Archives of Sexual Behavior, VoL 6, No. 5, 1977
Gender Identity Change in a Transsexual:
David H. Barlow, Ph.D., 1,3 Gene G. Abel, M.D., 2 and Edward B. Blanchard 2
Gender identity change in a conservatively diagnosed 21.year-old transsexual after faith healing was fortuitously observed, was objectively and independently measured, and is reported. This case, and other recent developments, suggests a reexamination of the possibilities of psychosocial intervention to modify atypical gender identity.
KEY WORDS: transsexual; gender identity; exorcism; sexuality.
The most effective treatment for the relief of suffering in transsexuals would seem to be sex-reassignment surgery (Green and Money, 1969). This radical and irreversible treatment for what is basically a psychological problem is indicated since the suffering of transsexuals is considerable and all efforts at treatment through psychotherapy have been ineffective (Pauly, t965; Benjamin, 1971; Green, 1974). Postsurgical reports from transsexuals have suggested a relief of suffering and moderate to good adjustments in approximately 75% of patients during the first few years of follow-up (e.g., Randell, 1969; Van Patten and Fawzy, 1976), but surgery is costly and not always available.
Although the prevention of transsexualism is the ideal, work in this area has been fraught with ethical problems, and data on the possibility of prevention, or even what to prevent, are not available (Qualls et al, in press; Rekers and
This research was supported in part by National Institute of Mental Health Grant MH-20258.
1 Brown University and Butler Hospital, Providence, Rhode Island 02906.
2 University of Tennessee Medical School, Memphis, Tennessee 38104.
3 Address correspondence to David H. Barlow, 345 Blackstone Boulevard, Providence, Rhode Island 02906.
388 Barlow, Abel, and Blanchard
Lovaas, 1974; Green, in press). In lieu of effective preventive measures or psychological treatments, an emphasis has been placed on increasing opportunities for surgery. However, two recent developments raise some questions about this approach. First, reports are beginning to appear describing patients so dissatisfied with sex-reassignment surgery that they discard their new gender identity and return to living in their biological gender role despite the physical irreversibility of the surgery (e.g., Money and Wolff, 1973; Van Patten and Fawzy, t976). Second, a recent report suggests that behavioral procedures were effective in changing gender identity in one patient (Barlow et aL, 1973). Although these procedures were relatively complex and the treatment was lengthy, the implication is that mistaken gender identity, which has been considered fixed and irreversible by the age of 3 (Green and Money, 1969), may be altered by psychological procedures. The following case strengthens this preliminary conclusion in a most dramatic fashion.
Information described below was obtained from the patient and verified, in most instances, in a separate interview with the patient's mother. Essentially the same information was obtained from the forwarded records of two psychiatrists who had independently interviewed the patient, 1 and 3 years, respectively, prior to our evaluation.
The patient, hereafter referred to by the pseudonym "John," was born in 1952 and always thought of himself as a girl. At the time of his birth his father was 45 and his mother 32. The marriage was unhappy and the father was seldom home, and, as a consequence, a permanent separation occurred when John was 8 years old. John had one brother, 5 years older, and a sister 2 years older. He reports being the baby of the family and more frail and delicate than his older sister, who was something of a tomboy. He thought that his mother compensated for his sister's tomboyishness by preventing him from engaging in any rough and-tumble games or other boyish activities. During his early years he stayed in the house and helped his mother clean or do chores in the kitchen, activities that pleased his mother. At age 4 he began applying makeup, much as his mother did, and shortly thereafter began cross-dressing in his sister's clothes. He was very pleased when his sister started school, since she bought a number of new clothes. For several years he made excuses to stay home alone in order to dress in his sister's clothes, an activity in which the family housekeeper acquiesced while warning him not to let his father catch him. At age 6 he broke his leg. He re-
Gender Identity Change in a Transsexual: An Exorcism 389
member that the most frustrating part of this injury was his inability to dress the way he wanted since wearing a cast made it difficult to change into the feminine clothes.
