Transgenderism and Intersexuality in Childhood and Adolescence: Making Choices
Publication Year: 2003
Transgenderism and Intersexuality in Childhood and Adolescence: Making Choices presents an overview of the research, clinical insights, and ethical dilemmas relevant to clinicians who treat intersex youth and their families. Exploring gender development from a cross-cultural perspective, esteemed scholar Peggy T. Cohen-Kettenis and experienced practitioner Friedemann Pfäfflin focus on assessment, diagnosis, and treatment issues. To bridge research and practical application, they include numerous case studies, definitions of relevant terminology, and salient chapter summaries.
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Typical Sexual and Psychosexual Differentiation
- General Terminology
- Sexual Differentiation
- Development of Gender Identity and Gender Role
- Chapter 2: Gender Identity Disorder in Childhood and Adolescence: A Cultural Blank Space
- Benefit of Historical and Cross-Cultural Data for Clinical Practice
- Cross-Cultural and Historical References (Adults)
- Cross-Cultural and Historical References (Children and Adolescents)
- Chapter 3: Atypical Sexual Differentiation
- Chromosomal/Gonadal Conditions
- Female Pseudohermaphroditism
- Male Pseudohermaphroditism
- Other Conditions
- Chapter 4: Atypical Development of Gender Identity and Gender Role
- Specific Terminology
- Clinical Picture
- Correspondence between Childhood Gender Identity Disorder and Transsexualism
- Prevalence and Sex Ratio of Gender Identity Disorder
- Theories about Atypical Gender Development
- Chapter 5: Clinical Management of Intersex Conditions
- Importance of Parent Counseling
- Importance of Child Counseling
- Neonatal Approach
- Information and Support
- Criticism of Clinical Policy
- Chapter 6: Clinical Management of Gender Problems in Children
- Chapter 7: Clinical Management of Gender Problems in Adolescents
- Effects of Sex Reassigment
- Chapter 8: Legal Issues of Intersexuality and Transsexualism
- Legal Sex Assignment of Intersexes
- Legal Implications of Transsexualism in Adults
- Legal Issues of Gender Identity Disorder in Childhood and Adolescence
Developmental Clinical Psychology and Psychiatry Series[Page ii]
Series Editor: Alan E. Kazdin, Yale University
Recent volumes in this series …
- LIFE EVENTS AS STRESSORS IN CHILDHOOD AND ADOLESCENCE by James H. Johnson
- CONDUCT DISORDERS IN CHILDHOOD AND ADOLESCENCE, 2nd Ed. by Alan E. Kazdin
- CHILD ABUSE, 2nd. Ed. by David A. Wolfe
- PREVENTING MALADJUSTMENT FROM INFANCY THROUGH ADOLESCENCE by Annette U. Rickel and LaRue Allen
- TEMPERAMENT AND CHILD PSYCHOPATHOLOGY by William T. Garrison and Felton J. Earls
- EMPIRICALLY BASED ASSESSMENT OF CHILD AND ADOLESCENT PSYCHOPATHOLOGY, 2nd Ed. by Thomas M. Achenbach and Stephanie H. McConaughy
- MARRIAGE, DIVORCE, AND CHILDREN'S ADJUSTMENT, 2nd Ed. by Robert E. Emery
- AUTISM by Laura Schreibman
- DELINQUENCY IN ADOLESCENCE by Scott W. Henggeler
- CHRONIC ILLNESS DURING CHILDHOOD AND ADOLESCENCE by William T. Garrison and Susan McQuiston
- ANXIETY DISORDERS IN CHILDREN by Rachel G. Klein and Cynthia G. Last
- CHILDREN OF BATTERED WOMEN by Peter G. Jaffe, David A. Wolfe, and Susan Kaye Wilson
- SUBSTANCE ABUSE IN CHILDREN AND ADOLESCENTS by Steven P. Schinke, Gilbert J. Botvin, and Mario A. Orlandi
- CHILD PSYCHIATRIC EPIDEMIOLOGY by Frank C. Verhulst and Hans M. Koot
- EATING AND GROWTH DISORDERS IN INFANTS AND CHILDREN by Joseph L. Woolston
- NEUROLOGICAL BASIS OF CHILDHOOD PSYCHOPATHOLOGY by George W. Hynd and Stephen R. Hooper
- ADOLESCENT SEXUAL BEHAVIOR AND CHILDBEARING by Laurie Schwab Zabin and Sarah C. Hayward
- EFFECTS OF PSYCHOTHERAPY WITH CHILDREN AND ADOLESCENTS by John R. Weisz and Bahr Weiss
- BEHAVIOR AND DEVELOPMENT IN FRAGILE X SYNDROME by Elisabeth M. Dykens, Robert M. Hodapp, and James F. Leckman
- ATTENTION DEFICITS AND HYPERACTIVITY IN CHILDREN by Stephen P. Hinshaw
- LEARNING DISABILITIES by Byron P. Rourke and Jerel E. Del Dotto
- PEDIATRIC TRAUMATIC BRAIN INJURY by Jeffrey H. Snow and Stephen R. Hooper
- FAMILIES, CHILDREN, AND THE DEVELOPMENT OF DYSFUNCTION by Mark R. Dadds
- ADOLESCENTS AND THE MEDIA by Victor C. Strasburger
- SCHOOL-BASED PREVENTION PROGRAMS FOR CHILDREN AND ADOLESCENTS by Joseph A. Durlak
- CHILDHOOD OBSESSIVE COMPULSIVE DISORDER by Greta Francis and Rod A. Gragg
- TREATING CHILDREN AND ADOLESCENTS IN RESIDENTIAL AND INPATIENT SETTINGS by Robert D. Lyman and Nancy R. Campbell
- THE IMPACT OF FAMILY VIOLENCE ON CHILDREN AND ADOLESCENTS by Javad H. Kashani and Wesley D. Allan
- CHILDREN'S ADJUSTMENT TO ADOPTION by David M. Brodzinsky, Daniel W. Smith, and Anne B. Brodzinsky
- MOTOR COORDINATION DISORDERS IN CHILDREN by David A. Sugden and Helen Wright
- CHILDHOOD SEXUAL ABUSE by David M. Fergusson and Paul E. Mullen
- POVERTY AND CHILDREN'S ADJUSTMENT by Suniya S. Luthar
- ALCOHOL USE AMONG ADOLESCENTS by Michael Windle
- CREATING HEALTH BEHAVIOR CHANGE by Cheryl L. Perry
- PSYCHOTIC DISORDERS IN CHILDREN AND ADOLESCENTS by Robert L. Findling, S. Charles Schulz, Javad H. Kashani, and Elena Harlan
- LANGUAGE IMPAIRMENT AND PSYCHOPATHOLOGY IN INFANTS, CHILDREN, AND ADOLESCENTS by Nancy J. Cohen
- TRANSGENDERISM AND INTERSEXUALITY IN CHILDHOOD AND ADOLESCENCE by Peggy T. Cohen-Kettenis and Friedemann Pfäfflin
Copyright © 2003 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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Library of Congress CataloginGIn-Publication Data
Cohen-Kettenis, Peggy Tine, 1948-
Transgenderism and intersexuality in childhood and adolescence: Making choices/Peggy
T. Cohen-Kettenis, Friedemann Pfäfflin.
p.cm. - (Developmental clinical psychology and psychiatry series; 46)
Includes bibliographical references and index.
ISBN 07-619-1710-1 (Cloth)
ISBN 0-7619-1711-X (Paper)
1. Gender identity. 2. Sex. 3. Sex role. 4. Transsexuals—Identity. I. Pfäfflin, Friedemann. II. Title. III. Series: Developmental clinical psychology and psychiatry; v. 46. HQ1075.
This book is printed on acid-free paper.
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Indexer: Kathy Paparchontis
Series Editor's Introduction[Page vii]
Interest in child development and adjustment is by no means new. Yet, only recently has the study of children benefited from advances in both clinical and scientific research. Advances in the social and neurobiological sciences; the emergence of disciplines and subdisciplines that focus exclusively on childhood and adolescence; and greater appreciation of the impact of such influences as the family, peers, and school have helped accelerate research on developmental psychopathology. Apart from interest in the study of child development and adjustment for its own sake, the need to address clinical problems of adulthood naturally draws one to investigate precursors in childhood and adolescence.
Within a few decades, the study of psychopathology among children and adolescents has proliferated considerably. Several different professional journals, annual book series, and handbooks devoted entirely to the study of children and adolescents and their adjustment document the proliferation of work in the field. Nevertheless, there is a paucity of resource materials that present information in an authoritative, systematic, and disseminable fashion. There is a need within the field to convey the latest developments and to represent different disciplines, approaches, and conceptual views to the topics of childhood and adolescent adjustment and maladjustment.
The Sage Series on Developmental Clinical Psychology and Psychiatry is designed to serve uniquely several needs of the field. The Series encompasses individual monographs prepared by experts in the fields of clinical child psychology, child psychiatry, child development, and related disciplines. The primary focus is on developmental psychopathology, which refers broadly here to the diagnosis, assessment, treatment, and prevention of problems that arise in the period from infancy through adolescence. A working assumption of the Series is that understanding, identifying, and [Page viii]treating problems of youth must draw on multiple disciplines and diverse views within a given discipline.
The task for individual contributors is to present the latest theory and research on various topics, including specific types of dysfunction, diagnostic and treatment approaches, and special problem areas that affect adjustment. Core topics within clinical work are addressed by the Series. Authors are asked to bridge potential theory, research, and clinical practice and to outline the current status and future directions. The goals of the Series and the tasks presented to individual contributors are demanding. We have been extremely fortunate in recruiting leaders in the fields who have been able to translate their recognized scholarship and expertise into highly readable works on contemporary topics.
In this book, Drs. Peggy Cohen-Kettenis and Friedemann Pfäfflin examine Transgenderism and Intersexuality in Childhood and Adolescence. The book is broad in its scope, delineating the range of the issues of sexual development, identity, and roles. Biological underpinnings and features of sexual differentiation; cultural and contextual issues; and ethical, legal, and policy issues are carefully described and integrated. Gender identity raises issues for the individual but also for society at large. For example, the book considers whether, for whom, and how to intervene and the many treatment options available over the course of infancy through adulthood. There are major dilemmas for clinical practice and society at large on which this book elaborates. Whether atypical forms of gender identity qualify or ought to be considered as a disorder and strong views of the public about gender identity reflect key contextual issues in which both research and clinical work are conducted. It is rare that a book elaborates a set of developmental paths or disorders and places these in the broader context of society at large. We are very fortunate to have such an enlightened, engaging, and authoritative statement on the topic.— Alan E. Kazdin, Ph.D., Yale University School of Medicine
Most adults do not question the fact that they are male or female. However, a very small minority face a discrepancy between their subjective experience of being a man or a woman and their biological sex. They are individuals with gender identity problems. In others, discrepancies exist between their genetic, gonadal, hormonal, or genital sex. These individuals suffer from so-called intersex conditions. Many have great difficulties in classifying members of these groups as males or females. Others do not even want to classify at all and insist on allowing for more than two sexes. They argue that the mere existence of only two social categories, men and women, creates intolerance.
Western cultures tend to reject certain deviations from the gender norm, making life hard for those who physically and/or psychologically have not differentiated completely in the male or female direction. If certain deviations from the gender norm are substantial enough they are regarded as psychiatric disorders (as defined in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV), American Psychiatric Association, 1994). A significant amount of research and clinical attention have been given to children who belong to this group. Though many enigmas remain, the study of these children has increased our understanding of their situation. But studying these children as if they have a psychiatric disorder has also met with resistance. Some claim that the “Gender Identity Disorders” are not disorders at all, only behaviors that are not tolerated by our homophobic society. In their view, these behaviors have been called “disorders” to achieve gender conformity at all costs or even to “prevent” homosexuality. The suffering of the child is not seen as suffering from a condition, but from a stigmatizing society.
