Confusion and personality disorganization, dual personality with male and female names and disassociated personality components. Desire for Re-assignment: May consider late if very inadequate as males, dependent on commitments. Treatment: Integrative psychotherapy to stabilize androgeny. Support for re-assignment if appropriate.
Group Four: Moderate Intensity Transsexual
Gender Identity: Feel female but able to supress until age 30-50. Increasing dichotomy with age. Gender Role: Try macho lifestyle to compensate. Increasing depression and anxiety over time. Never comfortable as males. Eroticism: Genital if fantasizing self as female. Low libido. Biological feminization: Requested late or intermittent. Conflicts: Guilt, loss + fear of passing. Fear of rejection. Confused sexual orientation. Desire for Re-assignment: Re-assignment hoped for, often attained. Treatment: Supportive psychotherapy for symptomatic relief, family therapy, education group for stabilization of female identity.
Group Five: High Intensity Transsexual
Gender Identity: Total gender inversion. Never able to supress femininity. Feminine boys. Gender Role: Dressing insufficient relief. Cross-live early. Eroticism: Often asexual. Biological Feminization: Urgent request. Late teens, early 20's. Conflicts: Stigma of re-assignment. Family and cultural attitudes. Desire for Re-assignment: Urgently requested. Self-mutilate if too long frustrated. Treatment: Education support and family therapy. Assisting process of re-assignment.