During grammar school John refused to participate in gym or other related activities. His mother, meanwhile, had obtained a job and he assumed the role of housekeeper. He remembers being the object of scorn and criticism in elementary school for effeminate behaviors, but in the early years of school his brother was somewhat protective of him. Although his family identified themselves as Southern Baptists, they seldom attended church. During his childhood he continued to sleep in the same bed with his mother. He envied his sister and mother as females and loathed his maleness. Thus his childhood was marked by a history of spontaneous cross-dressing before age 5, early crossgender identification and fantasies, very early development of feminine activities, and absence of masculine activities or interests. These features are stated by Stoller (1968) to be prerequisites for categorization as a transsexual.
John attended school, performed marginally, and remained socially isolated. He occupied himself with housekeeping and cooking. At 15 he read about transsexualism in a national magazine and began corresponding with The Johns Hopkins Hospital and experts of whom he had learned.
Shortly thereafter he dropped out of school and began intensive reading on the subject in the library. A woman with whom he was acquainted mentioned a doctor who treated hormonal problems. Based on his readings, he was aware of the effects of female hormones and told the physician that he was on female hormones for an endocrine disorder and needed additional prescriptions, which he obtained. He remembers the estrogen as producing a tranquility which he had not experienced for some time and eliminating his unwanted erections. From oral estrogen he progressed to occasional self-injection of estrogen, but was concerned lest his mother find his medication.
In 1969, at age 16, he was involved in a serious car accident and medical treatment for resulting conditions led to discovery of the effects of the hormone (some breast enlargement and thinning of body hair) and the specifics of his cross-gender identity. He was subsequently referred to a psychiatrist, whom he saw periodically in years to come. His mother became extremely upset on learning of his cross-gender identity, blaming it on the automobile accident. This began a very stormy period in the patient's life, where his mother would attempt to manipulate him with frequent suicidal gestures and other histrionic behavior in an attempt to force him to seek psychiatric care. At his mother's insistence, he was admitted to a state hospital for evaluation. A psychiatric examination and psychological testing, later forwarded to our offices, revealed no psychosis
390 Barlow, Abel, and Blanchard
but a mild situational depression, presumably due to family pressures. Physical examination revealed breast enlargement. He was discharged on no medications with a diagnosis of transvestism.
Several months before this hospitalization, he had successfully begun working a fried chicken stand and was considered dependable and a good worker. He resumed this work upn discharge from hospital and was referred to our offices for the first time by his present psychiatrist, where one of us (D.H.B.) diagnosed him as a transsexual. He noted that he enjoyed his work, was saving money for sex-reassignment surgery, a portion of which he had received as a settlement for his automobile accident, but was continuing to have difficulty with his mother and thus had moved into his own apartment. He was started, once again, on oral doses of estrogen by his private psychiatrist and reported during his time that his voice hightened and that he again felt calm and relaxed. He would often dress as a female when away from work and reported that he was extremely comfortable, did not attract attention, and was never apprehended for crossdressing.
John rose to the position of manager in his job but continued to have difficulty with his mother and her friends, who insisted that he "make a man of himself." To "quiet her down" he entered the Navy, at their suggestion, in November 1972, but was quickly medically discharged after a thorough psychiatric examination, later forwarded to us, with a diagnosis of transsexualism. A buccal smear at this time revealed a normal male chromosomal pattern and psychological testing revealed no psychosis, no severely defective judgment, and no abnormal affect. After returning from service, he continued to have difficulties with his mother, and by the end of 1972, at age 20, was admitted to our psychiatric unit after overdosing in response to his mother's attempt to move into his apartment with him. Treatment consisted of teaching him to deal more assertively and effectively witti his mother, and the patient decided, with our consent, that it was time to begin the process of preparing for surgery.
