TAOISM

TAOISM AND SEX
THERAPY: SEX THERAPY
TOUCH AND SEXUALITY
TOYS: SEX TOYS
TRANSSEXUALISM
TAOISM AND SEX

In China, Taoism has both a philosophical and a religious tradition. Although philosophical Taoism flourished early in the fifth century B.C.E., Taoism as a religion did not develop until the first century C.E. Next to Confucianism, it ranks as the second major belief system in traditional Chinese thought. The philosophy of Taoism is outlined in Lao-tzu's Tao-te Ching, offering a practical way of life. Later, its teachings came to be utilized in the popular religion called Tao-chiao. In the Chinese tradition, the two have been separate, but in the West they have often been confused under the one name Taoism.

Lao-tzu's Tao-te Ching is so important for China that it has been argued that Chinese civilization and the Chinese character would have been utterly different if the book had never been written. No one can hope to understand Chinese philosophy, religion, government, art, medicine, sexology—or even cooking—without an appreciation of the philosophy taught in this little book. It is said that where Confucianism emphasizes social order and an active life, Taoism concentrates on individual life and tranquility.

Both philosophical Taoism and religious Taoism included in their classics many positive ideas about sex. The historical founder of the Taoist religion was Chang Ling, a popular religious leader and rebel. He urged his followers to read the Tao-te Ching and, in 143 C.E., organized them into Tao-chiao, or the Taoist religion. His followers called him Tien Shih, "Heavenly Teacher." After the founding of the Taoist religion, two major schools developed. One, Zheng Yi Pai ("Orthodox Unity School"), that is, Tien Shih Tao, was a highly organized religion. The other Taoist school, Quan Zhen Pai'm ("Perfect Realization School"), sought immortality through meditation, breathing exercises, bathing, gymnastics, sexual arts, medicines, chemistry, and other means. A measure of systemization was brought to this second school of Taoism by Wei Poyang (second century C.E.), who, in his Chou-i-ts'an-t'ung-chi (Textual Research on the Taoist and Magical Interpretation of the Book of Changes, or, in short, Ts'an-tung-chi), attempted to synthesize Taoist techniques for achieving immortality and teachings of the occult I Ching (Book of Change).

Later, the Perfect Realization School itself became divided into two major branches: the Northern Branch, which for centuries had its headquarters at Beijing's White Cloud Monastery and recognized Wang Chongyang (1112-1170 C.E.) as its founder; and the Southern Branch, which recognized Zhang Baiduan (Ziyang Zhenren) (984-1082) as its Original Master (hence, it was also called Ziyang Branch). The difference between the Northern and Southern branches, in a word, is that the Northern Branch denied fang zhong (sexual intercourse techniques) and the Southern Branch favored fang zhong as the way to achieve longevity and immortality. Zhang Baiduan wrote Wu Chen Phien (Poetical Essay on Realizing the Necessity of Regenerating the Primary Vitalities) before the division of Northern and Southern branches, and it is the basic book of Taoist sexual regimen.

Taoist sexual techniques were developed on the basis of the fang shu, also called fang zhong, or fang zhong shu. The meaning of these three Chinese words for sexual intercourse techniques are exactly the same, literally "inside the bedchamber" or "the art in bedroom." Fang-shu was created by a combination of experts: fang-shih (alchemists or prescription writers), fang-zhong-jia (experts on sexual techniques or ancient sexologists), and physicians in or before the Han dynasty (206 B.C.E.—220 C.E.); mainly it belonged to the medical field.

For descriptive and analytic purposes, the entire Taoist sexual system may be divided into two categories: (1) beliefs or myths, and (2) methods or techniques.

