Literature Review:

Preface: This literature review was part of an MSc dissertation exploring the level of training counsellors and therapists have in working with issues of sexuality and gender diversity.

Methodology

A combination of academic database searches, web search and citation tracking methods were used to accumulate a body of research material. Initially, University of Bristol library databases were searched for both books and journals. Internet searches were conducted over an extended period of approximately three years (to January 2008) using common search engines including Google Scholar. Search strings and web addresses of these databases are included in Appendix 8. Citation tracking proved particularly effective in linking to other relevant research and texts.

Findings

Male cross-dressing, despite being a common theme in problem pages has only infrequently been the focus of serious academic research. Quite why this is the case is hard to say, although as Suthrell (2004) notes

"friends expressed their surprise that I should want to study such a bizarre group, with their undertones of underground-verging-on-deviant lifestyles"(p3).

Reisbig (2007) remarks that a lack of literature makes it harder for therapists to be appropriately informed and that this has a negative impact on therapeutic interventions. That said, there is a wealth of literature on sexuality and gender studies and it is predominantly from these areas that I have been able to draw both explicitly and implicitly in understanding the phenomenon of why some men are so driven to wear the clothes of the opposite biological sex, despite the potential negative consequences.

In an analysis of over a hundred texts and academic papers on the subjects of sex, sexuality and gender the following themes emerged. Understandings on the aetiology of transvestism and transsexualism, fell broadly into three camps - the biological (neuro-hormonal; genetic), the Social Constructionist/Feminist and the Psychodynamic/Psychoanalytic. The latter, initiated chiefly by Ellis (1959) Storr (1964) and Stoller (1968) seemed to have influenced 'the medical model' and contemporary texts on sexual deviancy or sexual deviation have still referred back to these authors, emphasising the pathological and fetishistic aspects- suggesting transvestism is an un-natural part-object sexuality caused chiefly by parental dynamic (Laws & O'Donohue 1997; Rosen 1996; McConaghy 1993 among others). These authors have often recommended extreme and bizarre treatment protocols involving the use of such things as humiliation of the client, use of emetics, electric shocks applied to the genitals (McConaghy 1993, Zucker & Blanchard 1996,); Electro- Convulsive Therapy (Brierly 1979) and even castration (Stoller 1968)! Ultimately, McConaghy concedes defeat stating that psychotherapy was ineffective in eliminating cross-dressing behaviour leaving him to conclude:

"behaviour therapies are markedly less effective in giving transvestites control over the behaviour as compared to exhibitionists and voyeurs, suggesting that biological as compared to learned factors play a stronger role in transvestism" (1993:p173)

Interestingly, DSM-IV (Morrison 1995, APA 1994) presents 'transvestic fetishism' as a diagnosis of mental illness only in heterosexual men who wear clothes of the opposite sex , since being female or gay excludes one from the criteria. (For a critique of the diagnostic criteria and their application to a case scenario see Moser & Kleinplatz 2002). Recognising that the researchers cited so far were coming from a culturally hetero-normative framework we might consider how this influenced their work. Indeed, it is interesting to note that the dissenting voices historically were researchers such as Hirschfield, and Kinsey and who were acknowledged to have somewhat atypical sexualities.

The notion of transvestism as mental illness and or sickness is exemplified in Arndt (1991:p77) who says

"Psychiatrists consider transvestites more as ill or disabled than as sexual criminals"

Morrison (1995) describing transvestic fetishism, infers the category covers all men who cross dress going on to suggest "some patients have been previously involved in rape, exhibitionism or paedophilia." This paints neither an encouraging nor accurate picture. Bolin (1994) proscribing the notion of transgenderism as illness says:

