Psychiatry and The Beaumont Society - An Apologia

Dr. M. T. Haslam

Consultant Psychiatrist, Harrogate Clinic, Yorkshire. Trustee, Beaumont Trust
Gendys Conference, 1992

 
The inspiration for this talk has come from my scanning of various pieces of literature which emanate from the Beaumont Society, and other TV/TS organisations and which often seem to have a rather distorted view of the role of the psychiatrist, and also to look at a number of misconceptions which seem regularly to crop up. I would like to develop the concept of the "in between" in society and how society does and could perceive such people.

Perhaps a text for a talk of this kind could be taken from Sinatra "I have looked at life from both sides now. It's life's illusions I recall, I really don't know life at all".

It seems to me that the great last taboo is neither sex nor death, the two that are commonly quoted, but rather that of gender. So much of daily living and society's attitudes are designed to polarise the two, the masculine and feminine, to separate them and to distinguish them. The purpose of this I suppose is to allow an individual to know with whom they are dealing and this is a very basic concept which must derive from the rel ationship which will then take place between such two people and sexual attitudes that may be engendered. To be an inbetween therefore is to transgress these boundaries and is to confuse the observer at a very basic level as to how they should behave. This dilemma remains despite endeavours by some areas of society such as feminists to break down these barriers and indeed I would suggest that such organisations often inadvertently reinforce them.

But let us go back to the relationship of the psychiatrist to the inbetweens. What is a psychiatrist? A psychiatrist is a doctor who has been through medical school and qualifies and decides after completing his general training to specialise in diseases which affect mood, thinking and memory, and deriving out of these three, behaviour i.e. the mentally ill. Now what is cross dressing? Do we perceive this as an illness or a disease? If we do then the psychiatrist should take an interest in it. If on the other hand we perceive it as a piece of behaviour derived from whatever source which is outside the medical model (just as is red hair or a particular interest in playing golf) then it would seem to have no direct reason to impinge on the psychiatric profession. The psychiatrist need have no more knowledge of it than he would have of any other area of human behaviour, except as a general matter of interest or, conceivably, research. Research into this area would be as legitimate as research into why certain people have red hair when others are a black/blond continuum or why certain people grow up to be golfers in contrast to others who grow up to be snooker players. So why does the transvestite go to a psychiatrist and why does he expect the psychiatrist to know any more about his problems than he knows about those of golfers?

The fact is of course that inbetweens are subject to pressures from society in the same way as any minority group. Minority groups tend to feel stress because they are often alienated from the society in which they live and for this reason they go to a psychiatrist.

Not all psychiatrists by any means will have expertise in problems associated with cross dressing or indeed more especially with transsexual problems, and one must therefore find a clinic or a therapist who has got the expertise if one is going to get useful advice.

Another area that I have found to be controversial and frequently cropping up in the TV/TS literature is this "difference" between the two groups and the attempt to label people which, as in psychiatry itself can get more and more unnecessarily complicated. This whole issue of transvestism being distinct from transsexualism was really started by Sir Martin Roth when he was Professor of Psychiatry in Newcastle some twentyfive years ago. I was working with him at that time as was Harry Brierley who wrote the current definitive book on transvestism and was aware, of course, of Sir Martin's limited experience in the practical side of the management of these type of problems when they presented.

Sir Martin was also involved in another controversial area at the time; that being whether neurotic depression and endogenous or psychotic depression were two distinct entities or whether they formed part of a continuum, reactive depression being one end of the scale and endogenous depression at the other. The Newcastle School under Roth saw them as two separate entities while the Edinburgh School at that time I think under Forrest believed the contrary. This was all the result of a rather complicated statistical analysis of questionnaires, and the matter was to some extent resolved when Max Hamilton from Leeds pointed out that neither was the case since people had to be mapped on a diagram which showed two scales at right angles to each other, one being from normal to neurotic depression and the other from normal to psychotic depression, people clustering in certain quadrants of that graph.

The distinction between transexualism and transvestism resolved upon a rather similar line of argument and of course depended very much on the type of questions that were asked. It is certainly true that at one end of the scale or one end perhaps of the spectrum there are individuals who cross dress purely as a fetishistic type of sexual arousal. It is equally true at the other end of the scale that there are individuals who are almost delusionally convinced that they are trapped in the wrong body for their real gender. This concept would only be provable if we could establish that there is such a thing as a male or female brain inside the wrong genetic body, but the point is whether the vast majority of people who cross dress fall at either end of these extremes, or whether not rather there is a normal curve of distribution with the majority of cross dressers falling within one standard deviation of the mean.