The major Taoist sexual belief is that longevity or immortality are attainable by sexual activity. One way for men to achieve this is by having intercourse with virgins, particularly young virgins. In Taoist sexual books, the woman sexual partner is called ding, originally an ancient cooking vessel with two loop handles and three or four legs, used in the practice of alchemy. The Taoist sexual books, such as the Hsuan wei Hshin (Mental Images of the Mysteries and Subtleties of Sexual Techniques') and San Feng Tan Cheueh (Zhang Sanfeng's Instructions in the Physiological Alchemy), written, respectively, by Zhao Liang Pi and Zhang San Feng, state that the most desirable ding is a girl about 14, 15, or 16 years old just before or after menarche. Zhang Sanfeng went further and divided ding into three ranks: the lowest rank, 21- to 25-year-old women; the middle rank, 16- to 20-year-old menstruating virgin girls; and the highest rank, 14-year-old premenarche virgin girls.

There was also a belief in the desirability of multiple sexual partners. For example, Sun Simiao, in his Prescriptions Worth a Thousand Gold, wrote that the art of the bedchamber was for a man to copulate on one night with ten different women without emitting semen a single time. Ability to control ejaculation was a key for both men and women. For men, it was called cai Yin pu Yang (gathering a woman's yin to nourish a man's yang) and for women cai Yang pu Yin (gathering a man's yang to nourish a woman's yin). The technique was a secret and a learned one, since it was most desirable to have one's partner reach orgasm without having orgasm oneself. This was particularly important for the male, because by practicing coitus reservatus it was believed that the semen found its way to the brain, huan jing pu lau (making the seminal essence return to nourish the brain). Thus, at the point of orgasm, the male prevents or interrupts ejaculation by pressing the "point" at the base of the penis. Taoist belief further emphasizes that sexual satisfaction may be derived from coitus without ejaculation.

The major Taoist sexual techniques include teaching how to master the differences of sexual arousal of male and female, harmonizing the sexual will and desire, and liberating and activating the female while relaxing the male.

For example, the Taoist sex handbook True Manual of the "Perfected Equalization" states:

In the Taoist master's sexual "battle" (to give the woman an orgasm while avoiding ejaculation), his enemy is the woman. He should begin by touching her vulva, kissing her lips and tongue, and touching her breasts, making her highly aroused. But he should keep himself under control, his mind as detached as if it were floating in the azure sky, his body sunk into nothingness. He must close his eyes, avoid looking at the woman, and maintain an utter nonchalance so that his own passion is not roused. When she makes sexual movements, the man must remain still rather than take any action. When her hand actively touches the penis, the man avoids her caress. The man can employ stillness and relaxation, to overcome the woman's excitement and movement.
It is important for the male to understand the female sexual responses so he can penetrate her at the appropriate time, use the correct sexual postures, positions and movements that include controlled breathing, preventing ejaculation by stopping and pressing the base of the penis and achieving sexual satisfaction by coitus without ejaculation. Interestingly though, women also had their own techniques that are not discussed in the manuals that were written for men. These techniques remained women's secrets. Still the use of the male technique can be used to prolong the sexual act and contribute to the pleasure of both partners. Many modern sex therapists have adapted the Taoist sexual teachings as a way to treat premature ejaculation and other sexual dysfunctions.
REFERENCES

Bullough, V. L. Sexual Variance in Society and History. Chicago: Univ. of Chicago Press, 1976.

Chan, Wing-tsit, translator and compiler. A Source Book in Chinese Philosophy. Princeton, NJ.: Princeton Univ. Press, 1963.

Van Gulik, R. H. Sexual Life in Ancient China: A Preliminary Survey of Chinese Sex and Society from ca. 1500 BC till 1644 AD. Leiden: E. J. Brill, 1961.

Ruan, F. F. Sex in China: Studies in Sexology in Chinese Culture. New York: Plenum Press, 1991.

Zhang Mingcheng. A History of Traditional Chinese Medicine: Herbs, Acupuncture, and Regimen. Tokyo: Hisaho, 1974. (In Japanese.)

Zhou Shaoxian. Daojia yu Shenxian ("Taoists and Immortals"). 3d ed. Taipei: Chung Hwa, 1982. (In Chinese.)