"Ten years ago transexualism supported the binary gender schema by dividing gender dysphoric individuals into transvestites who were 'sick' or transsexuals who were unfortunates, women trapped in men's bodies"

and argues that transgenderists need to 'come-out' in the way homosexuality had to come-out to gain acceptance and generate understanding. Research by Howells (1984) and Brown et al (1996) challenges the notion that transvestite men are psycho- pathologically any different to the more general male population, (and are therefore not 'ill') a point re-iterated in Moser & Kleinplatz (2002) who argue that diagnostic criteria create the problem, not the cross-dressing. Lance (2002) in a project set within an American educational campus, illustrated that intolerance towards homosexual students (and their resultant psychological distress) was reduced through the delivery of a program of education about, and awareness of LGBT issues to the wider college population. This he proposes as a model for society more generally with regard to transgenderism.

Historical Conceptualisations:

Ekins (1997) makes the point that the 'medical model' dominant until recently was conceptualised from within the historical, biological and psychological understandings of the time. Since sexual minorities had not been explored or understood from within, they could not develop their own legitimacy. It's a classic Catch-22. Ramet (1996) notes that it is chiefly Western and Christian culture that has attached gender to the notion of 'biological' sex dimorphism noting as others do that the Christian faith unlike other faith systems avoids presenting intersex or cross- gendered icons and 'forbids' cross-dressing through a section in the Bible under Deuteronomy 22:5. (see Whittle 2000; Fausto-Sterling 2000). If the dominant discourses of Western culture through the earlier part of the twentieth century were caught up in patriarchy and the religious doctrine of Christianity, (and thus tending perhaps towards a notion of 'sex' as procreation not recreation and hetero-sexuality as part of the 'natural order of things') it starts to make sense that gender images and sexualities that deviated from that 'natural' logic would be deemed un-natural or pathological. Similarly, if we give consideration to Butler's (2007) description of 'gender' as the 'sexualisation of the inequality of men and women' (pxiii) we might understand the way in which it becomes the enforced and enforcing paradigm, given the almost exclusively male ownership of Religious, Governmental, Medical and Psychiatric institutions. Might this also explain the greater fear within men of homosexuality and effeminacy associated as they are with subordination and weakness. (Suthrell 2004; O'Keefe 1999)

Working from within these cultural zeitgeists and viewing the phenomenon of transgenderism and homosexuality through a hetero-normative lens it is understandable that early theorists looked to find 'causes' for these atypical sexualities rather than simply acknowledge, name and understand them.

Although Kinsey et al (1953) had not specifically investigated transvestites as a group per se he did challenge the perception that transvestites were 'repressed homosexuals', describing these as entirely separate phenomenon. Interestingly, so pervasive was the 'repressed homosexual' argument that as Bullough & Bullough (1993) comment, "even if the client claimed he was heterosexual the psychoanalyst could still label him as a latent homosexual." p216

Magnus Hirschfield in 1938 (see Bullough & Bullough 1993; Whittel 2000) had differentiated transvestism as separate from homosexuality repressed or otherwise and it was he who coined the phrase 'transvestism' (literally cross-clothing). Havellock Ellis, one of the leading sex researchers of his time described transvestism as a form of what he termed Sexo-aesthetic inversion (Ellis 1953). Seeing it as more complex than simply adopting the clothes of the opposite sex (transvestism), he coined the phrase 'Eonism' after the Chevalier d'Eon a man who had lived much of his life presenting to the world as female through attire and mannerism. Ellis noted that generally transvestites were heterosexual in orientation but suggested a strong identification with the mother possibly due to an over close attachment. He also noted that like homosexuality, it was not apparently curable. Storr (1964) takes a much more pejorative and dogmatic slant on things suggesting castration anxiety and a failed Oedipal resolution explain the phenomenon. His assertion is that the transvestite is trying to create an idealised fantasy woman because of innate 'inhibitions and fears in any sexual situation with a real woman'. He states that it is the mother who 'wears the trousers' in the home of the transvestite and that at some level he is identifying with this powerful dominant (and therefore 'phallic') woman rather than the 'inadequate' father. (Note that this follows Lacanian thought - the phallus is associated with, or more correctly symbolises, ownership of power and dominance, rather than the notion merely of possessing a penis per se: which set within a patriarchal milieu becomes a logical albeit flawed corollary.) With extraordinary conviction he asserts that transvestites have thus overcome their castration anxiety through identification with this 'phallic woman'. He ultimately describes it as 'emotional immaturity of a rather profound kind' (1964:62).

