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Most of the currently available methods for the psychological treatment of behavioral disturbances (including sexual disturbances) are one of two models, the psychoanalytic or the behavioral. The psychoanalytic methods range from the orthodox free-association and dream interpretation to the newer methods such as primal scream and bioenergetics. All have in common the «freeing» of unconscious forces and feelings and the consequent change in the behavioral disturbance. The behavioral model provides a completely opposite approach. It either denies, ignores, or minimizes unconscious forces and attempts to change the disturbed behavior directly. To understand fully the behavioral approach to the treatment of sexual disorders, the difference between these two models must be examined.
One clarification of the difference between the two models is provided by Wachtel’s consideration of the unconscious processes. He argues that these processes may be viewed as either independent variables or as dependent variables.
When these unconscious processes are considered as independent variables, it is assumed that they are tendencies within the person, locked in the past and unresponsive to current events in the person’s life. They exert a pressure unchanging in quality or intensity. Behavior is the dependent variable in that these unconscious forces influence feelings, perceptions, and actions. Changing the independent variables, the unconscious processes, thus is the only way to change the dependent variables, the behaviors. Insight, conflict resolution, working-through, abreaction, and other methods stemming from the Freudian paradigm are the only means of altering the behavioral disturbance, in a meaningful way.
But when considered as a dependent variable, it is the reverse: the person’s action and life-style influence the unconscious processes. Although the unconscious processes originally may have caused the person to act in certain ways, to form a given life-style, it is these actions and their consequences that now perpetuate and maintain these very same unconscious forces. By deliberately changing specific behaviors (now considered the independent variable), not only may various symptoms be made to disappear, but also the (dependent) intrapsychic forces maintained by these behaviors may be changed. Following this line of reasoning, changing behaviors does lead to «deeper» change even in the Freudian sense of these words. The technology of behavior therapy is the most effective means for achieving these behavioral changes.
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Sex reassignment is a rehabilitative form of therapy, not a cure. It is used because other forms of therapy capable of ameliorating the transsexual’s suffering have not, to date, been proved effective.
Initially the therapeutic goal is for the patient to achieve success in the two-year, real-life test. During this period, hormonal reassignment is instituted. With the exception of deepening of the voice in the female-to-male transsexual, hormonal changes are reversible if the test proves to the patient that his or her transsexualism does not warrant further pursuit of reassignment.
The following male-to-female hormone dosages have been found satisfactory: Estinyl (ethinyl estradiol) 0.02 mg. daily, or Premarin (conjugated equine estrogens) 0.6 to 1.25 mg. daily. Before gonadectomy, the treatment would be every day for a minimum of four to eight months. Following surgery, treatment should be cyclic, for the first three weeks of each month, missing the fourth week.
An alternative to the foregoing would be a commercial product combining estrogen and progestin, for example: Lo-Ovral 1 mg. (norgestrel 0.3 mg. and ethinyl estradiol 0.03 mg.), or Ovral (norgestrel 0.5 mg. and ethinyl estradiol 0.05 mg.). The dosage of those preparations is one tablet daily for the first three weeks of each month.
If the patient prefers not to accommodate to a daily oral therapy, but to an intramuscular one instead, then the following could be prescribed: Delestrogen (estradiol valerate) 5 mg. plus Delalutin (hydroxy-progesterone caproate) 62.5 mg. every two weeks. Another intramuscular combined treatment could be: Depo-Estradiol cypionate 1 mg. plus Depo-Provera 25 mg. every two weeks.
After four to eight months of biweekly therapy, the same dosages could be given once every three or four weeks.
If in the preoperative state, the above dosages prove insufficiently effective after four to six weeks, then the dosage could be doubled. Otherwise, the rule is to use the dosage that is thought presently to be replacement therapy for normal women.
Hormonal feminization of male-to-female transsexuals promotes a female appearance insofar as it brings about a feminine redistribution of subcutaneous fat. It also stimulates breast enlargement (gynecomastia), and may somewhat retard the growth of facial and body hair.
Hormone dosage for female-to-male transsexuals which has provided satisfactory results is: Delatestrel (testosterone enanthate) 400 mg. intramuscularly once a month.