When cross-gendered children enter puberty, new dilemmas emerge: Boys begin to grow beards and their voices become deeper, whereas girls [Page x]develop breasts. When they come to gender clinics they have often already lived in the opposite gender role for an extended period of time. They very much want to take hormones to delay their puberty or even to start the development of physical characteristics of the opposite sex (e.g., breasts in boys and a beard in girls). To the despair of these youngsters, most clinicians are reluctant to prescribe hormones for this purpose to adolescents. Should one wait until adulthood before prescribing hormones when it is clear that they have a gender identity disorder and will never live in the role of their sex of birth?
In the field of sexual differentiation disorders, an intense dispute is taking place along similar lines. However, in this field doctors are often accused of intervening all too readily. If a child is born with genitals that are not clearly male or female, surgeons tend to “adjust” the child to the sex of assignment as early as possible. Since the early 1990s, adults with intersex conditions have heavily criticized this policy. Many of these adults are very unhappy with the result of their own treatment. They insist on letting children make their own decisions regarding the type and timing of their genital surgery in due time.
There are clinicians who do (e.g., “adjusting” babies with intersex conditions) and do not want (e.g., prescribing sex hormones to adolescents with gender identity disorders) to intervene medically. Though they seem to behave in opposite ways, they may act out of a similar motive: the fear of bringing or leaving children in a situation between that of “male” and “female.” This, in their view, is not in the best interest of the child.
Another question concerns to which sex a child with ambiguous sex characteristics should be assigned. We do not yet know much about the factors determining gender identity development in children with intersex conditions. To make a perfect prediction in any individual case, whether the child will be happier as a girl or as a boy, is impossible. Some argue that one should refrain altogether from assigning children to one of the sexes. By doing so we would force society to accept and get used to more gender variance. This would ultimately make life easier for gender variant individuals. Whether children in our society will actually be happier when growing up as a member of a “third sex” is, however, questionable.
Whichever side one takes in these debates, all discussants agree that large numbers of children with gender problems and with an atypical sexual differentiation suffer psychologically and existentially. These children are seen in clinics on a daily basis. Clinicians cannot sit and wait until more research has been done or consensus is reached. They are continuously faced with dilemmas and have to make choices even without a substantial [Page xi]empirical knowledge base. The choices they make have far-reaching consequences for their patients. The discussion on gender problems in adults touches sensitive strings. When it comes to children and adolescents the issues are sometimes beyond a rational discussion.
In this volume, we give an overview of the research, clinical insights, and ethical dilemmas for those confronted with these patients.[Page xii]
We gratefully acknowledge the contributions of the many children and their parents who came to us for help and support. In doing so they helped us in better understanding nonstandard gender development. They shared their distress, but also their problem-solving capacities and their creativity. It has always been a challenge and at the same time inspiring and pleasurable to work with these youngsters and their families.
We also thank the members of the Gender Team at the Child and Adolescent Psychiatry Department of the University Medical Center Utrecht (UMCU): Karin Tobias-Dillen, Jan Duyx, Tineke Mooibroek, Ciska van der Laan, Winkie Sandberg, and Dr. Hanna Swaab-Barneveld; and the members of the Sexual Differentiation Disorders team of the Wilhelmina Kinder Ziekenhuis/UMCU: Dr. Monique de Vroede, Dr. Maarten Jansen, Dr. Tom de Jong, Pieter Dik, Aart Klijn, Dr. Jacques Giltay, and Ineke van Seumeren. The many patient discussions enormously increased my (P. C.-K.) knowledge and understanding of atypical sexual differentiation and gender development. Maarten Jansen and Tom de Jong were so kind as to allow us to use photographs of their patients.
We thank Professor Dr. jur. Michael R. Will and Professor Dr. jur. Heinz-Peter Mansel for their juridical advice; Dr. Luk Gijs and Professor Dr. Louis Gooren for their valuable comments on earlier drafts; Margreet van Eck, Irene de Jonge, and Elke Kunert for lots of help in finding references; Russell Deighton and Liesbeth Klein for polishing our nonnative English; and Margreet van Eck, Joke van Katwijk, and Eleonore Cohen for their administrative assistance and Max Cohen for his technical assistance when preparing the book.[Page xiv]
List of Abbreviations[Page xv]
17ß-HSD 17ß-hydroxysteroid dehydrogenase deficiency 5α-RD 5α-reductase deficiency AIS androgen insensitivity syndrome BSTc central part of the bed nucleus of the stria teminalis CAH congenital adrenal hyperplasia CBCL child behavior checklist (a parent questionnaire listing emotional and behavioral problems of the child) CVAH congenital virilizing adrenal hyperplasia DES diethylstilbestrol DHT dehydrotestosterone DSM Diagnostic and Statistic Manual (of mental disorders) FM female-to-male transsexual GID gender identity disorder HBIGDA Harry Benjamin International Gender Dysphoria Association ICD International Classification of Diseases KS Klinefelter Syndrome LH lutinizing hormone MF male-to-female transsexual MIS Müller Inhibiting Substance MMPI Minnesota Multiphasic Personality Inventory PAIS partial androgen insensitivity syndrome PIQ performance IQ SOC Standards of Care SR sex reassignment SRS sex reassignment surgery SRY a gene located on the Y chromosome TRF teacher report form (of the CBCL) VIQ verbal IQ WISC-R Wechsler Intelligence Scale for Children—Revised WAIS Wechsler Adult Intelligence Scale
To our children Eleonore and Max Cohen Vincent and Tycho Pfäfflin
References[Page 181]1931). Genitalumwandlung an zwei männlichen Transvestiten. Zeitschrift für Sexualwissenschaft und Sexualpolitik, 18, 223–226.(1998). Genital reassignment on two male transvestites [On-line]. Available: http://www.symposion.com/ijt/ijtc0302.htm(1986). Psychosocial outcomes of sex reassignment surgery. Journal of Consulting and Clinical Psychology, 54, 183–189.(1986). Sibling and peer interactions: A final follow-up and a comparison. Child Development, 57, 217–229., , , & (1981). Behavioral problems and competencies reported by parents of normal and disturbed children aged four through sixteen. Monographs of the Society for Research in Child Development, 46, 1–82., & (1983). Manual for the Child Behavior Checklist and revised Profile. Burlington, VT: University of Vermont Department of Psychiatry., & (1986). Manual for the Teacher's Report Form and Teacher Version of the Child Behavior Profile. Burlington, VT: University of Vermont Department of Psychiatry., & (1987). Manual for the Youth Self Report and Profile. Burlington, VT: University of Vermont Department of Psychiatry., & (2001). Beginnings of sex reassignment in Japan [On-line]. Available: http://www.symposion.com/ijt/ijtvo05no01_02.htm.(1971). Transsexualism. Psychiatrica Fennica, 343–358., & (1996). Gender identity and role in a pedigree of Arabs with intersex due to 5 alpha reductase-2 deficiency. Psychoneuroendocrinology, 8, 651–657.(1999). Feminizing genitoplasty for adrenal hyperplasia: What happens at puberty. Journal of Urology, 161, 1588–1591., , , , & (1980). Group therapy with gender identity patients. International Journal of Group Psychotherapy, 30, 481–489., & (American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (DSM-III). Washington, DC: Author.American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM-IV). Washington, DC: Author.1985). Left, right, hand and brain: The right shift theory. Hillsdale: Lawrence Erlbaum.([Page 182]1985). Organizational and activational effects of sex steroids on brain and behavior: A reanalysis. Hormones and Behavior, 19, 469–498.& (1995). Childhood sex-types behavior and sexual orientation: A conceptual analysis and quantitative review. Developmental Psychology, 31, 43–55., & (1970). Chromosome errors in men with antisocial behavior: Comparison of men with Klinefelter's and XYY chromosome pattern. Journal of the American Medical Association, 214, 869–878., , , & (1993). The prevalence of transsexualism in the Netherlands. Acta Psychiatrica Scandinavica, 87, 237–238., , , & (1989). Chronic psychosis in Turner's syndrome: Case report and a review. British Journal of Psychiatry, 155, 857–859., & (1982). The personality and psychosexual development of boys with 47XXY chromosome constitution. Journal of Child Psychology and Psychiatry, 23, 169–180., , & (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.(1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.(1992). Testicular feminization syndrome and associated gonadal tumors in Denmark. Acta Obstretica et Gynecologica Scandinavica, 71, 63–66., , , & (1979). Gender identity change in transsexuals. Archives of General Psychiatry, 36, 1001–1007., , & (1973). Gender identity change in a transsexual. Archives of General Psychiatry, 28, 569–576., , & (2000). Is gender identity disorder in children a mental disorder?Sex Roles, 43, 753–785., , & (1973). Play activities of normal and effeminate boys. Developmental Psychology, 9, 20–27., & (1973). Measurement of deviant gender behavior in boys. Child Development, 44, 591–598., , & (1979). Gender-deviant boys compared with normal and clinical control boys. Journal of Abnormal Child Psychology, 7, 243–259., , & (1985). A psychological comparison of heterosexuals, transvestites, preoperative transsexuals and postoperative transsexuals. Journal of Nervous and Mental Disease, 173, 358–365.(1981). Sexual preference: Its development in men and women. Bloomington: Indiana University Press., , & (1981). Gender schema theory: A cognitive account of sex typing. Psychological Review, 88, 354–364.(1989). Genital knowledge and gender constancy in preschool children. Child Development, 60, 649–662.(1995). Psychosocial adaptation of 39 adolescents with sex chromosome abnormalities. Pediatrics, 96, 302–308., , , & (1987). Environment and developmental risk in children with sex chromosome abnormalities. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 499–503., , & (1953). Transvestism and transsexualism. International Journal of Sexology, 7, 12–14.([Page 183]1964). Nature and management of transsexualism. With a report on thirty- one operated cases. Western Journal of Surgery, Obstetrics and Gynecology, 72, 105–111.(1966). The transsexual phenomenon: A scientific report on transsexualism and sex conversion in the human male and female. New York: Julian Press.(1976). A typology of transsexualism: Gender identity theory and data. Archives of Sexual Behavior, 5, 567–584.(1999). Effects of early androgens on sex-typed activities and interests in adolescents with congenital adrenal hyperplasia. Hormones and Behavior, 35, 102–110.(2000). Psychological outcome in congenital hyperplasia. In B.Stabler & B. B.Bercu (Ed.), Therapeutic outcome of endocrine disorders: Efficacy, innovation, and quality of life (pp. 186–199). New York: Springer-Verlag.(2000). Behavioral effects of prenatal versus postnatal androgen excess in children with 21-hydroxylase-deficient congenital adrenal hyperplasia. Journal of Clinical Endocrinology and Metabolism, 85, 727–733., , & (1997). Early androgen effects on aggression in children and adults with congenital adrenal hyperplasia. Psychoneuroendocrinology, 22, 505–515., & (1994). Polynesian gender liminality through time and space. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 285–328). New York: Zone Books.