Stoller (1964) interestingly took a multi-factorial approach to the phenomenon, arguing that:

" The sense of maleness is present and permanent from earliest life and that the penis is not essential to this sense of maleness" p46

He cited the case of two boys who, due to birth abnormalities were born without penises and yet clearly identified as male and engaged in masculine behaviours. Stoller did align though to the passive father and dominant mother argument, popular then, asserting that the mothers of transvestites had secretly wanted girls and had dressed these boys in female attire when the fathers were not around. Interestingly, Prince (in Arndt 1991) was later able to dispute this assertion finding only 4% of his survey of cross-dressers reported this experience.

Roiphe and Galenson (1981) again emphasise the significance of parental dynamics although without demonstrating meaningful clinical data asserting that:

"the importance of paternal availability and support for the boy's growing sense of his male sexual identity during the second part of the second year of life cannot be too strongly stressed" p273

What they don't do is explain for example, how the sons of service personnel manage to develop healthily when many will have experienced fathers away from home for extended periods. Similarly, given the incidence of single parent families, particularly 'single mother-absent father' families that have become increasingly common in the last thirty years might we expect to be 'over-run' with effeminate men by now?

Bullough et al (1983) challenging these explanations make reference to earlier work re-iterating the dominant mother, absent father conceptualisation.

"The so-called 'Bieber Mom' the dominant, overprotective, and close binding woman who superintended a family situation sufficiently pathological to induce sexual variation in her child, has been utilized to explain transvestism and transsexualism (Bieber, 1962, 1968)" p241

concluding from their own data that absent fathers were no more common among the sexual minority groups than they were in the general population.

Limentani (1998) coins the phrase 'vagina man' as his reciprocation to the phallic woman - a man who appears masculine but suffers from a psychic femininity due to an overpowering and symbiotic mother, thus becoming the:

".. mother's treasured phallus, his fate sealed by age 2 or 3 by excluded father and lack of oedipal relationship." p135

Mitchell (2000) agrees with Limentani suggesting the 'vagina man':

"escapes overwhelming primitive anxiety by identifying with an undifferentiated protector…an identification with the otherwise lost object he needs - the woman as mother"

Other contemporary authors have perpetuated this conceptualisation. As cited earlier, Skinner & Cleese (1983) and James (2002) dismissed biological factors in favour of the unresolved Oedipal issues scenario.

Maguire (2004) asserts that the effeminate boy is reacting to 'familial trauma':

"His 'girlish' persona may represent a desperate attempt to keep an abandoning or rejecting mother inside his psyche"p44

However, the clinical evidence base for these assertions is lean to say the least and at some level they have perhaps only sustained themselves through a process of self- reinforcement. Martell et al (2004) make the point that until recently certain schools of therapy (particularly psychoanalytic) would not admit openly homosexual therapists on to the training courses since anything less than heterosexual orientation was deemed 'immature' and thus the individual was considered 'impaired'. You'd need to be 'cured' or 'normal' before you could join and thus a circular argument is created. Increasingly researchers have used more scientific methods to challenge psychoanalytic conceptualisations. Acroyd (1979) describes evidence to back psychoanalytic explanations as 'not convincing', an outcome later repeated and echoed by Bullough et al (1983) and Schott (1995), the former concluding that:

"the psychoanalytic picture of the domineering mother and weak or absent father was not supported by the data",p249

If, even as early as 1949, Cauldwell had argued that trying to treat transvestism was 'as foolish as trying to treat some star to behave differently in the solar system'. What sense might we make of its aetiology and manifestations and how might we regard it?