Hormonal masculinization of the female-to-male transsexual induces suppression of the menses, but breakthrough bleeding may eventually occur. Permanent suppression requires castration (ovariectomy) or hysterectomy, preferably both. Other effects of hormonal masculinization include deepening of the voice and growth of facial and body hair. The shrinking effect on the breasts is minimal. The clitoris enlarges, but not sufficiently to permit masculinizing surgical reconstruction as even a very small micropenis. Its erotic sensitivity increases. The feeling of orgasm is reported as increased with no loss of the female capacity for multiple orgasm.
The above hormonal dosage does not prevent menopause-like symptoms following ovariectomy. Control of such symptoms may require additional estrogenic therapy with gradual withdrawal over a period of three to six months.
During the period of the real-life test, male-to-female transsexuals may take voice retraining. They may also begin electrolysis for removal of facial hair and perhaps body hair also. These services are provided by trained and certified experts, usually in private practice, not in a hospital.
In some cases of female-to-male transexualism, mastectomy is necessary during the period of the real-life test, especially if the patient works as a male in a job in which exposure of a female chest contour, however disguised, is incompatible with continued employment.
A few patients need cosmetic and etiquette counseling, but most are masters of these arts without special help.
To a variable extent, local legal advice may be needed during the period of the real-life test, especially if a divorce is necessary, and also with regard to change of name and sex on documents. Complete legal recognition of the change of sexual status, in the form of a reissued birth certificate, varies according to legal jurisdiction. Usually a medical statement is needed for the legal change, after the sex reassignment has been completed.
The amount of counseling needed during the real-life test varies according to individual need and traveling distance. Patients from far away need a local counselor working in collaboration with the main center.
Some transsexuals disown their families, and others are disowned by their families. The ideal of rehabilitation is to have the reassigned transsexual acceptable to the family, however limited the personal contact. Therefore, family counseling is also a prerequisite. The siblings, especially the young ones, should not be overlooked in the overall plan of counseling. Non-family members, including the lover, personal friends, teachers, and employers also may be given information and advice on how to contribute to the transsexual’s total rehabilitation.
Sex reassignment surgery is too highly technical a procedure to be discussed here in detail. Male-to-female surgery has been reasonably well perfected, though in some cases there are residual problems of contracture and constriction of the vaginal canal requiring an additional operation. The end result can be convincingly feminine in appearance and function. Female-to-male surgery of the external genitalia presents insurmountable problems as great as in the case of congenital aplasia of the penis or accidental amputation of the penis. A plastic surgeon can make a penis of grafted skin, but it requires from five to fifteen surgical admissions, and the end result is a penis that is numb, unable to erect, and subject too easily to urethral constriction and urinary infection. For sexual intercourse, such an organ can penetrate the vagina only if supported, as in a hollow dildo. Thus, there is very good reason for the female-to-male transsexual to settle for a strap-on prosthetic penis and to avoid the expense, pain, and poor result of very time-consuming surgery.
Female-to-male transsexuals who undergo genital surgery do not lose the clitoris and so retain the capacity for orgasm. In fact, the orgasm is enhanced under the influence of androgen therapy. Male-to-female transsexuals lose the kind of ejaculatory orgasm they once knew, but without regret, for it is replaced by a climactic feeling which, even though more diffuse, satisfies them all the more because they are able to satisfy a male partner.
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Sex and sexual relations are variously understood by Americans through shifts in the respective stress given to the order of nature and the order of culture (or law). Sex may be posed as animalistic. Equally, «proper» sexual relations entail ritualization, order, and control. Even for groups within the population that accept forms of sexual relations more generally viewed as deviant, sex involves ritualized behavior and technique. Within American society, mainstream understandings of sexual relations as an exclusive intimacy enjoyed between wife and husband seem increasingly to be complemented by alternative notions of what sex is or should be. David Kemnitzer) writes about a new cultural construction of sex among young professional and white-collar workers. In analyzing the fact that there is a crucial stress on sex-as-technique among this group, Kemnitzer notes the wide popularity of Masters’ and Johnson’s Human Sexual Response «despite its turgid prose, outlandish price, and lack of pictures». Although sexual how-to-do-it books proliferate, the essence of the new sexuality may well be not what it initially appears. Kemnitzer concludes: «For sex to be a matter of technique, a form of work an arena for competence, the partner . . . must be rendered a thing, rather than a person». Precisely among the very groups which mainstream society sees as most animalistic in their sexual behaviors, «technique» and «competence» commandeer sexual relations.