(1999). Gender identity reversal in an adolescent with mixed gonadal dysgenesis. Journal of Pediatric Endocrinology and Metabolism, 12, 687–690., , , , & (2000). How sexually dimorphic are we? Review and synthesis. American Journal of Human Biology, 12, 151–166., , , , , & (1992). The sex-typing of children's household labor: Parental influences on daughters' and sons' housework. Youth and Society, 24, 178–203.(1985). Typology of male-to-female transsexualism. Archives of Sexual Behavior, 14, 247–261.(1988). Nonhomosexual gender dysphoria. Journal of Sex Research, 24, 188–193.(1989). The classification and labeling of nonhomosexual gender dysphoria. Archives of Sexual Behavior, 18, 315–334.(1997). Birth order and sibling sex ratio in homosexual versus heterosexual males and females. Annual Review of Sex Research, 8, 27–67.(2001). Fraternal birth order and the maternal immune hypothesis of male homosexuality. Hormones and Behavior, 40, 105–114.(1995). Comparison of height and weight in homosexual versus nonhomosexual male gender dysphorics. Archives of Sexual Behavior, 24, 543–554., , & (1990). Clinical management of gender identity disorders in children and adults. Washington, DC: American Psychiatric Press., & (1989). Prediction of regrets in postoperative transsexuals. Canadian Journal of Psychiatry, 34, 43–45., , , & (1994). Self-image and personality traits in gender identity disorders: An empirical study. Journal of Sex and Marital Therapy, 20, 303–317., & (1996). Transsexualism - General outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the progress of changing sex. Archives of Sexual Behavior, 25, 303–316., & ([Page 184]1993). Personality traits and disorders among transsexuals. Acta Psychiatrica Scandinavica, 88, 322–327., , , & (1994). Transcending and transgendering: Male-to-female transsexuals, dichotomy and diversity. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 447–486). New York: Zone Books.(1950-1951). Erwiderung zum Bericht über mein Referat auf der 66. Wanderversammlung der südwestdeutschen Psychiater und Neurologen in Badenweiler. Psyche, 4, 394–400.(2001). The gender identity disorder in the DSM-IV classification: A critical evaluation. Australian and New Zealand Journal of Psychiatry, 35, 1–8.(1991). Interim report of the DSM-IV Subcommittee on Gender Identity Disorders. Archives of Sexual Behavior, 20, 333–343., , , , , , & (1998). Experiment of nurture: Ablatio penis at 2 months, sex reassignment at 7 months, and a psychosexual follow-up in young adulthood [On-line]. Available: http://www.pediatrics.org/cgi/content/full/ 102/1/e9., , , & (1998). A reply to Menvielle. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 244–245., & (1998). Sexual science: Whose cultural difference?Sexualities, 1, 313–326.(1994). Sexual differentiation of the human nervous system. Annual Review of Psychology, 45, 389–418.(1993). Person drawings by transsexual clients, psychiatric clients, and nonclients compared: Indicators of sex-typing and pathology. Archives of Sexual Behavior, 22, 253–264., , & (1988). Cerebral specialization: Clinical and experimental assessment. In F.Boller & J.Grafman (Ed.), Handbook of neuropsychology (pp. 143–159). Amsterdam: Elsevier Science.(1983). Transsexuelle in Prag. Sexualmedizin, 3, 110–112., & (1978). Two transsexuals with 47, XYY karyotype. British Journal of Psychiatry, 133, 77–81., , & (1978). Two clinically discrete syndromes of transsexualism. British Journal of Psychiatry, 133, 73–76., & (1993). Cross dressing, sex, and gender. Philadelphia: University of Pennsylvania Press., & (Bullough, B., Bullough, V. L., & Elias, J. (Eds.). (1997). Gender blending. Armherst, NY: Prometheus Books.1940). Über den Transvestitismus bei Männern. Monatsschrift für Kriminalbiologie und Strafrechtsreform, 31, 125–143., & (1990). Clinical features of patients attending a gender- identity clinic. British Journal of Psychiatry, 157, 265–268., , & (1972). Actions, styles and symbols in Kinetic Family Drawing (K-F-D): An interpretative manual. New York: Brunner and Mazer., & (1999). Social cognitive theory of gender development and differentiation. PsycholgicalReview, 106, 676–713., & (1998). Afterword. Sexualities, 1, 355–359.(1983). The North American berdache. Current Anthropology, 24, 443–470., & ([Page 185]1984). The epidemiology of adolescent sex-role attitudes. Sex Roles, 11, 657–767., & (1987). The roles of peers in sex role socialization. In D. B.Carter (Ed.), Current conceptions of sex roles and sex typing: Theory and research (pp. 101–121). New York: Praeger.(1988). Cognitive aspects of children's early sex-role development: The influences of gender schemas on preschoolers' memories and preferences for sex-typed toys and activities. Child Development, 59, 782–793., & (1949). Psychopathia transexualis. Sexology, 16, 274–280.(1989). Occurrence of male phenotype in geno- typic females with congenital virilizing adrenal hyperplasia. American Journal of Medical Genetics, 34, 406–412., , & (1965). A case of transvestism in a six-year-old boy. Journal of the Hillside Hospital, 14, 160–177., & (1997, October 14-15). Spare the knife, study the child [Letter]. Ob.Gyn. News, 1. Available: http://hiv.medscape.com/IMNG/ClinPsychNews/1997/v25.n09/cpn2509. 08.1.html.(1975). The preschool-teacher dyad: Sex differences in verbal interaction. Child Development, 46, 532–535.(1988). Enfance et transsexualisme. Psychiatrie de l'enfant, 31, 313–373.(2000). The psychoanalyst and the transsexual patient. International Journal of Psychoanalysis, 81, 24–35.(2000). Sexual orientation of female-to-male transsexuals: A comparison of homosexual and nonhomosexual types. Archives of Sexual Behavior, 29, 259–278., & (1985). Extreme boyhood femininity: Overview and new research findings. In Z.De Fries, R. C.Friedman, & R.Corn (Ed.), Sexuality: New perspectives (pp. 101–124). Westport, CT: Greenwood.(1990). Ontogenesis of boyhood gender identity disorder. Journal of the American Academy of Psychoanalysis, 18, 414–438.(1991). The etiology of boyhood gender identity disorder: A model for integrating temperament, development and psychodynamics. Psychoanalytic Dialogues, 1, 481–523., , & (1985). Extreme boyhood femininity. Isolated behavior or pervasive disorder?Journal of the American Academy of Child Psychiatry, 24, 702–709., & (1997). Gender identity disorders of childhood. In J. D.Noshpitz (Ed.) & S.Greenspan, S.Wieder, & J.Osofsky (Vol. Eds.), Handbook of child and adolescent psychiatry: Vol. I. Infants and preschoolers: Development and syndromes (pp. 453–472). New York: Wiley., & (1995). Auditory cerebral lateralization following cross-gender hormone therapy. Cortex, 31, 565–573., & (1997). Psychological functioning of adolescent transsexuals: Personality and psychopathology. Journal of Clinical Psychology, 53, 187–196., , , & (2001). Effects of prenatal exposure to testosterone on cerebral lateralization: A twin study. Poster presented at the 10th International Congress on Twin Studies, Imperial College, London., , , & ([Page 186]1994). Die Behandlung von Kindern und Jugendlichen mit Geschlechtsidentitätsstörungen an der Universität Utrecht. Zeitschrift für Sexualforschung, 7, 231–239.(2001). Gender identity disorder in DSM?Journal of the American Academy of Child and Adolescent Psychiatry40, 391.(1997). Sex reassignment of adolescent transsexuals: A follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry36, 263–271., & (1998). Pubertal delay as an aid in diagnosis and treatment of a transsexual adolescent. European Child and Adolescent Psychiatry, 7, 246–252., & (1998). Cognitive ability and cerebral lateralization in transsexuals. Psychoneuroendocrinology, 23, 631–641., , , & (2000). Internalizing disorders in prepubertal children with gender identity disorder. Poster presented at the 26th annual meeting of the International Academy of Sex Research, Paris, France., , & (Demographic characteristics, social competence, and behavior problems in children with gender identity disorder: A cross-national, cross-clinic comparative analysis., , , , & (in press).1996). Seksueel gedrag van kinderen: Een kwantitatief onderzoek onder moeders. Tijdschrift voor Seksuologie, 20, 254–265., & (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual Behavior, 26, 13–26., , , & (1988). Spatial ability in members of opposite sex twins pairs [Abstract], Behavior Genetics, 18, 710., , & (1993). Homosexual and bisexual identity in sex-reassigned female-to-male transsexuals. Archives of Sexual Behavior, 22, 37–50., , & (1990). Skoptic Syndrome: The treatment of an obsessional gender dysphoria with lithium carbonate and psychotherapy. American Journal of Psychotherapy, 2, 204–217., & (1992). Male cross-gender behavior in Myanmar (Burma). Archives of Sexual Behavior, 21, 313–322., , & (1998). Corbett v Corbett: Is it still good law? Unpublished manuscript, presented at the Third International Congress on Sex and Gender, Exeter College, Oxford, UK, 18-20 September, 1998 [On-line abstract]. Available: http://www.symposion.com/ijt/whittle_congress.htm.(1995). Human behavioral sex differences: A role for gonadal hormones during early development?Psychological Bulletin, 118, 55–107., & (Committee on Genetics/American Academy of Pediatrics. (1995). Health supervision for children with Turner syndrome. Pediatrics, 96, 1166–1172.1979). Doctor or nurse: Children's perception of sex typed occupations. Child Development, 50, 590–593., , & (1995). Family patterns in handedness: Evidence for indirect inheritance mediated by birth stress. Behavior Genetics, 25, 517–524.(Council of Europe (Ed.). (1995). Transsexualism, medicine and law. Strasbourg: Author.2001). Managing intersex: Most vaginal surgery in childhood should be deferred. British Medical Journal, 323, 1264–1265.([Page 187]2001). Objective cosmetic and anatomical outcomes at adolescence of feminizing surgery for ambiguous genitalia done in childhood. Lancet, 358, 124–125., , & (1992). Transsexualism in a Klinefelter male: A case report. Journal of Psychological Medicine, 9, 45–46., & (1969). Mental illness and patterns of behavior in 10 XYY males. Journal of Nervous and Mental Disease, 144, 318–327.(2001). Ethics and the management of the patient with intersex: A middle way. Journal of Pediatric Endocrinology and Metabolism, 14, 1575–1583., & (1981). Anorexia nervosa and ‘Turner syndrome’: Cause or coincidence?Psychological Medicine, 11, 141–145., , , , & (1977). Gender identity change in a female adolescent transsexual. Archives of Sexual Behavior, 6, 327–340., & (1966). Transsexualism in Klinefelter's Syndrome. Psychosomatics, 7, 94–98.(1995). Transsexualiteit: Psychiatrische aspecten in het kader van de geslachtsaanpassende behandeling. Gent, Belgium: University of Gent.(1995). Neonatal management of female intersex by clitorovaginoplasty. Journal of Urology, 154, 830–832., & (1993). Commentary: Sorry, wrong number: A reply to Gentile's call. Sex or gender?Psychological Science, 4, 125–126.(1989). The tradition of female transvestitism in early modern Europe. Badingstoke, UK: Macmillan., & (1981). A psychological profile of the transsexual II: The female. Journal of Nervous and Mental Disease, 169, 157–168., , & (1999). Prenatal exposure to anticonvulsants and psychosexual development. Archives of Sexual Behavior, 28, 31–44., , , , , & (1997). Sex reassignment at birth: Long-term review and clinical implications. Archives of Pediatrics and Adolescent Medicine, 151, 298–304., & (1998). Management and therapeutic aims in working with children and adolescents with gender identity disorders, and their families. In D.Di Ceglie & D.Freedman (Ed.), A stranger in my own body: Atypical gender identity development and mental health (pp. 185–197). London: Karnac Books.(Di Ceglie, D., & Freedman, D., (Eds.) (1998). A stranger in my own body: Atypical gender identity development and mental health. London: Karnac Books.2002). Children and adolescents referred to a specialist gender identity development service: Clinical features and demographic characteristics [On-line]. Available: http://www.symposion.com/ijt/ ijtvo06no0101.htm., , , & (1998). Gender identity disorders in children and adolescents: Guidelines for management (Council Report CR63). London: Royal College of Psychiatrists., , & (1998). Ambiguous genitalia, gender identity problems, and sex reassignment. Journal of Sex and Marital Therapy, 24, 255–271.