Contemporary understandings:

Increasingly, theorists are suggesting the possible influence of pre-natal hormonal environments and genetic predispositions as formative in the phenomenon of gendered behaviours and thus transgenderism. Interestingly, ultimately aligned to the biological influence theorists was Money (1995) who gained considerable attention earlier in his career through what has now come to be known as the 'notorious' John/Joan case. (as detailed in Appendix 3). Originally supporting a notion that gender identity was entirely socially defined he has since implicated the influence of prenatal hormones and maternal stress during key points in the pregnancy on gendered behaviour of the infant suggesting a 'critical phase' hypothesis. This view is supported by McConaghy (1993) who notes that even Freud originally suggested 'constitutional and experiential elements' in the development of homosexuality and transsexualism, and cites research from as early as 1953 (Bakwin and Bakwin 1953) which proposed a biological mechanism behind homosexual and trans-gendered identity/behaviour, challenging the underlying model of the time which was more focussed on the family dynamics.

Brizendine (2007) argues that at the heart of enduring misunderstandings about female [and implicitly male] psychology was the mistaken belief that women were 'small men'. Moir & Moir (1998) similarly note how political correctness confused equality with sameness and argue that biologically male and female brains are structurally and functionally different. Brizendine (2007) makes the point:

"Until eight weeks old every brain looks female - female is nature's default gender setting. A huge testosterone surge beginning in the eighth week will turn this unisex brain male". p14

Citing the example of girls born with congenital adrenal hyperplasia she asserts that prenatal hormonal environments affect the outcome on key identifiers such as 'rough and tumble play'. Evidence for the influence of prenatal hormones at critical developmental phases is also put forward by Howells (1984), Durden-Smith & deSimone (1983), Mustanski et al (2002) Lippa (2005) and Manning (2008), chiefly citing animal experiments and human intersex conditions as evidence (for more on intersex conditions refer to O'Keefe 1999; Lippa 2005; Fausto-Sterling 2000).

Kruijver et al (2000) investigated a specific portion of the brain (the bed nucleus of the stria terminalis) and identified significant differences between male brains, and those of male-to-female transsexuals noting the latter closely matched more typically female patterns. Wilson et al (2002) investigating the same area of the brain present findings suggesting these brain sex differences develop over a period possibly extending into adulthood but is defined and influenced by prenatal elements.

Lippa (2005) suggests the middle third of pregnancy as potentially critical to brain based gender identity. Suggesting DNA as a human 'recipe' (and using a cake baking analogy) he argues that external conditions such as hormones and early rearing can significantly affect the outcome. Gosselin & Wilson (1980) supporting the argument for a combination of genetic and environmental components comment on the greater vulnerability of the male foetus to environmental variables in-utero (given that all foetuses start as female and need to become masculinised through a series of hormonal developmental phases). It is already widely acknowledged that male children are more likely to suffer from autism, dyslexia, ADHD and left-handedness, and theories on the aetiology on these include brain development trauma and 'developmental instability' during pregnancy. It is interesting to note that there is a significantly higher incidence of left-handedness in homosexual and transsexual males than the general population (see Coren 1982; Howells 1984; McManus 2002; Reed 2006; Blanchard & Lippa 2007; Manning 2008).

Mustanski et al (2002) find strong evidence to support the influence of genetics and some evidence to support hormonal influences in the development of sexual and gendered behaviour, particularly in male foetuses. Howells (1984) suggests minor damage to the left side of the brain, as "more likely to result in bizarre or unorthodox targets for sexual arousal" which if true, is interesting given that left-handed males are right brain dominant. Coren (1982) cites research linking testosterone levels in-utero to developmental problems with the left hemisphere implicating this in the aetiology of left-handedness.