Such alternative sexual patterns notwithstanding, notions of «proper» sex would seem to be predicated largely upon images of sex within marriage and certainly of sex between two adult partners of different gender. Though this image may be of shifting consequence to constraints imposed by law or enacted in behavior, it is sustained as the one sexual relation which receives legal prescription: non-consummation is grounds for annulment or divorce. Until recently sex within marriage was the only form of sexual relation not explicitly prohibited in at least some states. For the most part, the constraints of law within the United States have restricted legal sexual relations to those between particular sorts of people (related in law but not in blood), to particular (private) places, and to particular forms (genital-to-genital contact). «Indeed it has been said,» writes Schur, «that all unmarried adolescents and adults in our society—male and female, heterosexually inclined as well as homosexually oriented—are forced to choose between abstinence and ‘criminality’ «. Almost every sexual act not contained within the rigid definitions of person, place, and form has been defined as criminal. Criminal sexual activities with the wrong person have included incest with relatives (a category which itself is variously defined from state to state), homosexuality with a member of the same sex, fornication or adultery if the partners are unmarried or are married to others, masturbation if with oneself, and sodomy if with an animal. Sex in the wrong place may constitute the criminal act of public lewdness. Perhaps most surprising, even when the partner and the place do not contravene the bounds of legality, the mode of enactment may open the partners to criminal accusation. Anal sex or oral-genital sex variously defined as sodomy or as the «crime against nature,» offer accused parties long jail terms and heavy fines. (Most convictions for this last crime have not involved married partners; however, sodomy, including anal or oral intercourse, has been formally illegal in the United States even between husband and wife.)
These three sorts of limitations on sexual behavior (with whom, where, and how), though changing over time and in their specific content and application, allow classification of legislative enactments and judicial decisions pertaining to the legality of sex. Each separately and the three together are part of more pervasive cultural contrasts within American society. The category, spouse, as the most appropriate sexual partner, is based on a classification which separates family from non-family and within the family, a particular relation-in-law (that of spouse) from other relations-in-law and from relations-in-blood. In defining the bedroom or other similar place as that appropriate for sex, a domain of private space is distinguished from one of public space. The third limitation on sexual activity—how—is perhaps the most tricky; on the one hand, culture or law (ordered, prescribed, or prohibited activity) is separated from nature (unordered, even animalistic, activity); the first has been considered appropriate, tolerable, or legal; the second has not. This division is complicated precisely because culturally created notions of proper sexual forms frequently have been justified through the admonition that they are natural. The term «crimes against nature» has served as a euphemism for sodomy (itself a term variously referring to any or all of mutual masturbation, oral intercourse, anal intercourse, and sex with animals). The confusion can be put to rest at least minimally in a cross-cultural perspective. One might note simply that the sexual form upheld as most respectable within the West has elsewhere been tagged the «missionary position» (Bullough). To the extent that proper sex has been conceived as natural, the intent has been not to define natural in opposition to cultural or lawlike, but rather has been based on an equation between that which is natural and that which is approved by the Divinity.
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The clinical study of children who early in their lives show evidences of faulty or deviant gender identity formation is another area of recent exploration. We owe much to the pioneer work done by Money, Hampson, and Hampson, Money and Erhardt, Green and Money, and Stoller. Because of these and similar studies, there now are new ways of looking at sexual development and its fundamental and prevailing influence upon the development of personality.
These investigators began their studies from a clinical perspective. They attempted to understand those individuals with anatomically ambiguous genitalia, such as hermaphrodites, whose condition is due to gonadal, hormonal, and genetic factors. This line of inquiry has its counterpart in the study of transsexualism, the extreme form of gender reversal in which the anatomical male believes he is inwardly female, or the anatomical female considers herself psychologically a male. It appears now that in the development of sexuality and personality, certain influences are responsible for the final patterns of personality functioning, the nature of affectional affiliations, and the individual’s personal identity. A most important question is what influences are responsible for one’s gender identity or, as Stoller puts it, for «one’s sense of masculinity and femininity», regardless of the individual’s anatomical and biological sex assignment. It would seem that the individual’s gender identity is not based wholly on his or her biological and genetic imprint. Environment, culture, and parents exert a very important and, at times, crucial influence. Children born with anatomically ambiguous genitalia will act, feel, and desire as males or females depending upon their sex assignment by the parents, independent of their genetic sexual make-up. In fact, these individuals in adulthood are not distinguishable from those with an absolutely clear sexual/gender identity. Some whose gender identity is based on the sex role assigned by the parents early in life despite their genetic and biological sex assignment, function normally. Others exhibit gender identity, confusion, and conflicts similar to those observed in neurotics. These conflicts, however, seem to be related to various traumas and early frustrations that are the basis of many neurotic behaviors, rather than to specific disorders of core gender-identity development.