Fang-fu Ruan
THERAPY: SEX THERAPY

Historical Perspectives
Sex Therapy Today
Assessment
Sexual Problems and Therapy
The modern practice of sex therapy is a relatively recent attempt by behavioral and medical scientists to respond to the need for therapeutic intervention in the area of human sexual functioning. The term "sex therapy" refers to a specific focus of treatment rather than to a type of therapeutic technique. The field of sexology as a science has grown to include the understanding of human sexual behavior and functioning from a multidisciplinary perspective that considers the biological, psychological, social, and cultural aspects of sexuality.

From the outset, it is important to stress that a sex therapist should be a fully trained psychotherapist who is familiar with human behavior and psychopathology and is capable of applying a number of therapeutic techniques that are determined by the specific needs of a clinical situation. The sex therapist needs to understand the dynamics of the individual patient as well as the complicated interactions of the patient with his or her sexual partner. The sex therapist is expected to be flexible in the treatment approach lest any "marriage" to one particular theoretical orientation lead to a bias that overlooks appropriate therapeutic intervention.

Ideally, all clinician-therapists would have been trained in sex therapy. Unfortunately, that has not been the case. Training programs in sex therapy are limited throughout the country. At present, there are two certifying bodies, the American Association of Sex Educators, Counselors and Therapists (AASECT) and the American College of Sexology (ACS), which offer certification to those candidates meeting their requirements of training and supervised experience. There are also well-trained sex therapists who do not seek either AASECT or ACS certification, whether their original license is in medicine, psychology, marriage counseling, or clinical social work. Potential patients should inquire about the credentials of therapists before initiating treatment.

Historical Perspectives

Concern about sexual functioning and the understanding and causes of dysfunctions and their remedies have been evident in literature throughout the centuries. In ancient times, the sexual potency of the king was believed to affect the success of the harvest. Moreover, impotence was often seen as a divine punishment both in pagan and Biblical literature. For example, in the Book of Genesis, Abimelech, King of Gerar, was rendered impotent for taking Abraham's wife, Sarah.

In the Middle Ages, witchcraft was believed capable of causing sexual dysfunction. Interestingly, medieval literature on demonology and impotence often bears a close resemblance to the explanations of impotence presented by theologians and the present-day psychodynamic theories. Modern secular literature has also reflected preoccupation with worries about sexual functioning.

Despite reference to sexual concerns over the centuries, myth, superstition, and unfounded scientific speculation generally marked the understanding of sexual function. The modern era of investigating human sexuality was influenced by the publication of Psychopathia Sexualis, in 1886, by Richard von Krafft-Ebing. This work stressed a debased nature of sexuality, although it probably conformed to the general assumptions about sex of the time. Following close behind Krafft-Ebing was Sigmund Freud, who also accepted some of the same notions about sexual deviation and disease but added that certain sexual problems are themselves signs of underlying neurosis that have their root in childhood.

It was the writing of Havelock Ellis (1859-1939) that called attention to the normalcy of sexual behavior rather than its deviance. He was able to describe the human sexual experience in positive terms and freed from sexual guilt and repression many notions of sexual behavior. By viewing sexuality as part of the fabric of life, Ellis, in effect, established the foundation for modern sex therapy.

Sex Therapy Today

Historically, the treatment of sexual disorders was regarded as within the domain of psychiatry. Freudian theory, which viewed symptoms of sexual dysfunction as being surface manifestations of underlying psychological conflicts, was responsible for treating sexual problems chiefly within a psychodynamic framework. It was not unusual for patients to undergo years of psychoanalysis in an attempt to overcome sexual dysfunctions. Treatment was often ineffective and costly. Insight gained in therapy did not always lead to behavioral change. The analytic technique was limited in its ability to make direct therapeutic intervention.