After discharge, John was placed on full therapeutic dosages of estrogen and he intensified treatments for electrolysis of facial hair, a process he had begun sometime earlier. As part of the process of preparing for surgery, a variety of assessment procedures were administered to measure gender identity, gender role behavior, and sexual arousal patterns. All assessment remained consistent with a diagnosis of transsexualism, as it had in his previous visit in 1971. Sexual arousal patterns, as measured by rating scales and penile circumference measures (Barlow et aL, 1970; Barlow and Abel, 1976), were exclusively transsexual but sexual arousal was relatively low, consistent with his expressed lack of interest in sex. The patient had never had any sexual contact and masturbated
Gender Identity Change in a Transsexual: An Exorcism 391
very infrequently, because of disgust over awareness of his male genitalia. Sexual attractions to males consisted mostly of feeling "warm and close" to a male and were always fantasized with the patient in the female role.
From this battery of assessment procedures (Barlow, 1977; Abel, 1977), two measures were repeated periodically over the next 2 years. One was an attitudinal "card sort" measure of gender identity in which statements describing masculine gender identity and feminine gender identity were typed on 3×5 cards and rated based on desirability (see Barlow etaL, 1969, 1973; Barlow and Abel, 1976). This attitudinal measure revealed maximal feminine gender identity. Gender role behavior was measured by a behavioral checklist of gender-specific motor behavior while sitting, standing, and walking (Barlow et al., 1973). This behavioral checklist was filled out surreptitiously by a secretary as the patient walked into the office, stood, and sat down while waiting for his appointments. Feminine gender motor behavior was emitted consistently.
With some assistance from us, cross-living as a female began uneventfully in the winter of 1972 and John assumed the name of "Judy." The maturity with which she approached this transition is evident in that she was able to explain the situation to her employees and continued working at this job, changing only her apartment at this time. By the summer of 1973 Judy was doing extremely well and had reconciled her upcoming surgery with her mother and the rest of her family. Judy passed well as a female, had straightened out most .of her legal affairs, such as a change of driver's license, and was successfully wearing a bikini (having progressed to bra size 36B).
In the summer of 1973 Judy requested to commence surgery. In view of her excellent adjustment, we agreed and referred her to a medical center in a nearby state.
After a l~rief note indicating that she had arrived, we received no word for several months. One day in the late fall, a research assistant who had worked with the case came back from a half-Finished lunch of fried chicken and shouted, "Judy is back at the restaurant, but she's not Judy anymore, she's John!" Other reports quickly confirmed this, and John was invited back to our offices for a session which ocurred in early January of 1974. He entered the office in a three piece business suit, with polished shoes, neatly cut short hair, clipped fingernails, and consistently masculine motor behaviors. Even to trained eyes, the only sign of his former feminine role was the almost complete absence of facial hair, which in view of his light complexion and in the context of his total masculinity would normally go unnoticed. He enthusiastically related the following story.
After leaving our offices and journeying to the gender identity clinic in the nearby state where he was expected, he kept a promise he had made to the owner
392 Barlow, Abel, and Blanchard
of his fast-food restaurant. He had developed a close relationship with the owner of this restaurant over the years in which he had productively and reliably worked; and, although this woman was quite accepting of his transitions, she did request that he check with one physician in the city to which he was traveling before checking into the gender identity clinic. The physician shared with the owner of the restaurant a fundamental Protestant religion quite foreign to John, who had been brought up as a Baptist but was not religious. The physician administered a total physical exam and said that he could live quite well as a woman, but the real problem was possession by evil spirits. After some discussion of this, John reported a session which lasted 2-3 hr and involved exhortations and prayers over John by the physician and laying on a hands on John's head and shoulders. During this period, John reported fainting several times and arising to the continuing of the prayers and exhortations, resulting in the exorcism of 22 evil spirits which the physician called by name as they left his body. During and after this session John felt waves of God's love coming over him but was physically drained. A letter to us, from the physician, confirmed this basic process. The physician noted in his letter that he showed John that his life was a fake and that Jesus could redeem him and that a standard prescription of Scripture readings caused the spirit of the woman in John to disappear.