I would like to remind you briefly of some work which we did, some of which was presented at this meeting two years ago, in two studies which have been published in the British Journal of Clinical and Social Psychiatry. In the first study 600 members of the Beaumont Society were sent a questionnaire which they were asked to complete anonymously and return to the author. 220 replies were received. The results of the questionnaire were analysed and were compared with a smaller but reasonably matched control group. Now these were Beaumont Society members so in theory should have been weighted very much to the TV as opposed to the TS scene, if such a distinction is to be made. I quote a few of the results:

The mean age at which respondents recalled the first cross dressing experience was 9, and 50% of the cases recalled dressing as young children, the majority beginning well before puberty. There was little association with sexual response in the early days, but during the teens an element of sexuality often appeared since cross dressing was incorporated as part of a masturbatory routine. In the control group some 7% recalled cross dressing experiences in childhood but the majority had attached no significance to this, though in 3% it had been associated with masturbation.

Profile of family history, of peer relationships and of personality as tested by the MPI, a personality assessment used at that time showed no difference between the controls and the respondent group. Furthermore though some 35% of respondents had considered that there had been some sort of early reason for their having developed cross dressing interests, this group showed no positive correlation with any of the rest of the data and the reasons given were many and varied, for example some 10% recalled being seduced into a cross dressing experience by some older person, usually a relative, but conversely of course this means that 90% of respondents did not have this experience even though 100% of them cross dressed. Indeed the positive results that came out of comparing the control group were simply that death of a father, death of the mother, having sisters only as siblings and being subjected to a separation experience were all commoner in the respondent than in the control group as was a rather strict and dominant mother.

However when the respondents were questioned about transvestism versus transexualism we found that 65% of the respondents wished that they had been born a woman. 40% perceived themselves as having a feminine psyche trapped in a male body, and this correlated with a submissiveness factor and being born to older mothers, and 30% saw themselves has having progressed through a transvestite phase to what they perceived as a transexual phase. 48% of our respondents were living as women for as much of their lives as was possible and would have lived full time if circumstances allowed, and as many as 30% were interested in the possibility of exploring a sex change operation, though 60% would become women were there some magic wand way of achieving this. Only 2% had actually completed gender reorientation surgery and I must remind you that these were respondents from a purportedly transvestite club, namely the Beaumont Society.

Much recent evidence indeed suggests that there may be some prenatal factor involved in the general syndrome of gender dysphoria and the results of factor analysis of our study identified a series of principle factors, the first factor being a matriarchal family structure and the second a high parental age at birth of the respondent. The third factor identified the sibling structure within the family where an only child or first born predominated in the transvestite group compared with the controls, but there was no direct relationship within the 220 respondents between family factors and the types of TV or TS behaviour described.

The next stage in such an analysis is to remove general factors which appear irrelevant and to carry out a further principle factor analysis on those remaining, and this showed that a "severity of transexualism factor" related to an early age in cross dressing, a progression of transvestism to transexualism, the expression of a wish to have been born a female, a desire for operation, and a desire to live full time. This accounted for 11% of variance. The second factor which accounted for 8% of variance related to the sexual drive component and the third factor accounting for 7% of the variance, of that of maternal power within the family unit, but this was not related to any of the other variables directly. Thus it would seem that a number of non specific factors occur in the early history and environment more commonly in the respondent group than in the general population, a separation experience being one such. The awareness on the whole however was prepubertal and the suggested environmental reasons did not remotely reach any sort of statistical significance.

The other paper which was presented related to a test done on a number of individuals in the York/Leeds area some ten years ago which was an estrogen provocation test whereby some 30 individuals who volunteered and who were not taking hormones and were pre-operative had a four day series of blood tests where an injection of an estrogen preparation was given and measurements were made of pituitary hormone levels from a pre-injection baseline for the next four days.