Although searching for biological aetiologies is controversial (given that it can be used as an argument to find 'cures' or to eliminate certain sub-groups from society) I assert that it can also be of value if it challenges those who believe the symptoms are merely 'narcissistic choice'. I would ultimately concur with Bullough & Bullough (1993), who argue that whilst evidence for genetic and physiological precursors has been 'growing over the last two decades' their conclusion is that:

"Gender identity is apparently the product of a complex interaction among three factors - a genetic predisposition, physiological factors and the socialization process" p313.

If, as seems to be the case, sexual orientation and gendered behaviours are separately defined aspects of brain development, what implications does this have for the male child who has a brain more oriented towards the feminine developmental pattern?

Social Constructionism - The 'Self' defined through family, school and society:

As my research journey has increasingly illustrated to me the complexity and diversity of the origins of the gendered and sexual self, I am reminded of a remark by a lesbian friend of mine some years ago.

"God's idea of a joke was to create ten different sexes and then call them 'man' and 'woman'"

Dzelme & Jones (2001) comment:

"At birth, society and family begin the pattern of mapping out the appropriate gender role" p294

I have always been aware of the very narrow bandwidth of socially acceptable masculine identity. In school in the 1970's, there were clear delineations between male and female, enforced mostly by the social group with threats of being identified as 'poof''; 'sissy'; 'queer'; or 'gay' for any non-conformity. It seems little has changed in the past thirty years (see Frosh et al 2002; Renold 2005; Lippa 2005). Recent research in schools looking at the development of gendered and sexual identities by these authors shows that 'homophobia' is still rife (and at some level still officially sanctioned) although it is fairer to say that it refers more to non-masculine behaviour rather than a perception that the boy accused is sexually attracted to other boys. As Renold (2005) identifies it was

"children who actively persisted to subvert and resist dominant and hegemonic identities who were routinely targeted [for bullying]; P82:

It remains the case then that the main way of defining masculinity and boy-ness is in opposition to feminine, leading to an essential suppression of the feminine for fear of exposure, ridicule and rejection. In endeavouring to understand the need for a male to adopt the clothing and or part time identity of a woman we might consider the internal conflict and shame between these internalised messages about acceptable identities and the inner experiencing of the self. For the girl who wishes to explore and at some level express her masculine elements is the option of the tom-boy which seems to have greater social acceptability. (see Hite 1981; Woodhouse 1989; Ramet 1996; Atkinson et al 1996; Garber 1997; Wilson & Rahman 2005; Moorhead 2007). For boys wishing to identify with or venture into any part of 'girl-world' comes the rejection of the peer group and the threat of physical violence. Haywood & Mac an Ghaill (2003) describe the use of physical violence to reinforce 'appropriate maleness' within boyhood school culture; the notion of femininity (and therefore by implication homosexuality) becoming 'structuring anxieties' for men (see also Denman 2004; Schaivi 2004). Boys who wish to express aspects of a feminine self may also experience rejection from fathers (Atkinson et al 1996) indeed, an interesting counter to the dominant mother absent father model is put forward by Wilson & Rahman (2005) who suggest that it is fathers who withdraw from their effeminate sons. Roiphe & Galenson (1981) comment on the overt and covert gendered socialisation process of children by their parents: a point re-iterated in Chesser (1964) who remarks that the:

" child learns to adapt behaviour to accord with parental non-verbal cues" p147

Schaivi (2004) coins the phrase effeminaphobia to describe the social (and here I would add paternal) discomfort with 'effeminate' boys saying:

"If a girl-boy has any story to tell it would seem to be that of compulsory integration within recognizable narrative passages of heterosexual love and family"(2004:1)

Ramet (1996) describes 'gender' as being 'the very core of an individuals self- definition' and identity. Devor (2004) suggests that within the self is a 'deep need to be witnessed by others for whom we are' but notes that intense social disapproval of effeminate behaviour in men constrains this. Suthrell (2004) remarks,