Immediately after the session John announced he was a man, discarded his female clothes (hiding his breasts as best he could), and went to the barber shop to have his long hair cut into his current short, masculine style. After this session John returned home and live with his mother for approximately 2 weeks but remembers the beginning of some doubts about his conversion and the reoccurrence of some feminine feelings. At this point he accompained his employer to services of a very well-known faith healer in another state where the miracles that he saw renewed his faith and reaffirmed the correctness of his decision. After waiting 3½ hr in line, he confronted the healer who told the patient that he was having sexual problems (having perhaps seen his breasts?) and began the healing process, including praying and laying on of hands once again. During this period, which John estimated as 10 or 15 min, he fainted, regained consciousness, fainted again, and, as he stood to step off the platform down into the audience, realized that his breasts were gone.
John was followed for 2½ years after the exorcism and measures of gender identity and gender role behavior were administered at each follow-up session. All data are presented in Fig. 1 and reflect the clear reversal of gender identity after the exorcism and during follow-up. He reported heterosexual arousal at the first postexorcism interview but refused measurement of penile circumference changes to erotic slides. His minister recommended that he not view slides of nude males for fear that the Devil might once again gain access to his soul. In the confusion, gender-specific motor behavior was not formally scored.
Gender Identity Change in a Transsexual: An Exorcism 393
Fig. I. Masculine and feminine gender-specific motor behavior and score on "card sort"
measure of gender identity before and after exorcism.
Examination revealed no residual gynecomastia, although the interval of time between cessation of hormonal therapy and examination was adequate for this "shrinkage" to occur naturally.
He started dating several months later, and at the last interview in December 1975 reported that he had dated approximately ten gifts intermittently but had dated one girl for an extended period of time. He reported some sexual arousal toward these girls but did not masturbate, nor did he consider sexual intercourse, because of his religious beliefs. He did admit having some sexual thoughts of males for several months after returning from his faith healing, but attributed these to the Devil and has not had thoughts of men for almost 2 years. He continued to do extremely well in his job, benefiting from- several promotions, and was looking forward to getting married.
"'I can't believe that, "" said Alice.
"Can't you?" the Queen said in a pitying tone. "Try again, draw a long breath, and shut your eyes."
With that exchange from Through the Looking
Glass by Lewis Carroll, Jerome Frank leads off a chapter in his now famous
book, Persuasion and
394 Barlow, Abel, and Blanchard
Healing (1961). With Frank's book, this case raises questions on the nature of the process of therapeutic change and the role of various therapeutic procedures in this process. Although most psychotherapists would not deny the role of suggestion, instructions, and persuasion with many psychological disorders, what is important in this case is that no psychotherapeutic procedure of any kind, with whatever element of suggestion or persuasion, has been effective for transexualism, with the possible exception of behavior modification in one case (Barlow et al., 1973). But even the most facile operant conditioner would be hard pressed to explain the sudden and massive behavioral change observed and objectively measured in this case. Furthermore, this case would be less impressive without the presence of the repeated measures, particularly the behavioral measure independently administered, to bolster our subjective impression of change. It is noteworthy that in the earlier case, where behavior modification procedures were seemingly effective in changing gender-specific motor behavior, and in subsequent cases, a period of several months was necessary to teach these behaviors step by step. In this case, without any instruction and presumably without familiarity with the behaviors in the checklist, all of the components of masculine motor behavior were seemingly acquired in a matter of hours.
Obviously, this case has little relevance for therapeutic intervention at this time since most transsexuals are unlikely to flock to the nearest faith healer. But the fact that it did occur could extend the study of the effects of social influence variables to what has been the most intractable of all psychiatric disorders to determine if it is possible to develop psychological intervention to replace surgical treatment in at least some cases. Fortunately, this type of change is not without precedent, although one must go outside the purview of clinical psychology and psychiatry to find parallels. Anthropological study has yielded data from more primitive cultures where changes in gender role behavior and presumably gender identity result from religious or other tribal customs (e.g., Levy, 1973). A closer study of this process in a number of cultures might yield information of some use in our own culture.