Several other theoretical models developed that seemed better adapted to helping patients with sexual problems. One such model, behavior therapy, provided clinicians with therapeutic techniques that could be directly applied to the treatment of sexual dysfunctions. Arnold Lazarus and Joseph Wolpe were pioneers in the development of behavior therapy in its applications in sex therapy. Basic to their behavior therapy was a learning-theory model, which viewed behavior as a function of its consequences. Maladaptive behavior is maintained by positive and negative reinforcers. Sexual dysfunction could be seen as a learned behavior that is maintained internally by performance anxiety and externally by a nonreinforcing environment. This view of the cause and maintenance of sexual dysfunctions is quite different from the psychodynamic model.

The social-learning-theory model was responsible for the development of a number of sex therapy techniques, including systematic desensitization and relaxation training, that targeted the anxiety response that surrounded inadequate sexual functioning. Patients often achieved adequate sexual functioning by overcoming anxiety about sexual performance. Reeducation of the patient was undertaken with an active role of the patient in treatment being essential. Negative habits were unlearned, new adaptive repertoires of behavior were strengthened, and fear of failure was diminished. The work of Joseph LoPiccolo was important in the development of behavioral sex therapy techniques.

Key to the development of much of modern sex therapy was the research of Masters and Johnson. They not only gave a better physiological understanding of sexual function but also developed new psychosocial approaches to treatment. They introduced the use of conjoint treatment teams into the therapeutic milieu. They also emphasized treating both partners, as the sexual problem was seen as a couple's problem rather than an individual one. Masters and Johnson viewed sex as a natural function, one that cannot be learned, but a person could be helped by removing the obstacles that interfered with normal sexual reflexes and functioning. Masters and Johnson posited that a host of influences, including cultural conditioning, family and childhood attitudes about sex, religious attitudes, poor communication skills, and many other circumstances contributed to the development of sexual dysfunction.

Shortly after the pioneering work of Masters and Johnson, a significant contribution to the treatment of sexual problems was made by Kaplan. Her approach, as developed in her 1974 book The New Sex Therapy, provided an integration of behavioral techniques along with a psychodynamic understanding of sexual problems. Kaplan also provided a method of continuing assessment of the levels of the problem that allowed for intervention along both behavioral and psychodynamic lines. Medical aspects of dysfunctions were carefully evaluated, and the use of medication in treatment became an option as ongoing research was conducted into a better understanding of the pharmacology of sexual functioning.

The importance of cognitive aspects in the development and maintenance of sexual problems was stressed by Lazarus. He also introduced the use of imagery techniques in treatment. In conducting a functional analysis of the presenting problem, Lazarus was impressed with the interplay of a number of modalities that are important for treatment that were absent or not emphasized in existing systems. His multimodal therapeutic approach included a variety of assessment areas that spelled the acronym BASIC ID. This useful conceptual and intervention perspective took into account the complexity of the individual's sexual behaviors, affects, sensations, images, and cognitions, as well as the important interpersonal and biological (drug) components of sexual functioning. Lazarus's focus on some of the nonsexual aspects of a couple's relationship, especially communication, has proven helpful in treatment outcome. Such an approach is in line with Liefs statement that "it is impossible to be a competent sex therapist without being a capable marital therapist."

The emphasis on the couple dyad is also the focus of the family-systems-theory approach to treatment, which holds that sexual partners can create a sexually destructive environment through dysfunctional and pathological transactions between them. In this view, sexual functioning is restored by improving the interaction between partners.

Assessment

Adequate treatment cannot be undertaken without a thorough evaluation and assessment of the presenting sexual complaint. This assessment includes a thorough history of the complaint and appropriate diagnostic examinations, including physical examinations by appropriate medical specialists to rule out the presence of organic conditions that frequently are the cause of sexual dysfunction. For example, the sexual complaint could be the result of a disease process, such as diabetes, or could represent the presence of a problem in the nervous or endocrine systems. Medication side effects must be considered. Psychological evaluation should rule out the presence of an emotional condition that could be the basis of the sexual complaint. An evaluation of the relationship, if there is a couple involved, for the presence of other sexual or nonsexual concerns and stresses is important. This is especially important when dealing with dual-career couples who face the stress of the demands of career and family or child-rearing responsibilities. Only when an adequate assessment has been made can treatment planning and appropriate intervention begin.