" For males to espouse female traits is somehow not only pointless but deeply ridiculous – in an unacceptable way…" p154

Others comment on the social injunctions against males adopting cross-gendered identities identifying terms such as "silly; freakish; funny; deviant; perverted; un- natural; un-manly; repulsive; morally perverse; wierdos; queers" (Acroyd 1979; Woodhouse 1989; Peakman 2004; Bloom 2002; Perlman 2003; Ekins 1997). So that perhaps as Bullough & Bullough (1993) remark:

"This perceived unwillingness of society to allow males to express what society has labelled a feminine side is more a pathology of our society than of the individual" p363

Given the social stigma associated with the expression of femininity in boys it seems hardly surprising that the male who experiences the world through a brain that bio- psychically sits somewhere between the binary divide (male-or-female) is faced with an impossible dilemma, which Lee (2005) describes as the 'beach-ball held under water' scenario: it takes a lot of energy to keep it hidden and eventually it needs to surface in some way. Butler (1993, 2007) describes 'gender' as 'performed; reiterative'; arguing that:

"Heterosexual gender norms produce inapproximable ideals, heterosexuality can be said to operate through the regulated production of 'man ' and 'woman'. These are for the most part compulsory performances, ones which none of us choose but which each of us is forced to negotiate."(1993:237).

I concur, although suggest that women have greater freedom through the advancement of feminism to perform a more diverse 'femininity' than men do their 'masculinity'.

Cross-dressing carries with it great internalised shame (Bullough and Bullough 1993; Martell et al 1994; Schott 1995; Suthrell 2004; Lippa 2005), perhaps because historically it has been associated with homosexuality and or fetishistic and thereby masturbatory fantasies. Generally conducted in secret, as Reisbig (2007) points out, the clinical samples historically may not be truly representative of the more general transgendered and cross-dressing population.

For the male with a strong desire to experience a feminine aspect of self against these cultural injunctions, the social disapproval and messages of internal shame it seems reasonable to deduce that occasions to cross-dress become highly charged events emotionally and therefore sexually. It is understandable but incorrect to assume that the cross-dressing is invariably fetishistic. As Lee (2005) points out, there is no reason to believe that there are any more fetishists in the cross-dressing community than in the male population as a whole. Ekins (1997) from his extensive study and involvement in the transgendered community reports that when opportunities for dressing are more frequent and less covert, the sexual element becomes un-important, and these men simply describe a sense of 'inner peace' when dressed - an escape from the demands of 'performing' the false 'masculine' self. Bullough et al (1983) comparing transsexuals with transvestites, found that:

"Transvestites were eminently successful, were heavily into male identified occupations, and, outwardly, seemed secure in their role as males. Perhaps the very security of success in the male world carries a burden which the adoption of a feminine persona allows them to escape". p250

Moser & Kleinplatz (2002) suggest therapists challenge their preconceptions about the maladaptivity of cross-dressing arguing that there is no empirical evidence that it is problematic or a mental disorder. Whilst I agree with the latter I assert that it is naive to assume that it is not problematic for many. The cross-dresser has to accept the limitations and prejudice of current society - walking down the street cross- dressed is not necessarily safe (Eddie Izzard describes being beaten up for being cross dressed (Izzard et al 1998); Vicky Lee (2005) suggests using a taxi to move between T-girl friendly hotel and trans-venue). And few are fortunate enough to have a partner who can manage to do any more than perhaps tolerate the behaviour.