(1990). Congenital adrenal hyperplasia I: Gender-related behavior and attitudes in female patients and sisters. Psychoneuroendocrinology, 15, 401–420., , , , , , & ([Page 188]1992). Sexual behavior in adolescent and adult females with congenital adrenal hyperplasia. Psychoneuroendocrinology, 17, 151–170., , & (1983). On the LH response to estrogen and LHRH in transsexual men. Experimental and Clinical Endocrinology, 82, 257–267., , , & (1976). On the evocability of a positive estrogen feedback action on LH secretion in transsexual men and women. Endokrinologie, 67, 20–25., , , , & (1989). Psychopathology and social functioning in women with Turner's syndrome. Journal of Nervous and Mental Disease, 177, 191–201., , , , & (1987). Gender role development in two clinical syndromes: Turner's Syndrome versus constitutional short stature. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 566–573., , , , & (1998). Ethical questions relating to the postponement of puberty in adolescents with gender dysphoria. Paper presented at the Third International Congress on Sex and Gender, Exeter College, Oxford, UK [On-line]. Available: http://www.symposion.com/ijt/whittle_congress.htm., & (Dreger, A. D. (Ed.). (1999a). Intersex in the age of ethics. Hagerstown, MD: University Publishing Group.1999b). A history of intersex: From the age of gonads to the age of consent. In A. D.Dreger (Ed.), Intersex in the age of ethics. Hagerstown, MD: University Publishing Group.(1989). Birth order and activity level in children. Developmental Psychology, 25, 668–672., , & (2001). Gender identity: A multidimensional analysis with implications for psychosocial adjustment. Developmental Psychology, 37, 451–463., & (1968). Influence of androgen and some aspects of sexually dimorphic behavior in women with late treated adrenogenital syndrome. Johns Hopkins Medical Journal, 123, 115–122., , & (1970). Female gender identity and absence of fetal gonadal hormones: Turner syndrome. Johns Hopkins Medical Journal, 126, 237–248., , & (1984/1992). Transsexualismus. Stuttgart: Fisher.(1996). Blending genders. Social aspects of cross-dressing and sex-changing. London/New York: Routledge., & (2001). Transgendering, migrating and love of oneself as a woman: A contribution to a sociology of autogynephilia [On-line]. Available: http://www.symposion.com/ijt/ijtvo05no03_01.htm., & (1988). Prevalence of transsexualism in the Netherlands. British Journal of Psychiatry, 152, 638–640., , & (1995). Annotation: Psychological characteristics of Turner syndrome. Journal of Clinical Psychology and Psychiatry, 36, 1109–1125., , & (1932). Ein Mensch wechselt sein Geschlecht: Eine Lebensbeichte. Dresden: Carl Reissner.(1997). Long-term follow up after sex reassignment surgery. Scandinavian Journal of Plastic and Reconstructive Hand Surgery, 31, 39–45., , & (1984). Childhood sex role behaviors: Similarities and differences in twins. Acta Geneticae Medicae et Gemellologiae, 33, 173–179., & ([Page 189]1998). Why can't we go on as three?Hastings Center Report, 28, 36–39.(Ellis, L., & Ebertz, L. (Eds.). (1997). Sexual orientation: Toward a biological understanding. London: Praeger.1977). Evidence for a transitional phase in the development of gender constancy. Child Development, 48, 930–936., , , & (European Court of Human Rights, Strasbourg (2002). Judgement of 11 July 2002 (Grand Chamber) - Application no. 28957/95 - Christine Goodwin v. the United Kingdom. Human Rights Law Journal, 23(1-4), 72–85.1977). Teachers' reinforcement of sex-preferred behaviors in Dutch preschools. Psychological Reports, 41, 1249–1250.(1985). Changes in thinking about early sex role development. Developmental Review, 5, 83–98.(1995). Psychosocial and cognitive determinants of early gender role development. Annual Review of Sex Research, 6, 1–31.(1985). Gender identity: Some thoughts on an old concept. Journal of the American Academy of Child Psychiatry, 24, 684–688., & (1989). The young child's gender schema: Environmental input, internal organization. Child Development, 60, 663–672., & (1993). Gender-role development in young children: From discrimination to labeling. Developmental Review, 13, 205–224., & (1986). Gender labeling and the adoption of sex-typed behaviors. Developmental Psychology, 22, 440–443., , & (1992). Myths of gender. New York: Basic Books.(1997). Disciplining the family: The case of gender identity disorder. Philosophical Studies, 85, 195–211.(1994). Outcome analysis of the psychosexual and socio-economical development of adult patients born with bladder exstrophy. Journal of Urology, 152, 1417–1419., , , & (1992). Relations between prenatal testosterone levels and cognitive abilities at 4 years. Developmental Psychology, 28, 1075–1089., , & (1980). Exclusive adult lesbianism associated with Turner's syndrome mosaicism. Archives of Sexual Behavior, 9, 349–353., & (1973). Gender dysphoria syndrome (the how, what and why of a disease). In D. R.Laub & P.Gandy (Eds.), Proceedings of the 2nd Interdisciplinary Symposium on Gender Dysphoria Syndrome. Stanford, CA: Division of Reconstructive and Rehabilitation Surgery, Stanford University Medical Center.(1998). A role for ovarian hormones in sexual differentiation of the brain. Behavior and Brain Sciences, 21, 311–327., & (1982). Preliminary results of pre- and postoperative transsexuals. Journal of Clinical Psychology, 38, 408–514., , & (1985). The dyadic adjustment of female-to-male transsexuals. Archives of Sexual Behavior, 14, 47–55., , & (1980). Methodological problems in assessing sex-reassignment surgery: A reply to Meyer and Reter. Archives of Sexual Behavior, 9, 451–456., , & (1982). Two types of cross-gender identity. Archives of Sexual Behavior, 11, 49–63., , & ([Page 190]1996). Physical attractiveness of girls with gender identity disorder. Archives of Sexual Behavior, 25, 17–31., , , & (1988). Male homosexuality: A contemporary psychoanalytic perspective. New Haven, CT: Yale University Press.(1995). XYY syndrome and other Y chromosome polysomies: Mental status and psychosocial functioning. Genetic Counseling, 6, 197–206., , , & (1992). Vested interests: Cross-dressing and cultural anxiety. London: Penguin.(Gay American Indians & Roscoe, W. (Eds.). (1988). Living the Spirit: A gay American Indian anthology. New York: St. Martin's Press.1988). Sex determination and differentiation. In E.Knobil and J.Neill (Ed.), The physiology of reproduction (pp. 3–26). New York: Raven Press., & (1988). Transsexualism and anatomic sex: Ratio reversal in Poland. Archives of Sexual Behavior, 17, 547–549.(1994). Gender development. New York: Cambridge University Press., & (1993). The preschool activities inventory: A standardized assessment of gender role in children. Psychological Assessment, 5, 131–136., & (1985). Study of the effect of estradiol on gonadotropin levels in untreated male-to- female transsexuals. Archives of Sexual Behavior, 14, 141–147., , , , , & (1986). The neuroendocrine response of luteinizing hormone to estrogen administration in heterosexual, homosexual and transsexual subjects. Journal of Clinical Endocrinology and Metabolism, 63, 583–588.(1988). An appraisal of endocrine theories of homosexuality and gender dysphoria. In J. M. A.Sitsen (Ed.), Handbook of sexology: Vol. 6. The pharmacology and endocrinology of sexual function (pp. 410–424). Amsterdam: Elsevier.(1992). Gender dysphoria in Pakistan: The Khusra. A traveller's report. Gender Dysphoria, 1, 35–36.(1991). Development of male gender identity/role and a sexual orientation towards women in a 46, XY subject with an incomplete form of the androgen insensitivity syndrome. Archives of Sexual Behavior, 20, 459–470., & (1996). The feasibility of endocrine interventions in juvenile transsexuals. Journal of Psychology & Human Sexuality, 8, 69–74., & (2000). Sexual differentiation of the nervous system. In E. R.Kandel, J. H.Schwartz, & T. M.Jessell (Eds.), Principles of neural science ((4th ed., pp. 1131–1148). New York: McGraw-Hill.1999). Criminality and antisocial behaviour in unselected men with sex chromosome abnormalities. Psychological Medicine, 29, 953–962., , & (1988). Oral and written language abilities of XXY boys: Implications for anticipatory guidance. Pediatrics, 81, 795–806., , , , & (1966). Transsexualism: Mythological, historical, and cross-cultural aspects. In H.Benjamin (Ed.), The transsexual phenomenon (pp. 173–185). New York: Julian Press.(1974). Sexual identity conflict in children and adults. New York: Basic Books.(1987). The “sissy boy syndrome” and the development of homosexuality. New Haven, CT: Yale University Press.([Page 191]1994). Transsexualism and the law. Bulletin of the American Academy of Psychiatry and the Law, 22, 511–517.(1990). Transsexual surgery follow-up: Status in the 1990s. Annual Review of Sex Research, 1, 163–174., & (1969). Transsexualism and sex reassignment. Baltimore, MD: Johns Hopkins University Press., & (1972). Treatment of boyhood “transsexualism.”Archives of General Psychiatry, 26, 213–217., , & (2001). Hand preference, sexual preference, and transsexualism. Archives of Sexual Behavior, 30, 565–574., & (1981). A comparison of the MMPI results for psychiatric patients and male applicants for transsexual surgery. Journal of Nervous and Mental Disease69, 320–323., & (2000). Gender and culture. In A. E.Kazdin (Ed.), Encyclopedia of psychology (Vol. 3, pp. 430–433). Oxford, UK: Oxford University Press.(1994). Woman becomes man in the Balkans. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 241–281). New York: Zone Books.(1995). Relations between prenatal testosterone and cerebral lateralization in children. Neuropsychology, 9, 68–79., , & (1995). Mental rotation at 7 years: Relation with prenatal testosterone levels and spatial play performance. Brain and Cognition, 29, 85–100., , & (1997). Judicial problems related to transsexualism in France. Medicine Science and the Law, 3, 27–31., , & (1998). Disorders of sexual differentiation. In J. W.Wilson & D. W.Foster (Eds.), Williams textbook of endocrinology (, & (9th ed., pp. 1400–1405). Philadelphia, PA: W. B. Saunders.1991). The psychoanalytic treatment of a preschool boy with a gender identity disorder. Journal of the American Psychoanalytic Association, 39, 107–130.(1975). Gender identity confusion, schizophrenia and a 47 XYY karyotype: A case report. Psychoneuroendocrino- logy, 1, 207–209., , , & (Hage, J. J., & Mulder, J. W. (Eds.). (1995). Plastische chirurgie van het genitale gebied. Leeuwarden: Nederlandse Vereniging voor Plastische en Reconstructieve Chirurgie.1992). Sex differences in cognitive abilities ((2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.1953). The desire for change of sex as shown by personal letters from 465 men and women. Acta Endocrinologica, 14, 361–375.(1953). Transvestism. Hormonal, psychiatric and surgical treatment. Journal of the American Medical Association, 152, 391–396., , & (1998). Spatial reasoning in children with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Developmental Neuro- psychology, 14, 299–320., , & (2000). Symptom profiles of gender dysphoric patients of transsexual type compared to patients with personality disorders and healthy adults. Acta Psychiatrica Scandinavica, 102, 276–281., & ([Page 192]1998). A mother's 10 commandments to medical professionals: Treating intersex in the newborn. In A. D.Dreger (Ed.), Intersex in the age of ethics (pp. 195–196). Hagerstown, MD: University Publishing Group.(1992). Left-handedness. In I.Rapin & S.J.Segalowitz (Ed.), Handbook of neuropsychology (pp. 145–208). Amsterdam: Elsevier Science.(1982). Gay children grow up: Gender culture and gender deviance. New York: Praeger.(1980). The eye of the very young beholder: Sex typing of infants by young children. Child Development, 51, 598–600., , & (1975). Transsexualism in Vietnam. Archives of Sexual Behavior, 4, 89–95., & (1994). “A female soul in a male body”: Sexual inversion as gender inversion in nineteenth-century sexology. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 213–239). New York: Zone Books.(1994). General intelligence and cognitive profile in women with congenital adrenal hyperplasia (CAH). Psychoneuroen- docrinology, 19, 343–356., , , & (1994a). Third sex, third gender: Beyond the dimorphism in culture and history. New York: Zone Books.(1994b). Mistaken sex: Culture, biology and third sex in New Guinea. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 419–445). New York: Zone Books.(1988). The Sambia “Turnim-man”: Sociocultural and clinical aspects of gender transformation in male pseudohermaphroditism with 5-alpha reductase deficiency in Papua Guinea. Archives of Sexual Behavior, 17, 33–56., & (1993). Transsexualism and sex related differences in hemispheric asymmetry. Acta Neurobiologiae Experimentalis, 53, 269–274., , & (1995). Vom Geschlechtsumwandlungswahn zur Geschlechtsumwandlung. Pro Familia Magazin, 23, 14–18.(1979). Transsexuality: Some remarks based on clinical experience. In Sex, hormones and behavior (pp.165–181). Amsterdam: Ciba Foundation Symposium 62., & (2000). Psychological development in androgen insensitivity syndrome. Poster presented at the 26th annual meeting of the International Academy of Sex Research, Paris, France., , & (1993). Die soziale Konstruktion der Transsexualität: Über die Medizin und den Geschlechtswechsel. Frankfurt am Main: Suhrkamp.(1997). The medicalization of gender migration [On-line]. Available: http://www.symposion.com/ijt/ijtc0104.htm.(1910). Die Transvestiten: Eine Untersuchung über den erotischen Verkleidungstrieb mit umfangreichem casuistischem und historischem Material (Vols. III). Berlin: Alfred Pulvermacher & Co.(1918). Sexuelle Zwischenstufen: Vol. 2. Sexualpathologie. Bonn: Marcus & Webers.(1923). Die intersexuelle Konstitution. Jahrbuch für sexuelle Zwischenstufen, 23, 3–27.(1994). Is there a sex difference in human laterality? 1: An exhaustive survey of auditory laterality studies from six neuropsychology journals. Journal of Clinical and Experimental Neuropsychology, 16, 423–435., , , , & ([Page 193]1964). Psychopathology in Klinefelter's Syndrome. Psychosomatic Medicine, 26, 207–223., , & (1987). Psychosexual outcome of assigned females and males with 46,XX virilizing congenital adrenal hyperplasia. European Journal of Pediatrics, 146, 497–499., , & (1985). The origin of gender identity. In B. W.Steiner (Ed.), Gender dysphoria: Development, research, management (pp. 11–32). New York: Plenum Press.(1971). Surgical treatment for transsexualism. Acta Psychiatrica Scandinavica, 47, 106–133., , & (1994). Turner syndrome: Final height, glucose tolerance, bone density and psychosocial status in 25 adult patients. European Journal of Pediatrics, 15, 11–16., , , , & (1974). Transsexuals: Legal considerations. Archives of Sexual Behavior, 3, 33–50.(1983). The distribution of chromosomal genotypes associated with Turner's syndrome: Live birth prevalence rates and evidence for diminished fetal mortality and severity in genotypes associated with structural X abnormalities or mosaicism. Human Genetics, 64, 24–27., & (1992). Ambiguous genitalia: Diagnosis, evaluation, and treatment. Urologic Radiology, 14, 306–318., & (1949). Ein Transvestit (Der Fall Hinrich B.). Kriminalistik, 3, 91–92.(1981). Cognitive correlates of biologic sex and gender identity in transsexualism. Archives of Sexual Behavior, 10, 65–77., , & (1992). The psychosocial effects of ambiguous genitalia. Comprehensive Therapy, 18, 22–25.(1987). Psychological findings in early treated cases of female pseudohermaphroditism caused by virilizing congenital adrenal hyperplasia. Archives of Sexual Behavior, 16, 209–223., & (1974). Steroid 5alpha- reductase deficiency in man: An inherited form of male pseudohermaphroditism. Science, 27, 1213–1215., , , & (1979). Androgens and the evolution of male-gender identity among male pseudohermaphrodites with 5alpha- reductase deficiency. New England Journal of Medicine, 300, 1233–1237., , , & (1979). Male pseudohermaphroditism secondary to 17ß-hydroxysteroid dehydrogenase deficiency: Gender role change with puberty. Journal of Clinical Endocrinology and Metabolism, 49, 391–395., , , & (1988a). Children's concepts of gender. Norwood, NJ: Ablex.(1988b). Gender concepts of Swedish and American youth. Hillsdale, NJ: Lawrence Erlbaum.(1997). Remove gender identity in DSM. Psychiatric News, 32, 9 and 13.(1983). Neonatal sex-steroid hormones and timidity in 6-18 month-old boys and girls. Developmental Psychobiology, 16, 163–168., , & (1988). Neonatal sex-steroid hormones and cognitive abilities at six years. Developmental Psychobiology, 21, 567–574., , & (1999). Neurodevelopmental disorders: Diagnosis and treatment. New York/Oxford: Oxford University Press.([Page 194]1997). Congenital adrenal hyperplasia in Turkey: A review of 273 patients. Acta Paediatrica, 86, 22–25., & (1973). Sex change: The achievement of gender identity among feminized transsexuals. Springfield, IL: Charles C. Thomas.(1993). Sam: A child analysis. Journal of Clinical Psychoanalysis, 2, 43–62.(1978-1979). Transsexualism and a new type of psychosurgery. International Journal of Psychoanalytic Psychotherapy, 7, 366–372., & (1996). Sex, lies, and androgen insensitivity syndrome. Canadian Medical Association Journal, 154, 1827–1834., , , , , & (1975). Borderline conditions and pathological narcissism. New York: Science House.(1998). Lessons from the intersexed. New Brunswick, NJ: Rutgers University Press.(1986). Television and sex-role attitudes. In T. M.Williams (Ed.), The impact of television: A natural experiment in three communities (pp. 265–301). Orlando, FL: Academic Press.(1986). The transvestite and the transsexual: A case study of public categories and private identities. Ph.D. Thesis, University of Essex.(1998). From one ‘battle’ to another: The making of a travesti political movement in a Brazilian city. Sexualities, 327–342.(1988). Male-to-female and female-to-male transsexuals: A comparison. Archives of Sexual Behavior, 6, 539–546., & (1966). A cognitive-developmental analysis of children's sex role concepts and attitudes. In E. E.Maccoby (Ed.), The development of sex differences (pp. 82–173). Stanford, CA: Stanford University Press.(1985). Male pseudohermaphroditism due to 17ß-hydroxysteroid dehydrogenase deficiency (17ß HSD) in a large Arab kinship: Studies on the natural history of the defect. Journal of Pediatric Endocrinology, 1, 29–37., , , , , & (1981). Treatment of transsexualism in adolescence. Journal of Adolescence4, 177–185., , , & (2000). Male-to-female transsexuals have female neuron numbers in a limbic nucleus. Journal of Clinical Endocrinology and Metabolism, 85, 2034–2041., , , , , & (1968). Critical issues raised by operations for gender transmutations. Journal of Nervous and Mental Disease, 14, 431–444., & (1978). Sex role concepts of two- and three-year old children. Child Development, 49, 445–451., , & (1995). The quality of life in adult female patients with congenital adrenal hyperplasia: A comprehensive study of the impact of genital malformations and chronic disease on female patients' life. European Journal of Pediatrics, 154, 708–716., , & (1991). Transseksualiteit: Evaluatie van de geslachtsaanpassende behandeling. Utrecht: Elinkwijk.(1998). Gender role reversal among postoperative transsexuals [On-line]. Available: http://www.symposion.com/ijt/ijtc0502.htm., & (1998a). Transgender in Latin America: Persons, practices and meaning, Sexualities, 1, 259–260.([Page 195]1998b). Fe/male trouble: The unsettling place of lesbians in the self-images of Brazilian travesti prostitutes. Sexualities, 1, 299–312.(1984). The emergence of same-sex affiliative preferences among preschool peers: A developmental/ethological perspective. Child Development, 55, 1958–1965., , & (1979). Peer influences on sex role development. Child Development, 50, 1219–1222., & (1998). Transgenderism in Latin America: Some critical introductory remarks on identities and practices. Sexualities, 1, 261–274.(1998). Factors predictive of regret in sex reassignment. Acta Psychiatrica Scandinavica, 97, 284–289., , , & (1996). Prevalence, incidence and sex ratio of transsexualism. Acta Psychiatrica Scandinavica, 93, 221–223., , & (1998). Clinical characteristics of a total cohort of female and male applicants for sex reassignment: A descriptive study. Acta Psychiatrica Scandinavica, 97, 189–194., , & (1998). Men as women, women as men. Changing gender in native American cultures. Austin: University of Texas Press.(1982). Paternity in Klinefelter's Syndrome. A case report. Archives of Andrology, 8, 149–151., , , & (1976). Cognitive style, hemispheric specialization, and tested abilities of transsexuals and nontranssexuals. Perceptual and Motor Skills, 43, 719–722., , & (1997). Gender development and heterosexual romantic relationships during adolescence. New Directions in Child Development, 78, 85–103., & (1998). Moderators of gender effects on parents' talk to their children: A meta-analysis. Developmental Psychology, 34, 3–27., , & (1990). Clinical patterns among male transsexual candidates with erotic interest in males. Archives of Sexual Behavior, 19, 491–505., & (1980). Presurgical adjustment in male transsexuals with and without hormonal treatment. Journal of Nervous and Mental Disease, 168, 693–697., , & (1986). Acquisition of gender labeling: A test for toddlers. Sex Roles, 15, 655–666., & (1998). Lean mean fighting queens: Drag in the world of Mexican professional wrestling. Sexualities, 1, 275–286.(1983). Gender identity/role: GI/R Part A: XY (androgen- insensitivity) syndrome and XX (Rokitansky) syndrome of vaginal atresia compared. In L.Dennerstein & G.Burrows (Ed.), Handbook of psychosomatic obstetrics and gynaecology (pp. 51–60). Amsterdam: Elsevier Biomedical., & (1983). A combined approach to the treatment of effeminate behaviour in a boy: A case study. Journal of Child Psychology and Psychiatry, 3, 469–479., & (1986). Long-term follow-up of “sex change” in 13 male-to-female transsexuals. Archives of Sexual Behavior, 15, 187–210., , & (1975). A body image scale for evaluating transsexuals. Archives of Sexual Behavior, 4, 639–656., & (1985). Emergence and characterization of sex differences in spatial ability: A meta-analysis. Child Development, 56, 1479–1498., & ([Page 196]2000). Dimensions of psychological masculinity-femininity in adult twins from opposite-sex and same-sex pairs. Behavior Genetics, 30, 19–28., & (1982). Sex reassignment surgery: Historical, bioethical, clinical and theoretical issues. American Journal of Psychiatry, 139, 417–426.(1984). Psychological testing with transsexuals: A 30 year review. Journal of Personality Assessment, 48, 500–507.(1984). Outcome of sex reassignment surgery. Acta Psychiatrica Scandinavica, 70, 289–294., , & (1995). Children and gender prejudice: Context, motivation, and the development of gender concepts. Annals of Child Development, 10, 131–166., & (1991). Parents' differential socialization of boys and girls: A meta-analysis. Psychological Bulletin, 109, 267–296., & (1998). The two sexes: Growing up apart coming together. Cambridge, MA: The Belknap Press of Harvard University Press.(1987). Gender segregation in childhood. In H.Reese (Ed.), Advances in child development and behavior (Vol. 20, pp. 239–287). New York: Academic Press., & (1979). Origin of estrogen in normal men and in women with testicular feminization. Journal of Clinical Endocrinology and Metabolism, 49, 905–916., , , , & (Maine Gender Resource and Support Service (MeGReSS) (2002). Transgender youth survey [On-line]. Available at: firstname.lastname@example.org and http://personalpages.tds.net/-megress.1982). A cultural approach to male-female miscommunication. In J. A.Gumperz (Ed.), Language and social identity (pp. 195–216). New York: Cambridge University Press., & (1991). Klinefelter Syndrome: The need for early identification and treatment. Clinical Pediatrics, 30, 161–164., & (1991). Mothers of boys with gender identity disorder: A comparison of matched controls. Journal of the American Academy of Child and Adolescent Psychiatry, 30, 310–315., & (2000). Adult gender identity disorder can remit. Comprehensive Psychiatry, 41, 273–275., , & (1981). A schematic processing model of sex typing and stereotyping in children. Child Development, 52, 1119–1134., & (1983). The effects of sex typing schemas on young children's memory. Child Development, 54, 563–574., & (1990). The development of gender stereotype components. Child Development, 61, 1891–1904., , & (1996). Constitution of semen samples from XYY and XXY males as analysed by in-situ hybridization. Human Reproduction, 11, 1638–1643., , , , , , & (1971). Fetal feminization and female gender identity in the testicular feminizing syndrome of androgen insensitivity. Archives of Sexual Behavior, 1, 131–142., , & (1988). Psychiatric symptoms in transsexualism. British Journal of Psychiatry, 150, 550–553.