The taking of a sex history, as pioneered by Alfred Kinsey, Wardell Pomeroy, and Clyde Martin, is one of the most important aspects of evaluation of sexual problems. The initial requirement in coming to an understanding of the presenting sexual problem is a detailed history of the current difficulty: this would include how and when and under what circumstances the problem began, whether there was a sudden situational reaction or a gradual onset of symptoms, the circumstances that contribute to the maintenance of the problem, and whether there is an internal state, such as anxiety or negative cognitions, or external negative reinforcers, such as a dysfunctional relationship or even ignorance about normal sexual functioning. It is also important to find out what the person's understanding of the problem is; what has previously been tried to remedy the situation; under what circumstances the problem occurs and under what circumstances, if any, the problem does not occur; and if there are other sexual dysfunctions present.

Information gained from an evaluation of the chief complaint helps the clinician better understand the presenting problem in terms of its being a sexual concern. This can range from incorrect information about sexuality to a communication problem between sexual partners to a sexual dysfunction such as erectile failure, which may require a specific treatment intervention. Personal and historical information is also needed to complete the sexual history and to aid in placing the sexual complaint into proper context.

The intention of the personal sex history is to gather facts about the person's background and experiences that influenced how they got to be where they are in terms of sexual experience, sexual attitudes, and values. Therefore, the clinician will review historical and developmental topics, including family background, religious and family attitudes and values about sex, presence or absence of sex discussion at home, and how sexual curiosity was dealt with. The therapist needs to find out if the client experienced any sexual traumas, such as molestation, rape, or incest, the age of first experience of sexual feelings and how they were dealt with; sexual experience during puberty and adolescence; experiences with masturbation and orgasm; and guilt about sexual feelings, thoughts, or activity. Continuing the questioning, the therapist needs to find out what the individual feels about being a male or female, confusion about sexual orientation, content of sexual dreams and fantasies, homosexual or lesbian experiences, early and later dating experiences, marital and extra-marital relationships, personal experience with intercourse from both the emotional and the physical perspective, information about pregnancies and abortions, the existence of variants of sexual behavior or disorders (paraphilias or "perversions"), and use of erotic material or pornography. Though this long listing might seem comprehensive, it is only a partial list of many of the topics contained in a complete sexual history. Often, the clinician may not take a detailed history because of time constraints or a judgment that an intervention can be made from information already available.

Sexual Problems and Therapy

Sexual concerns and difficulties can exist both for individuals and in relationships even when no sexual dysfunctions are present. For example, the person may be having sexual problems because he or she is missing important information about sexual functioning. Sexual ignorance can be eliminated at times by appropriate and accurate sex education or by consulting specialists in the field.

Many sexual concerns are centered around issues of what type of sexual feelings and behavior are "normal," concerns about body image (especially after mastectomy or similar surgery), sexual function after a prostatectomy, fear about aging, rejection by a partner, and religious guilt about sex. Most such concerns are readily diminished by education and counseling.

Sexual difficulties refer to the relational and feeling aspects of sexuality and usually not to sexual functioning. Such difficulties are often the cause for much unhappiness in relationships and are a frequent reason for bringing people to the office of a sex therapist. Examples of sexual difficulties commonly experienced are frequency and type of sexual activity, timing and settings for sex, amount of foreplay preceding intercourse, the extent of a couple's sexual repertoire, coital positions, type and timing of orgasms, afterplay following coitus, and the role of passion and affection in the sexual relationship. These and many other sexual difficulties are often the targets for intervention in sex therapy, and, in the absence of complications, such as serious personality disorders, the therapist can deal with them by giving information or introducing specific sex techniques.

Sexual dysfunctions refer to the occurrence of sexual inability or inadequacy to function within the human sexual response cycle—the usual sequence of internal and emotional feelings that accompany sexual behavior as well as the physical changes that are part of sexual response. These are often summarized by using the acronym DAVOS, standing for sexual desire, arousal, vasocongestion, orgasm, and satisfaction.