It appears that core gender identity is formed early in life, and that once formed it will endure throughout the individual’s life, highly resistant to environmental or psychotherapeutic intervention. Since the formation takes place over an extremely short period (the first eighteen months of life), many theoreticians use the process of imprinting (borrowed from ethologists) to explain not only the speed of the formation but also the later resistance to modification.
The question of how environment influences gender identity is of particular interest to those developmentalists who are exploring the roots of individuality and the determining forces behind it. There are several character traits that each culture assigns predominantly to either of the sexes. Of course, it is an oversimplification to talk about these traits as either male or female. Observation shows that what is called a male or female trait by the culture is usually present in both sexes, but often a cluster of «feminine» or «masculine» traits tend to predominate in a particular sex. These traits include such behaviors as manner of talking, pattern of postures and expressive body movements, preference for certain toys or tools, and style of grooming and clothing. In other words, it seems that each culture has a way of classifying feminine and masculine behavior, and hat in most instances the members of the culture adopt these behaviors according to their sexual and gender identity. There are a number of individuals within most cultures who for various reasons display behavior normally assigned to the opposite sex. These children with atypical sex-role behavior (Green), by their rigid attachment to the opposite sex’s patterns of clothing, peer-selection, and mannerisms once again provide strong evidence for the link between gender-identity formation and personality-trait development. The scant information about the later development of these children indicates that these early traits have an impact on their adult gender-role and sexual-orientation behavior. For example, Green reports that adult transsexualism could be an extension of early femininity in boys. Bieber reports that two-thirds of a group of adult homosexuals had some history of feminine behavior during their childhood. In another report (Prince and Bentler) there were episodes of cross-dressing during childhood among one-half of all adult transvestites.
To summarize, the development of core gender identity seems to depend upon genetic, gonadal, and early environmental influences. Once it is formed, gender identity and self-concept remain stable throughout life, resisting modification by environmental influences.
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The figures on the Redbook wives who had had extramarital sex by different ages are somewhat different, as one would expect, given the nature of the sample. Twenty-nine percent of the total sample had had extramarital sex, the accumulative incidence rising from 20% of the under-twenty-five wives to 40% by age forty and over. A very important variable not mentioned in the other studies was employment of the wife. Full-time employed wives were far more likely to have had extramarital relations than were stay-at-home wives. Among wives in their late thirties, for example, 53% of those employed had had extramarital sex, compared to only 24% of the housewives. Religion was also a factor, with more than twice as many non-religious women as devout women reporting such activity.
Other findings in these studies, which we will briefly summarize, relate to number of partners, frequency of orgasm, and overall pleasure of extramarital sex compared to marital sex, reported by those with both kinds of experience.
Kinsey did not report on any of these variables for his male sample. The data for the number of extramarital partners for both the Kinsey and the Hunt females are almost identical: about 40% in each had had only one partner, and more than 80% had had five or fewer. For the Redbook women, the corresponding percents are 50% and 40%.
The only data comparing marital and extramarital frequency of orgasm are from the Hunt female sample. These women who had had extramarital sex reported that they had orgasm all or almost all the time in 53% of their marital coitus, compared to only 39% of their extramarital coitus, and that they had orgasm almost none or none of the time in 7% of their marital coitus but in 35% of their extramarital coitus. These data suggest that extramarital intercourse is considerably less satisfying than marital intercourse. It is likely that factors such as guilt, haste, anxiety, and inexperience with the partner enter to some extent in these findings.
Related to the figures on orgasm are some data from Hunt’s survey on overall pleasure of marital and extramarital relations. Males rated both marital and extramarital sex more pleasurable than females did, and both sexes gave their marital sex higher ratings than their extramarital experiences.
While adultery seems to be an enduring and intimate aspect of marriage, the data are skimpy, indeed, to support a conclusion that it is increasing, compared to other forms of sexual experience such as premarital or postmarital sex. The exception is its rather dramatic rise among young married women, and this may portend a trend for future observations. As for the other parameters, though one must be very cautious in generalizing from the research, it appears that women, at least, who have extramarital experiences, tend to have few partners rather than many and share with men the experience of being less orgasmic and getting less pleasure from their extramarital encounters than from their sexual relations at home.
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