A typical male response is an initial drop in these pituitary hormone levels, in particular luteinising hormone, from the baseline to its lowest level after some forty eight hours, followed by a gradual return to normal. In the female however the initial drop is followed by a reflexive increase in levels of some 20% above the baseline norm before the return to normal making an S shape type of curve, the peak being reached on the third or fourth day after the injection. Complete data are only obtainable on 12 individuals. It would be anticipated from work done by D�rner in Germany that some 15% of males might show a female type of response by chance and if one uses this figure as the control and applies a chi squared test, for those of you who are familiar with statistics, our results show an increased female type of response in our volunteers at a level which would only be produced by chance one time in thirty, in other words chi squared = 4.46 and P would be 0.038.

I will not go into the theoretical background which would determine how reliable such a test would be, but the significance of it is that if it is accurate then it shows that in quite a high proportion of the individuals that we found as volunteers (and by no means all of them considered themselves as pure transexuals) there is some evidence at least for a female type of brain response pattern in a male body.

I would like to revert now to my concept of the "inbetween" which is of course not entirely original having also been developed as a theme by Money in his book. People like, particularly within gender concepts, to have a black/white concept but much of life is in fact grey. While the majority may fit into a clear male or female, masculine or feminine, heterosexual or homosexual model, there are many inbetweens within society. One could think of the true hermaphrodites, or homosexuals themselves, of the transexual and transvestite and many more. There is indeed a variety of human need and experience and this can he treated either with an interested tolerance by society or by a bigoted intolerance. Sadly the latter is often the case, but in a perfect world the inbetweens should be able to function satisfactorily in society at whatever level towards one or other pole they desire to take up, without condemnatory attitudes from others who are perhaps more or less fortunate, depending on one's point of view, in their normality.

Sex and gender are not totally fixed but are modifiable hormonally within the womb as many experiments have shown. Let us explore why society has a problem with inbetweens. They do not fit into the black/white role model. People are uncertain how to behave and this is particularly crucial in an area of gender. This however is a problem for society and perhaps could respond to education.

Unfortunately for the transvestite and transexual individual the black/white situation forces such people to have to try and prove the unprovable, and indeed impossible, in order to convince society that they are what they are quite palpably not, in other words real women or real men, by any conceivable definition. That they are inbetweens is acceptable. That they are as feminine or as female as a genetically born female (if we are thinking of the male to female syndrome) they are certainly not. It is rather absurd to try to prove otherwise. Indeed what does the TS mean by being "a woman locked in a male body" or vice a versa. The female mind does not make a female person any more or less than a female body makes a female person. The two are necessary in harmony for the totality to exist.

The question must arise therefore why inbetweens give offence. What if society completely accepted the male to female cross dresser? Why does one want to "pass"? Why does one want to pose as something that one is not, rather than being what one is, in other words why the need for padding, for wigs, for false attempts to change shape? Is the excitement in the masquerade? Is there an eroticism in the excitement? Much of transvestite literature indeed has an erotic element. Much of it is related to masochistic experiences, to bondage concepts and submission. What is wrong however with being excited? Normal heterosexuals get excited regularly and do not perceive anything wrong with this. Why should the TV try to pretend otherwise? In this perfect world, would the transvestite want to wear the clothes? Would the transvestite still not want to pretend not to be an inbetween, even if inbetweens were respected? I have posed a number of questions here to which there are no answers because we do not have this perfect world. Certain places and certain societies however, as we may see tomorrow, are much more tolerant of inbetweens than are others, and perhaps if one lived in a fully tolerant society one would not need to read the kind of attempt at justification (I quote from Dyscourse Vol. 4, No. 1, page 7) "I feel that I am as much a man as any male that was lucky enough to be born in the right body". One cannot help noticing that in most of the transvestite fantasy literature there is a syndrome of a masochistic forcing him to the role, a conversion and that this is followed by an acceptance on the part of the chosen gender as "one of them". This is of course fantasy rather than reality and sadly the inbetween is rarely accepted by the "normals" of society any more than any other sort of minority group or perceived freak group are. The transexual who has had the sex change operation rarely integrates fully into their own gender and mixes normally with their chosen sex or gender role. I speak in generalities and there are cases who can prove me wrong but the majority, sadly, continue to live within the somewhat twilight zone of their own kind, excluded from many of the activities which their non-inbetween brothers and sisters enjoy. Perhaps instead of trying to prove the impossible we should be trying to gain acceptance for inbetweens in society and allying ourselves with other inbetween groups rather than trying to distance ourselves from them.