Dysfunctions can exist anywhere along the continuum of DAVOS and can represent problems ranging from low levels of desire to inhibition of sexual desire, erection and ejaculation dysfunctions (too early or too late), inhibition of orgasm in women, and painful intercourse (dyspareunia), often caused by inadequate vaginal lubrication or involuntary constriction of musculature surrounding the vagina (vaginismus). The causes of these dysfunctions may be organic (physical or drug related) or psychological (including relational and environmental), and once a proper evaluation has been conducted, sex therapy can address both the causal and the ongoing aspects of the problem.

The practice of sex therapy can follow a number of theoretical and conceptual models and may involve both individual and couple formats. The therapy may be conducted by an individual practitioner or by a co-therapy pair of clinicians, usually a male and a female. The length of treatment varies, but sex therapy is usually conducted in a short-term format that is symptom focused and flexible in its approach. There are times, however, when the therapy uncovers additional material that may require further exploration by the therapist. As in any other therapy, resistance to change is often encountered, and attention will need to be focused on overcoming the resistance in order to move on with treatment.

One of the problems facing all therapists has been determining the extent and depth of therapy necessary to address the problem in order to effect change. Traditional models of treatment, as in the psychoanalytic model, spent much time uncovering material that may or may not have been related to or important to the therapy outcome. With the advent of behavior-therapy techniques, treatment should be both shorter and symptom focused. A combination of techniques, specifically applied, such as in multimodal therapy, should reduce treatment time. Still, a conceptualization of how and when to intervene is needed.

The PLISSIT model developed by Annon provides a way of looking at the presenting problem and suggesting the breadth of treatment initially needed. The model consists of level of intervention; permission giving; providing limited information about the problem or what to do; specific suggestions, which may include specific techniques to overcome the problem; and intensive therapy, required by relatively few cases, which either do not respond to earlier therapeutic attempts or, in the therapist's judgment, require a period of psychotherapy before sex therapy can be undertaken. Most sex therapy tends to use a combination of approaches that fairly approximates the PLISSIT model, even if the therapist is not consciously applying Annon's formula.

Most sex therapy techniques have as their goal a reduction in the level of anxiety that has developed over the course of the problem. In addition to commonly used couple's therapy techniques, such as communication enhancement and clarification and assertiveness training, sex therapy seeks to educate and review negative sexual scripts that have accrued over the years as a result of the person's upbringing and sexual history.

Several specific sex therapy techniques that are frequently used are sensate-focus exercises (touching and massage that concentrate on sensual contact and not performance or arousal demands); masturbation exercises to enhance confidence in obtaining and maintaining erections and gaining control over ejaculation; guided imagery and self-hypnosis exercises to increase confidence in sexual functioning; graduated exercises that move a couple closer to the desired behavior, but avoiding emphasis on performance; vibrators as an aid in achieving orgasm in cases of inhibited female orgasm; exposure to erotic material as a means of enhancing arousal and disinhibiting anxiety about sexual activities; and use of specific medications and surgical implants for the treatment of impotence (penile prosthesis implants).

Sex therapy techniques are not to be randomly applied but are part of the overall treatment plan, in which the patient is informed and guided by the therapist throughout the process. The sex therapist should be a therapist first and should be prepared to change and direct the therapy as determined by the demands and needs of treatment. The field of sex therapy is a young but rapidly growing one, with much research being conducted around the world. The recent availability to the public of accurate sexual information and a greater openness to the discussion of sexual issues has allowed many people to overcome their sexual difficulties on their own initiative. Others, motivated by an acceptance of the naturalness of sex and the right to enjoy one's sexuality, have felt free to consult professional sex therapists for the assistance that they need. Still others, uncomfortable with the perceived stigma of seeking assistance from a mental health professional, continue to suffer their difficulties with no attempt at correction. Finally, there is a large portion of society that has not labeled their sexual functioning and relationships as being problematic but yet are not experiencing the level of sexual satisfaction that could be theirs.