Conclusions arising from the review of available literature:

What has ultimately become clear to me as a researcher, is that 'transvestism' per se, is not a single or fixed entity but one with complex manifestations: further, its aetiology remains to some extent disputed. A comprehensive review of the literature has failed to find substantiated evidence to support earlier notions of dysfunctional parental dynamics (dominant mother-weak father hypothesis; mother dressing boy as girl scenario). There is however sufficient evidence from other research to clearly dispute these early theories. Feminism and Social Constructionism as philosophical schools have suggested that all gendered behaviours were learned and conditioned through the socialisation process and I have previously been strongly influenced by these ideologies. However, this has run contrary to the experience of even feminist friends of mine who, as parents have sometimes despaired at an apparent default programming in their children's behaviours and attitudes. Current research investigating brain development and function is increasingly demonstrating structural differences between typically male and female brains: that behavioural traits previously assumed to be socially conditioned are, in point of fact, hard wired to some extent. (see Holt &Ellis 1998; Fausto-Sterling 1998; Whittle 2000; Blanchard & Lippa 2007; Manning 2008). This notion I acknowledge, has been resisted politically by feminism as it appeared to favour patriarchy - but I argue that scientific truism does not have to imply hierarchical disadvantage: ultimately both sexes lose if we assert that 'equal' has to mean 'same'.

Although up to now, transvestism and transsexualism have been presented as separate phenomenon, I believe there is good reason to support the argument of contemporary authors who suggest conceptualising transvestism and transsexualism on a 'transgender continuum'. [See for example authors like Bolin (1998), Bornstein (1998), Denman (2004), Lee (2005); and so called 'queer theorists' mentioned later]. To set this in context: historically there was a necessary divide between the two, chiefly due to the diagnostic criteria the medical profession set for transsexualism. To 'qualify' as a transsexual and thereby access Sex-Reassignment programs one needed to clearly distinguish oneself from the 'transvestite' group. Known as 'learning the script' (O'Keefe 1999) one had to present a coherent and acceptable narrative or risk losing access to hormonal treatment and ultimately surgery.(see also Zandvliet 2000). Further, since medical (and thereby social) understanding of the phenomenon had been shaped strongly by the historical pathologising approach we might consider carefully the personal and professional epistemologies underpinning our work. Heron & Reason (1997) describe the way 'propositional knowledge' (underlying theory/intellectual conceptualisation) shapes the way we describe our 'experiencing' both to ourselves and to others, and thereby distort it through a process of filtered interpretation and reiteration.

Therefore, when understanding what it means to be transvestite, trans-sexual, trans- gendered we need to take account of how we are all inevitably influenced by this same cultural milieu, incorporating at some level, the social constructions that are part of that, and an emerging LGBT scene. For example, Grayson Perry describes how he 'discovered' that what he was doing was called 'transvestism' by reading an article in the 'News Of The World' when he was 15 (Jones & Perry 2006:p73). I would suggest that the Foucaultian argument (see Spargo 1999) that sees 'homosexuality' as a social construction applies equally here: that the use of the labels 'transvestite'/ 'transsexual' are unhelpful to us as therapists in truly understanding the client. What emerges from the literature is that transgenderism provides a more effective construct for conceptualising a spectrum of people who don't neatly fit the hetero-normative binary. An exciting new philosophy is emerging in the form of so called 'Queer theory' with authors like Bolin (1997), Bornstein (1994, 1998), O'Keefe & Fox (2003), Wilchins (2004) arguing in favour of creating new paradigms around gender- pluralism to allow people to express their gender in more diverse ways: I would like to think as a profession we might embrace some of these ideologies, recognising the cultural limits that impact on us all, but helping gender divergent clients become more self actualised. (see also Zandvliet 2000)

Summary:

Based on a thorough and extensive analysis of the literature available I summarise my findings thus:

Evidence suggests that male transgenderism is a complex and fixed phenomenon as intrinsic as (but separate from) sexual orientation.

A neuro-hormonal and/or genetic aetiological paradigm compounded by the social milieu provides the most credible explanation of the phenomenon to date.

Clinical studies have shown that male cross-dressing should not be seen as a symptom of psychological dysfunction in itself. However, complications arising from intolerance towards male gender diversity may lead some clients to suffer psychological distress - for example though marital discord; discrimination in the workplace; bullying and harassment.