(The politics of re-presentation: An analysis of Western academic treatments of male transgenderism in Thailand.(in press). [Page 197]1977). Role expectations and definitions: A comparison of female transsexuals and lesbians. Journal of Homosexuality, 3, 137–147., & (2001). Psychosocial development in adolescents with Turner syndrome. Journal of Developmental and Behavioral Pediatrics, 22, 360–365., , , & (1995). Self-esteem and behavior in girls with Turner syndrome. Journal of Developmental and Behavioral Pediatrics, 16, 82–88., , , & (1998). Effects of physical appearance on masculine trait ratings of boys and girls with gender identity disorder. Archives of Sexual Behavior, 27, 253–267., , , & (1992). Steroid hormones: Effects on brain development and function. Hormone Research, 37(Suppl. 3), 1–10.(1996) Acknowledging mixed-sex people. Journal of Sex and Marital Therapy, 22, 265–274.(1928). Coming of age in Samoa. New York: William Morrow & Co.(1930). Growing up in New Guinea. New York: William Morrow & Co.(1935). Sex and temperament. New York: William Morrow & Co.(1995). Male pseudohermaphroditism due to primary 5a-reductase deficiency: Variation in gender identity reversal in seven Mexican patients from five different pedigrees. Journal of Endocrinological Investigation, 18, 205–213., , , , , , , , & (1996). Male pseudohermaphroditism due to steroid 5alpha-reductase 2 deficiency: Diagnosis, psychological evaluation, and management. Medicine (Baltimore), 7, 64–76., , , , , , , , & (2000). Sex reassignment surgery in France: Analysis of the legal framework and current procedures and its consequences for transsexuals. Medicine and Law, 19, 827–837., , & (1998). Gender identity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 243–244.(1994). Kritik der hormonellen Behandlung Jugendlicher mit Geschlechtsidentitätsstörungen. Zeitschrift für Sexualforschung7, 343–349.(1999). Gender identity disorder in adolescence: Outcomes of psychotherapy. Adolescence, 34, 305–313.(1982). The theory of gender identity disorders. Journal of the American Psychoanalytic Association, 30, 381–418.(1979). Sex reassignment: Follow-up. Archives of General Psychiatry, 36, 1010–1015., & (2001). Standards of care, for Gender Identity Disorders of the Harry Benjamin International Gender Dysphoria Association (, , , , , , , , , , , , , , , , & (6th ed.) [On-line]. Available: http://www.symposion.com/ijt/soc2001/index/htm.1985). Gender identity disorder of childhood: Introduction. Journal of the American Academy of Child Psychiatry, 24, 681–683.(1993). Gender identity development in intersex patients. Child and Adolescent Psychiatric Clinics of North America, 2, 501–512.([Page 198]1994). Intersexuality and the diagnosis of gender identity disorder. Archives of Sexual Behavior, 23, 21–40.(1998). Gender assignment in intersexuality. Journal of Psychology and Human Sexuality, 10, 1–21.(1999). What causes low rates of child-bearing in congenital adrenal hyperplasia?Journal of Clinical Endocrinology and Metabolism, 84, 1844–1847.(2002). Gender identity disorder in young boys: A parent- and peer based treatment protocol. Clinical Child Psychology and Psychiatry, 7, 360–376.(1996). Gender change from female to male in classical congenital adrenal hyperplasia. Hormones and Behavior, 40, 319–332., , , , , , , , & (1994). Questionnaire scales for the assessment of atypical gender development in girls and boys. Journal of Psychology and Human Sexuality, 6, 19–39., , , , & (1994). Gender-related assessment of childood play. Journal of Abnormal Child Psychology, 22, 643–660., , , & (2000). Utility of the MMPI-2 in assessing gender dysphoric patients. Journal of Personality Assessment, 75, 268–279., , , & (1972). A case of transsexualism exhibiting intersexuality, having a possible XXY-sex determining mechanism. Journal of the American Society of Psychosomatic Dentistry and Medicine, 20, 58–60.(1999). Dexamethasone treatment of congenital adrenal hyperplasia in utero: An experimental therapy of unproven safety. Journal of Urology, 162, 537–540.(1965). Sex role reversal following castration of a homosexual transvestite with Klinefelter's Syndrome. Canadian Psychiatric Association Journal, 10, 223–227., & (1995). Analysis of the effect of hormones on opposite-sex twin attitudes. Acta Geneticae Medicae et Gemellologiae, 44, 41–52., & (1982). Categorization of male and female voices in infancy. Infant Behavior and Development, 5, 143–159., , & (1966). A social-learning view of sex differences in behavior. In E. E.Maccoby (Ed.), The development of sex differences (pp. 57–81). Stanford, CA: Stanford University Press.(1979). On the interface of cognition and personality: Beyond the personsituation debate. American Psychologist, 34, 740–754.(1950-1951). 66. Wanderversammlung der Südwestdeutschen Psychiater und Neurologen, Badenweiler, 2./3. Juni 1950. I. Erstes Leitthema: Daseinsanalyse. Psyche, 4, 226–234.(1950-1951a). Rundfrage über ein Referat auf der 66. Wanderversammlung der Südwestdeutschen Psychiater und Neurologen in Badenweiler. Psyche, 4, 448–477., , , , , , , , , , , , , , , , , , , & (1950-1951b). Rundfrage über ein Referat auf der 66. Wanderversammlung der Südwestdeutschen Psychiater und Neurologen in Badenweiler. Psyche, 4, 626–640., , , , , , & (1968). Sex errors of the body. Baltimore: Johns Hopkins.(1975a). Ablatio penis: Normal male infant sex-reassigned as a girl. Archives of Sexual Behavior, 4, 65–71.([Page 199]1975b). Human behavior cytogenetics: Review of psychopathology of 3 syndromes 47 XXY, 47XYY and 45X. Journal of Sex Research2, 181–200.(1993). The Adam principle: Genes, genitals, hormones & gender: Selected readings in sexology. Buffalo, NY: Prometheus Books.(1994). Concept of gender identity disorder in childhood and adolescence after 39 years. Journal of Sex & Marital Therapy, 20, 163–177.(1976). Iatrogenic homosexuality: Gender identity in seven 46XX chromosomal females with hyperadrenocortical hermaphroditism with a penis: Three reared as boys, four reared as girls. Journal of Homosexuality, 1, 357–371., & (1970). Transsexuelle nach dem Geschlechtswechsel. In G.Schmidt, V.Sigusch, & E.Schorsch (Ed.), Tendenzen der Sexualforschung (pp. 70–87). Stuttgart: Enke., & (1972). Man and woman, boy and girl: Differentiation and dimorphism of gender identity from conception to maturity. Baltimore, MD: Johns Hopkins University Press., & (1968). Fetal feminization by androgen insensitivity in the testicular feminizing syndrome: Effect on marriage and maternalism. Johns Hopkins Medical Journal, 123, 105–114., , & (1967). Verbal aptitude and eonism and prepubertal effeminacy: A feminine trait. Transactions of the New York Academy of Sciences, 29, 448–454., & (1970-1971). Sex reassignment. International Journal of Psychiatry, 9, 249–269., & (1970). Impulse, aggression and sexuality in the XYY syndrome. St. John's Law Review, 44, 220–235., , & (1955). An examination of some basic sexual concepts: The evidence of human hermaphroditism. Bulletin of the Johns Hopkins Hospital97, 301–319., , & (1957). Imprinting and the establishment of gender role. Archives of Neurology and Psychiatry, 77, 333–336., , & (1970). Lack of personality pathology in Turner's syndrome: Relation to cytogenetics, hormones and physique. Behavior Genetics, 1, 43–56., & (1974). Behavioral sexology: Ten cases of genetic male intersexuality with impaired prenatal and pubertal androgenization. Archives of Sexual Behavior, 3, 181–205., & (1979). Homosexual outcome of discordant gender identity/role: Longitudinal follow-up. Journal of Pediatric Psychology, 4, 29–41., & (1977). Dating, romantic and non-romantic friendships and sexuality in 17 early-treated adrenogenital females, aged 16-25. In P. A.Lee, L. P.Plotnick, A. A.Kowarski, & C. J.Migeon (Eds.), Congenital adrenal hyperplasia. Baltimore, MD: University Park Press., & (1984). Adult erotosexual status and fetal hormonal masculinization and demasculinization: 46,XX congenital virilizing adrenal hyperplasia and 46,XY androgen insensitivity compared. Psychoneuroendocrinology, 9, 405–414., , & (1926). Chirurgische Eingriffe bei Anomalien des Sexuallebens. Therapie der Gegenwart, 6, 451–455.(1987). Fertility rates in female patients with congenital adrenal hyperplasia due to 21hydroxylase deficiency. New England Journal of Medicine, 316, 178–182., , & ([Page 200]1995). Psychosexual adjustment of children and adolescents after different types of hypospadias surgery: A norm-related study. Journal of Urology, 154, 1902–1907., , , , , & (1998). Defiance or defilement? Undressing cross-dressing in Martinique's carnival. Sexualities, 1, 343–354.(1985). Borderline manifestations in the Rorschachs of male transsexuals. Journal of Personality Assessment, 49, 454–466.(1994). Hijras: An alternative sex and gender role in India. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 373–417). New York: Zone Books.(1908). Hermaphroditismus beim Menschen. Leipzig: Dr. Werner Klinkhardt.(1998). Turner's syndrome, anorexia nervosa, and anabolic steroids. Archives of Disease in Childhood, 79, 94., & (1995). Steroid 21-hydroxylase deficiency (congenital adrenal hyperplasia). American Journal of Medicine, G8(1A), 2S–8S.(1973). Childhood of males with XYY syndrome. Journal of Autism and Childhood Schizophrenia, 2, 5–26., , , , & (1987). Follow-up 20 years later of 34 Klinefelter males with karyotype 47XXY and 16 hypogonadal males with karyotype 46XY. American Journal of Human Genetics, 77, 188–192., & (1988). Follow-up of 30 Klinefelter males treated with testosterone. Clinical Genetics, 33, 262–269., , & (1982). Follow-up until age 7 to 11 of 25 unselected children with sex chromosome abnormalities. Birth Defects: Original Article Series, 18, 61–97., , & (1991). Chromosome abnormalities found among 34,910 newborn children: Results from a 13-year incidence study in Arhus, Denmark. Human Genetics, 87, 81–83., & (1992). Elevated sinistrality in transsexuals. Neuropsychology, 6, 351–355., , , , & (Overzier, C. (Ed.). (1961). Die Intersexualität. Stuttgart: Thieme.1968). The current status of the change of sex operation. Journal of Nervous and Mental Disease, 147, 460–471.(1981). Outcome of sex reassignment surgery for transsexuals. Australian and New Zealand Journal of Psychiatry, 15, 45–51.(1995). Psychosocial and sexual functioning in women with Turner syndrome. Clinical Genetics, 47, 85–89., , & (1982). Learning disabilities in children with sex chromosome anomalies. Child Development, 53, 1182–1192., , , , & (1974a). The transsexual syndrome in males I: Primary transsexualism. American Journal of Psychotherapy, 28, 4–20., & (1974b). The transsexual syndrome in males II: Secondary transsexualism. American Journal of Psychotherapy, 28, 174–193., & (1995). Surgical sex reassignment: A comparative study of international centers. Archives of Sexual Behavior, 24, 135–156., & (1981). Psychiatric and legal implications of the new law for transsexuals in the Federal Republic of Germany. International Journal of Law and Psychiatry, 4, 191–198.([Page 201]1992). Regrets after sex reassignment surgery. Journal of Psychology and Human Sexuality, 5, 69–85.(1993). Transsexualität: Beitrage zur Psychopathologie, Psychodynamik und zum Verlauf. Stuttgart: Enke.(1997). Sex reassignment, Harry Benjamin, and some European roots [On-line]. Available: http://www.symposion.com/ijt/ijtc0202.htm.