The facts in this case are far from certain in all instances. Despite John's report and corroboration from his employer, it is certainly hard to believe that John's breasts disappeared instantaneously in view of our medical understanding of the thne necessary for the physical effects of estrogen to reverse. Furthermore, we were not able to obtain objective measures of John's sexual arousal patterns after the exorcism, although it would seem that if John were fabricating his report he would not have indicated continued sexual arousal to men for several months subsequent to the faith healing. Additional follow-up is also necessary to confirm the stability of the measures and any changes in his life situation over a long period of time. What cannot be denied, however, is that a patient who was very clearly a transsexual, by the most conservative criteria (e.g., Stoller, 1968, 1969), assumed a long-lasting masculine gender identity in a remarkably short period of time following an apparent exorcism.
Gender Identity Change in a Transsexual: An Exorcism 395
Abel, G. G. (1977). Assessment of sexual deviation in the male. In Hersen, M., and Bellack, A. S. (eds.), Behavioral Assessment: A Practical Handbook, Pergamon Press, New York, in press.
Barlow, D. H. (1977). Assessment of sexual behavior. In Ciminero, A. R., Calhoun, K. S., and Adams, H. E. (eds.), Handbook of Behavioral Assessment, Wiley New York.
Barlow, D. H., and Abel, G. G. (1976). Sexual deviation. In Craighead, E., Kazdin, A., and Mahoney, M. (eds.), Behavior Modification: Principles, Issues, and Applications, Houghton Mifflin, Boston.
Barlow, D. H., Leitenberg, H., and Agras, W. S. (1969). The experimental control of sexual deviation through manipulation of the noxious scene in covert sensitization J. Abnorm. Psycho174: 596-601.
Barlow, D. H., Becker, R., Leitenberg, H., and Agras, W. S. (1970). A mechanical strain gauge for recording penile circumference change. Y.. Appl. Behav. Anal 3: 73-76.
Barlow, D. H., Reynolds, E. H., and Agras, W. S. (1973). Gender identity change in a transsexual. Arch. Gen. Psychiat. 28: 569-579.
Benjamin, H. (1971). Should surgery be performed on transsexuals? Psychiat. Digest, p. 37.
Frank, J. (1961). Persuasion and Healing, Johns Hopkins Press, Baltimore.
Green R. (1974). Sexual Identity Conflict in Children and Adults, Basic Books, New York.
Green, R. (1977). Atypical sex role development: Strategy and ethics of prevention. In
Quails, C. B., Wincze, J. P., and Barlow, D. H. (eds.), The Prevention of SexualDisorders: Issues and Approaches, Plenum Press, New York, in press.
Green, R., and Money, J. (1969). Transsexualism and Sex Reassignment, Johns Hopkins Press, Baltimore.
Levy, R. I. (1973). Tahitians: Mind and Experience in the Society Islands, University of Chicago Press, Chicago.
Money, J., and Wolff, G. (1973). Sex reassignment: Male to female to male. Arch. Sex. Behav. 2: 245-250.
Pauly, I. B. (1965). Male psychosexual inversion: Transsexualism. Arch. Gen. Psychiat. 13: 172-181.
Quails, C. B., Wincze, J. P., and Barlow, D. H. (eds.), (1977). The Prevention of Sexual Disorders: Issues and Approaches, Plenum Press, New York, in press.
Randell, J. (1969). Preoperative and postoperative status of male and female transsexuals. In Green, R., and Money, J. (eds.), Transsexualism and Sex Reassignment, Johns Hopkins Press, Baltimore.
Rekers, G. A., and Lovaas, O. I. (1974). Behavioral treatment of deviant sex-role behaviors in a male child. J. Appl Behav. Anal. 7: 173-190.
Stoller, R. J. (1968). Sex and Gender, Science House, New York.
Stoller, R. J. (1969). Parental influences in male transsexualism. In Green, R., and Money J. (eds.), Transsexualism and Sex Reassignment, Johns Hopkins Press, Baltimore.
Van Patten, T., and Fawzy, F. I. (1976). Sex conversion surgery in a man with severe gender dysphoda. Arch. Gen. Psychiat. 33: 751-753.