Previous conceptualisations regarding the aetiology of transvestism as being a function of parent-child dynamics are no longer useful or valid to us as practitioners.

Societal expectations of males to 'perform masculine' (and disassociate from feminine and or effeminate) creates internal tension for some men. This may be stronger in a male with a brain that has retained some elements of the primary female developmental patterns.

The psychiatric paradigm of male transvestism as 'paraphilia' (thus fetishistic) does not fit the data from research in non-clinical transgender male client groups and is likely to relate only to a small sub-group of this population.

Transgendered males might be defining themselves according to the dominant discourses of 'transvestite' or 'trans-sexual' and may narrate their stories according to these 'scripts'. They may not be aware of contemporary and developing discourses of gender-pluralism and indeed transgenderism itself. This has implications for how therapists might explore and make sense of our clients and their stories, and thus, how we reflect that back in the process of therapy.

Footnote:

The findings of this research concluded that LGBT issues are not generally addressed in counsellor training and that many counsellors and therapists had little understanding of LGBT issues and less again of transgenderism.

Eddie Izzard:

I went to see the Doctor wearing make-up: Izzard: 'I've got a cough' Doctor: 'You've got what?' Izzard: 'I've got a cough.' Doctor: 'You're a transvestite?' Izzard: 'No. I've got a cough. I am a transvestite, but I've got a cough.' Doctor: 'Well, I'd better sort the transvestite thing out. Have to refer you for that' Izzard: 'No, that's not a problem. Just the cough thanks.' (Izzard et al. 1998:P63)

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(1997) Ma Vie En Rose (My Life In Pink)

Ludovic Fabre: I'm a girlboy. Jérôme: A girlboy? Ludovic Fabre: To make a baby, parents play tic-tac-toe. When one wins, God sends Xs and Ys. XX for a girl, and XY for a boy. But my X for a girl fell in the trash, and I got a Y instead. See? A scientific error! But God will fix it and send me an X and make me a girl and then we'll get married, okay? Jerome: That will depend on what kind of girl you are. Screenplay: Director: Alain Berliner, Writers: Alain Berliner, Chris Vander Stappen Featuring: Georges Du Fresne as Ludovic Fabre, Julien Rivière as Jérôme

APPENDIX 1: A FINAL THOUGHT

Homosexuality achieved a significant shift in public and legal perception over the latter part of the twentieth century. New understandings challenged the previous mindsets and although we still have some way to go to get to a position of full acceptance we are increasingly getting there. I would like to think that greater pluralism in the expression of the gendered self could become more tolerated in society through a similar mechanism: as new scientific insights increasingly inform our understanding, people will be freer to actualise their true self. The quote below summed this up for me:

"Karen who waited until she was forty-five to pursue full female attire, expresses self- identity this way:

-To use the more common terminology, I would say I am trans-gendered. I cross- dress but not for sexual display or attraction. There is a feeling that is feminine, pretty, and desirable. Yet, I don't change as a person. My gestures and walk are compatible with a feminine appearance, but not exaggerated, my voice unchanged, I don't consider myself a different person, just another visage or aspect of the same person My friends that observe me in both modes would substantiate this, In addition, passing is of no concern to me. I don't really 'do outreach' or 'in your face' but only subject myself to situations in which people are aware of my maleness. At times I prefer feminine gestures and expressions but more often masculine responses, When societal binarism insists I choose one pole or another, I choose masculine. I have been raised as a male, my sexual anatomy is male, etc. Nonetheless, I insist that I am ambigenderal. I claim all gender space, if you will, and exist within this spectrum at different points at different times."

(Bolin 1994, 464)

For further insight into transgenderism consider O'Keefe & Fox (2003) and for a view into transgender political thinking I encourage the reader to consider Bornstein (1995) 'Gender Outlaw'. Both texts are informative and presented in an easily accessible way by authors on the inside of transgenderism.