(1992). Geschlechtsumwandlung: Abhandlungen zur Transsexualität. Stuttgart: Schattauer., & (1998). Sex reassignment: Thirty years of international follow- up studies. A comprehensive review, 1961-1991 [On-line]. Available: http://www.symposion.com/ijt/books/index.htm., & (1959). Organizing action of prenatally administered testosterone propionate on the tissues mediating behavior in the female guinea pig. Endocrinology, 65, 369–382., , , & (1964). A case of transvestism in a 17-year-old girl. Acta Psychothera- peutica, 12, 29–37.(2000). Gender self-reassignment in an XY adolescent female born with ambiguous genitalia. Pediatrics, 106, 135–137., , & (1990). Children's sex-related stereotyping of colors. Child Development, 61, 1453–1460., , & (1996). Elevated androgen, brain development and language/learning disabilities in children with congenital adrenal hyperplasia. Developmental Medicine and Child Neurology, 38, 423–437., , , & (1999). Ethical issues in diagnosing and treating gender-dysphoric children and adolescents. In M.Rottnek (Ed.), Sissies and tomboys: Gender noncomformity and homosexual childhood (pp. 34–51). New York: New York University Press.(1967). Behavior disorders and pattern of crime among XYY males identified at a maximun security hospital. British Medical Journal, 1, 533–536., & (1998). Bodily and symbolic constructions among homosexual men in Mexico. Sexualities, 1, 287–289.(1990). Management of male pseudohermaphroditism: A case report spanning twenty-one years. Journal of Pediatric Psychology, 15, 699–709., , & (1987). Sexual development and life of women with gonadal dysgenesis. Journal of Sex and Marital Therapy, 13, 117–127., , , , & (1996). The outcome of sex reassignment in Belgrade: 32 patients of both sexes. Archives of Sexual Behavior, 25, 515–525., , , & (1969). Preoperative and postoperative status of male and female transsexuals. In R.Green & J.Money (Ed.), Transsexuals and sex reassignment (pp. 355–381). Baltimore, MD: Johns Hopkins University Press.(1959). Transvestism and transsexualism: A study of 50 cases. British Medical Journal, 2, 1448–1452.(2001). Statement of the British Association of Paediatric Surgeons' Working Party on the Surgical Management of Children Born with Ambiguous Genitalia [On-line]. Available: http://www.baps.org.uk/documents/intersex%20statement.htm., , , , , & (1999). Long term outcome in children of sex chromosome abnormalities. Archives of Disease in Childhood, 80, 192–195.([Page 202]1982). Klinefelter's syndrome in adolescence. Archives of Diseases in Childhood, 57, 6–12., , , & (1990). Edinburgh study of growth and development of children with sex chromosome abnormalities. Birth Defects: Original Article Series, 26, 1–44., & (1994). Head circumference and IQ of children with sex chromosome abnormalities. Developmental Medicine and Child Neurology, 36, 533–544., , , & (1986). Edinburgh study of growth and development of children with sex chromosome abnormalities. Birth Defects: Original Article Series, 22, 73–118., , & (1997). To be male or female—That is the question [Editorial]. Archives of Pediatrics and Adolescent Medicine, 151, 224–225.(2000). Developmental ramifications of aphallia: The life story perspective. Dialogues in Pediatric Urology, 23, 2–3.(1992). Hormonal contributions to sexually dimorphic behavioral development in humans. Psychoneuroendocrinology, 16, 213–278., , & (1982). Growing up straight: What every family should know about homosexuality. Grand Rapids, MI: Baker Book House.(1995). Assessment and treatment methods for gender identity disorders and transvestism. In G. A.Rekers (Ed.), Handbook of child and adolescent sexual problems (pp. 272–289). New York: Lexington Books.(1995). Differential diagnosis and rationale for treatment of gender identity disorders and transvestism. In G. A.Rekers (Ed.), Handbook of child and adolescent sexual problems (pp. 255–271). New York: Lexington Books., & (1990). Long-term effects of the treatment for gender identity disorder of childhood. Journal of Psychology and Human Sexuality, 3, 121–153., , & (1983). Family correlates of male childhood gender disturbance. Journal of Genetic Psychology, 142, 31–42., , , & (1989). Sex typed body movements as a function of severity on degree of gender disturbance in boys. Journal of Psychology and Human Sexuality2, 183–196., & (1990). Projective test findings for boys with gender disturbance: Draw-a-Person test, IT scale, and Make-a-Picture-Story test. Perceptual and Motor Skills, 71, 771–779., , & (1976). Sex-typed play in feminoid boys versus normal boys and girls. Journal of Abnormal Child Psychology, 4, 1–8., & (1986). Early hormonal influences on cognitive functioning in congenital adrenal hyperplasia. Developmental Psychology, 22, 191–198., , , & (1993). Sensation seeking in opposite-sex twins: An effect of prenatal hormones?Behavior Genetics, 23, 323–329., , & (1999). Response: Finding the disorder in gender identity disorder. Harvard Review of Psychiatry, 7, 43–50.(1994). Living in the shadows: Eunuchs and gender in Byzantium. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 85–109). New York: Zone Books.([Page 203]1976). Psychopathology in female sex change applicants and two help-seeking controls. Journal of Abnormal Psychology, 85, 430–432., , , , & (1987). Boyhood gender identity development: A statistical contrast between two family groups. Developmental Psychology, 23, 544–557., , , & (1991). Summary of clinical findings in children and young adults with sex chromosome abnormalities. Birth Defects: Original Article Series, 26, 225–228., , & (1999). Geschlechtliche Zeit: Vol. 17. Geschlechtlicher Raum. Schriften der Philosophisch-historischen Klasse der Heidelberger Akademie der Wissenschaften. Heidelberg: Universitätsverlag C. Winter.(2001). Religion, Ritual und Alltag in den Anden: Die zehn Geschlechter von Amarete, Bolivien. Berlin: Dietrich Reimer.(1992). Steroid 17ß-hydroxysteroid dehydrogenase deficiency in man: An inherited form of male pseudohermaphroditism. Journal of Steroid Biochemistry and Molecular Biology, 43, 989–1002.(1983). Male pseudohermaphroditism due to 17ß-hydroxysteroid dehydrogenase deficiency: Studies on the natural history of the defect and effect of androgens on gender role. Journal of Steroid Biochemistry, 19, 663–674., & (1989). Effects of adequacy of gender reassignment surgery on psychological adjustment: A follow-up of fourteen male-to-female patients. Archives of Sexual Behavior, 18, 145–153., & (2000). Neurodevelopmental and psychosocial aspects of Turner syndrome. Mental Retardation and Developmental Disabilities Research Reviews, 6, 135–141., , & (1993). The psychoeducational characteristics of children with Turner syndrome. Journal of Learning Disabilities, 26, 333–341.(1995). Turner syndrome. In B. P.Rourke (Ed.), Syndrome of nonverbal learning disabilities: Neurodevelopmental manifestations (pp. 351–371). New York: Guilford.(1996). The psychoeducational profile of boys with Klinefelter Syndrome. Journal of Learning Disabilities, 29, 180–196., , , , & (1998). Gender development. In W.Damon (Editor-in-Chief) & N.Eisenberg (Vol. Ed.), Handbook of child psychology: Social, emotional, and personality development (, & (5th ed., pp. 993–1016). New York: Wiley.1996). Turner's syndrome. New England Journal of Medicine, 335, 1749–1754.(1987). Gross and fine motor development, in 47, XXY and 47, XYY males. Pediatrics, 80, 240–244., , , , & (1998). Homosexual and bisexual behaviour in European countries. In M. C.Hubert, N.Bajos, & T. G. M.Sandfort (Ed.), Sexual behaviour and HIV/AIDS in Europe (pp. 68–105). London: UCL Press.(1984). Sex chromosome anomalies, hormones, and aggressivity. Archives of General Psychiatry, 41, 93–99., , , & (1988). Sex chromosome anomalies, hormones, and sexuality. Archives of General Psychiatry, 45, 19–24., , , & (1998). A surgeon's response to the intersex controversy. Journal of Clinical Ethics, 9, 393–397.([Page 204]1999). Quality-of-life studies in patients with ambiguous genitalia. World Journal of Urology, 17, 249–252.(1995). Transsexual development of a patient with Klinefelter's Syndrome. Psychopathology, 28, 312–316., & (1993). The development of sex-typing in middle childhood. Monographs of the Society for Research in Child Development, 58 (Serial No. 232)., , & (1977). Shaping cooperative cross-sex play. Child Development, 48, 924–929., , & (1978). Abnormal gonadotropin secretory responses to LRH in transsexual women after diethylstilbestrol priming. Journal of Clinical Endocrinology and Metabolism, 47, 176–183., , , & (1995). Clinical perspectives on gender role/identity disorder. Psychoanalytic Inquiry, 15, 39–59., & (1990). The role of peers' gender in children's naturally occurring interest in toys. International Journal of Behavioral Development, 13, 373–388., & (1995). The role of emotion beliefs and values in gender development. In N.Eisenberg (Ed.), Social development: Review of personality and social psychology (Vol. 15, pp. 212–232). London: Sage.(1987). Are sons and daughters treated more differently by fathers than by mothers?Developmental Review7, 183–209.(1998). The psychological consequences of Turner syndrome and review of the National Cooperative Growth Study psychological sub- study. Pediatrics, 102, 488–491., , & (1993). Developmental differences in children's gender schemata about others: A meta-analytic review. Developmental Review, 13, 147–183., , & (1984). Recall and reconstruction of gender-related pictures: Effects of attitude, task difficulty and age. Child Development, 55, 393–405., & (1990). The prehomosexual boy in treatment. In C. W.Socarides & V. D.Volkan (Ed.), The homosexualities: Reality fantasy and the arts (pp. 177–197). Madison, CT: International Universities Press.(1983). Teachers' verbal and nonverbal communication patterns as a function of teachers race, student gender, and student race. American Educational Research Journal, 20, 183–198., & (1974). Transsexualism: Disorder of gender identity, thought disorder, or both?Journal of the American Academy of Psychoanalysis, 2, 201–213.(1999). Quality of life in Turner syndrome is related to chromosomal constitution: Implications for genetic counselling and management. Acta Paediatrica, 88(Suppl), 110–113., , & (1994). Psychosocial functioning in the Turner syndrome. In B.Stabler & L. E.Underwood (Ed.), Growth, stature, and adaptation: Behavioral, social, and cognitive aspects of growth delay (pp. 151–164). Chapel Hill: North Carolina Press., , & (2000). The dermatoglyphic characteristics of transsexuals: Is there evidence for an organizing effect of sex hormones. Psychoneuroendocrinology, 25, 365–375., , , , & ([Page 205]2001). Effects of cross-sex hormone treatment on emotionality in transsexuals [On-line]. Available: http://www.symposion.com/ijt/ijtvo05no03_02.htm., , , & (1975). Development of gender constancy and selective attention to same-sex models. Child Development, 52, 849–856., & (1984). Androgens and gender role behavior in girls with congenital adrenal hyperplasia (CAH). Progress in Brain Research, 61, 417–422.(1998). Long-term psychological evaluation of intersex children. Archives of Sexual Behavior, 27, 125–144., , , & (1994). Neonates with abnormal genital development assigned the female sex: Parent counseling. Journal of Sex Education and Therapy, 20, 9–17., , , & (2000). Androgen insensitivity syndrome (AIS): Emotional reactions of parents and adult patients to the clinical diagnosis of AIS and its confirmation by androgen receptor gene mutation analysis. Hormone Research, 53, 9–15., , , & (1992). Evaluation of psychosexual development of young women with congenital adrenal hyperplasia: A pilot study. Journal of Sex Education and Therapy, 18, 200–207., , , , , & (2002). Sex reassignment: Predictors and outcomes of treatment for transsexuals. Doctoral thesis, University of Utrecht.(2002). Postoperative psychological functioning of adolescent transsexuals: A Rorschach study. Archives of Sexual Behavior, 31, 255–261., , & (2001). Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: A prospective follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 472–481., , & (1991). Male-to-female transsexual with XYY karyotype. Lancet, 337, 557–558., , & (1970). A psychoanalytic study of the desire for sexual transformation (“transsexualism”): The plaster-of-Paris man. International Journal of Psychoanalysis, 51, 341–349.(1992). Physical and mental development of adolescent males with Klinefelter syndrome. Hormone Research, 37, 55–61.(1976). Long-term assessment of genital reconstruction in female pseudohermaphrodites. Journal of Urology, 115, 599–601., , , & (1988). Short-term patterns of pulsatile luteinizing hormone secretion do not differ between male-to-female transsexuals and heterosexual men. Psychoneuroendocrinology, 13, 279–283., , & (1989). Pulsatile luteinizing hormone release and ovarian steroid levels in female-to-male transsexuals compared to heterosexual women. Psychoneuroendocrinology, 14, 97–102., , , & (1994). The fate of the adult exstrophy patient. Journal of Urology, 152, 1413–1416., , , , , & ([Page 206]1981). Female-to-male transsexuals and their partners. Canadian Journal of Psychiatry, 26, 178–182., & (1992). Geschlechtswechsel in nichtklinischer Zeit: Der Chevalier d'Eon. In F.Pfäfflin & A.Junge (Ed.), Geschlechtsumwandlung: Abhandlungen zur Transsexualität (pp. 45–54). Stuttgart/New York: Schattauer.(1990). Clinical management of nontranssexual patients. In R.Blanchard & B. W.Steiner (Ed.), Clinical management of gender identity disorders in children and adults (pp. 107–117). Washington, DC: American Psychological Association Press.(1989). Sex stereotyping of infants: A review of gender labeling studies. Sex Roles, 20, 501–522., & (1990). Growth, development, and behavioral outcome from mid-adolescence to adulthood in subjects with chromosome aneuploidy: The Toronto Study. Birth Defects: Original Articles Series, 26, 131–188., , , & (1982). Growth and development of children with X and Y chromosome aneuploidy from infancy to pubertal age: The Toronto study. Birth Defecs: Original Article Series, 18, 99–154., , , , , , & (1980). Sex inequities in the experience of students. In J.Stockard, P. ASchmuck, K.Kempner, P.Williams, S. K.Edson, & M. A.Smith (Ed.), Sex inequities in education (pp. 49–77). New York: Academic Press.(1968). Sex and gender: On the development of masculinity and femininity. New York: Science House.(1970). Psychotherapy of extremely feminine boys. International Journal of Psychiatry, 9, 278–281.(1975). Sex and gender: Vol. 2. The transsexual experiment. London: Hogarth Press.(1985). Presentations of gender. New Haven, CT: Yale University Press.(1979). Psychopathology in self-identified female-to-male transsexuals, homosexuals, and heterosexuals. Archives of Sexual Behavior, 8, 491–496., , , , & (1995). Object relations and defense operations in transsexuals and borderline patients as measured by the Defense Mechanism Test. Nordic Journal of Psychiatry, 49, 379–388., , & (1992). A transsexual male with 47, XYY karyotype. British Journal of Psychiatry, 161, 698–699., , , , & (2001). Mak nyahs (male transsexuals) in Malaysia: The influence of culture and religion on their identity [On-line]. Available: http://www.symposion.com/ijt/ ijtvo05no03_04.htm.(1983). Aggression and the XYY personality. International Journal of Law and Psychiatry, 6, 413–421.(1984). A psychological study of the personalities of XYY and XXY men. Acta Psychiatrica Scandinavica, 315, 1–33.(1994). London's Sapphists: From three sexes to four genders in the making of modern culture. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 111–136). New York: Zone Books.(1988). The prevalence of transsexualism in Singapore. Acta Psychiatrica Scandinavica, 78, 501–504.(1977). Male transsexualism in Singapore: A description of 56 cases. British Journal of Psychiatry, 131, 405–409., , & ([Page 207]1995). A multidimensional study of gender typing in preschool children and their parents: Personality, attitudes, preferences, behavior, and cultural differences. Developmental Psychology, 31, 759–772., & (1994). The nature of gender. Demography31, 561–573.(1994). Sodomy and the pursuit of a third sex in the early modern period. In G.Herdt (Ed.), Third sex, third gender: Beyond the dimorphism in culture and history (pp. 137–212). New York: Zone Books.(1995). Gender differences in behavior: Activating effects of cross-gender hormones. Psychoneuroendocrinology, 20, 343–363., , , , & (1996). Handleiding voor de CBCL/4-18. Rotterdam: Afdeling Kinder- en Jeugdpsychiatrie, AZ/Erasmus Universiteit., , & (1997). Handleiding voor de Teacher Report Form (TRF). Rotterdam: Afdeling Kinder- en Jeugdpsychiatrie, AZ/Erasmus Universiteit., , & (1997). De Competentiebelevingsschaal voor kinderen, CBSK: Handleiding. Lisse: Swetz & Zeitlinger., , , , & (1994). A reproductive option for women with Turner's syndrome. Journal of Pediatric Nursing, 9, 321–325., & (1976). Psychiatric aspects of surgical treatment for problems of sexual identification (transsexualism). In J.G.Howells (Ed.), Modern perspectives in the psychiatric aspects of surgery (pp. 447–467). New York: Bruner/Mazel., & (1989). Vom Hermaphroditismus zum Transsexuellen - Zur Stellung von Zwittern in der Rechtsgeschichte. In H.Eyrich, W.Odersky, & F.Säcker (Ed.), Festschrift für Kurt Rebmann zum 65 Geburtstag (pp. 861–903). München: Beck.(1974). Ein Transsexueler mit XYY Syndrom. Nervenarzt, 45, 548–551.(1967). Transsexualism: A study of forty-three cases. Göteborg, Sweden: Scandinavian University Books.(1968). Transsexualism: Definition, prevalence and sex distribution. Acta Psychiatrica Scandinavica, 44(Suppl. 203), 255–258.(1978). Prognostic factors in the assessment of male transsexuals for sex reassignment. British Journal of Psychiatry, 132, 16–20., , & (1991). Cognitive and behavioral factors in the learning disabilities of 47XXY and 47 XYY boys. Birth Defects: Original Article Series, 26, 45–58., , & (1992). Left-handedness in male-to-female transsexualism [Letter to the editor]. Journal of the American Medical Association, 267, 1342., & (1998). Empirical data on epidemiology and application of the German transsexuals' act during its first ten years [On-line]. Available: http://www.symposion.com/ijt/ijtc0303.htm., & (1983). Normal plasma gonadotropin response to gonadotropin- releasing hormone after diethylstilbestrol priming in transsexual women. Journal of Clinical Endocrinology and Metabolism, 57, 197–199., & (1992). …ein Leiden mit dem Recht. Zur Namens- und Geschlechtsänderung bei transsexuellen Menschen in Europa. In F.Pfäfflin & A.Junge (Ed.), Geschlechtsumwandlung: Abhandlungen zur Transsexualität (pp. 113–147). Stuttgart/ New York: Schattauer.([Page 208]1995). Legal conditions of sex reassignment by medical intervention - situation in comparative law. In Council of Europe (Ed.), Transsexualism, medicine and law (pp.75–101). Strasbourg: Council of Europe.(1986). The spirit and the flesh: Sexual diversity in American Indian culture. Boston: Beacon Press.(1993). Steroid 5 alpha-reductase 2 deficiency. Endocrine Reviews, 14, 577–593., , & (1999). Management of intersex: A shifting paradigm. In A. D.Dreger (Ed.), Intersex in the age of ethics (pp. 119–135). Hagerstown, MD: University Publishing Group., & (1999). The prevalence of gender dysphoria in Scotland: A primary care study. British Journal of General Practice, 49, 991–992., , & (1990). Psychopathology and psychodynamics of parents of boys with a gender identity disorder. Unpublished doctoral dissertation, City University of New York, New York.(World Health Organization. (1992). Multi axial version of ICD 10: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.2000). Early physical intervention for young people with atypical gender identity development. Clinical Child Psychology and Psychiatry, 5, 220–231.(1994). The development of gender differentiation in young children. British Journal of Social Psychology, 33, 183–196., & (2000). Group psychotherapy with female-to-male transsexuals in Turkey. Archives of Sexual Behavior, 29, 279–290., , , & (1975). A psychiatric-psychological study of XYY males found in the general male population. Acta Psychiatrica Scandinavica, 51, 3–18., , , & (1995). A sex difference in the human brain and its relation to transsexuality. Nature, 378, 68–70., , , & (1999). Intersexuality and gender identity differentiation. Annual Review of Sex Research, 10, 1–69.(2001). Handedness in boys with gender identity disorder. Journal of Clinical Child Psychology and Psychiatry, 42, 767–776., , , & (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York/London: Guilford Press., & (1992). Gender identity disorder in children. Annual Review of Sex Research, 3, 73–120., , & (1985). Sex-typed behavior in cross-gender identified children: Stability and change at a one-year follow-up. Journal of the American Academy of Child Psychiatry, 24, 710–719., , , & (1999). Gender constancy judgments in children with gender identity disorder: Evidence for a developmental lag. Archives of Sexual Behavior, 28, 475–502., , , , , , , & (1993). A gender identity interview for children. Journal of Personality Assessment, 61, 443–456., , , , , & ([Page 209]1996). Psychosexual development of woman with congenital adrenal hyperplasia. Hormones and Behavior, 30, 300–318., , , , , & (1984). Two subgroups of gender problem children. Archives of Sexual Behavior, 13, 27–39., , , & (1992). Psychosexual disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 33, 107–151., & (1994). Prenatal gender preference of mothers of feminine and masculine boys: Relation to sibling sex composition and birth order. Journal of Abnormal Child Psychology, 22, 1–13., , , , , , & (1998). Birth order in girls with gender identity disorder. European Child and Adolescent Psychiatry, 7, 30–35., , , , & (1993). Physical attractiveness of boys with gender identity disorder. Archives of Sexual Behavior, 22, 23–36., , , & (1984). Early effeminate behavior in boys: Outcome and significance for homosexuality. Journal of Nervous and Mental Disease, 172, 90–97.(
About the Authors[Page 231]
Peggy T. Cohen-Kettenis, Ph.D., is Professor of Medical Psychology at the Vrÿe Universiteit Medical Center, Amsterdam, and Head of a gender clinic for children, adolescents, and adults. She was a pre- and postgraduate student in developmental and clinical psychology at the University of Utrecht, The Netherlands. She was trained to become a registered clinical psychologist and psychotherapist at the Utrecht Institute for Multidisciplinary Psychotherapy. After completing her Ph.D. thesis Cohen-Kettenis worked at the Department of Clinical Psychology of the Utrecht University. There she conducted a study evaluating sex reassignment, which was prompted by the advice of a committee of the Health Council, the medical advisory board of the Ministry of Public Health. The outcome of this study would also be the grounds for a new law allowing transsexuals to adjust their birth certificates. In 1987 she started the first outpatient clinic for children and adolescents with gender problems and intersex conditions in Europe at the Department of Child and Adolescent Psychiatry of the University Medical Center Utrecht. Her main areas of research are gender identity problems and gender-related psychopathology.
Friedemann Pfäfflin, M.D., Ph.D., is Professor of Psychotherapy and head of the Forensic Psychotherapy Unit at Ulm University, Ulm, Germany. Trained as psychiatrist at Hamburg University, he first engaged in transgender clinical work in the mid-1970s, when he visited the Psychohormonal Research Unit and the Gender Identity Clinic at Johns Hopkins University Clinic in Baltimore, Maryland. From 1978 to 1992 he worked at the Institute of Sex Research at Hamburg University, Hamburg, Germany, and continued his work with transsexuals after moving to Ulm University in 1992. His main areas of research are transsexualism, [Page 232]transgenderism, psychotherapy process research, forensic psychiatry and psychotherapy, and the history of psychiatry. From 1995 to1997 he was president of the Harry Benjamin International Gender Dysphoria Association, Inc. In 1997, together with Eli Coleman, he founded The International Journal of Transgenderism.