REFERENCES

Annon, J. The Behavioral Treatment of Sexual Problems. 2 vols. Honolulu: Enabling Systems, 1975, 1976.

Frank, E., et al. Frequency of Sexual Dysfunction in a "Normal" Couple. New England Journal of Medicine, Vol. 299 (1978), pp. 111-15.

Kaplan, H. The New Sex Therapy. New York: Brunner/Mazel, 1974.

Lazarus, A. The Practice of Multimodal Therapy. New York: McGraw-Hill, 1981.

Lief, H. Foreword. In S. Leiblum and L. Pervin, eds., Principles and Practice of Sex Therapy. New York: Guilford, 1980.

Masters, W., and V. Johnson. Human Sexual Inadequacy. Boston: Little, Brown, 1970.

Masters, W., and V. Johnson. Human Sexual Response. Boston: Little, Brown, 1966.

Pomeroy, W., C. Flax, and C. Wheeler. Taking a Sex History. New York: The Free Press, 1982.

Julian W. Slowinski
TOUCH AND SEXUALITY

Touch and Childhood Development
Developmental Neuropsychology of Touch
An Obstacle to Affection
It has been unusual for the majority of college-level human sexuality texts to discuss the topic of touch, except in the most cursory of descriptions. Most of these texts do not have the word "touch" in their index. Few have more than a page or two on the subject. This is dismaying, for a couple of reasons. The most obvious is that the expression of much of our sexuality occurs through touch and the largest organ of our body, our skin. Also, there is a growing body of writings, theory, and research in the field of touch that is of extreme importance to the studies of human development, health, and sexuality. The contributors to this body of work span the fields of philosophy, medicine, physiology, psychology, sociology, and anthropology. This article is a summary and synthesis of this work, with a special emphasis on the findings related to touch and human sexuality.

Touch and Childhood Development

Arguably, it was not until the appearance of the clinical reports by Spitz (in 1945 and 1947) that the seeds of research in the field of touch were sown. Spitz's reports reflect his anguished quest for a solution to the unexplained deaths and pathologies of infants and toddlers in his care. The diagnosis of that era for these terminal children was marasmus, the withering away and dying of no apparent cause. Spitz finally discovered that medicine, good nutrition, and clean surroundings had not the least impact on the tragic outcome. Only what Harlow was to later call contact comfort turned out to be the "cure" for the excruciating deaths of these children. Touch deprivation is probably most damaging to an infant because, unlike the other four senses, the neonate has an extremely small amount of control over somatosensory self-stimulation due to underdeveloped motor control capacities.

In the arena of social behavior and mother-offspring relationships, Harlow could easily and appropriately be called the "father of touch research." His "deprivation and wire mother" primate research remains one of those classic studies in the evolving history of psychology. However, we are only recently discovering just how important Harlow's work was.

Prior to Harlow's research, Freudian thought dominated, even in the informal field of touch. It was generally believed that touch is a somewhat minor component of the more important feeding process provided by a mother to her child. Mother-child attachment (or bonding) was assumed to occur in humans as a primary result of the mother providing food to the infant.

Harlow's studies done between 1962 and 1979 involved taking newborn monkeys from their mothers and raising them in isolation. The young monkeys were deprived of maternal and social touch (i.e., contact comfort). In every other way, the monkeys were very well cared for. They were well fed, their cages kept clean, and their medical needs attended to. They were "merely" isolated from any physical contact with their mother or other monkeys. Even physical contact with the researchers was severely limited.

In his original classic "wire mother" study, Harlow placed the touch-deprived monkeys in a large cage that contained two crude dummy monkeys constructed of wood and chicken wire. One dummy was bare wire with a full baby bottle attached. The monkeys had been regularly nursed from similar bottles. The other dummy was the same as the first, except that it contained no bottle and the chicken wire was wrapped with terry cloth. Placed in this strange environment, the anxious young monkey very quickly attached itself to the cloth-wrapped dummy and continued to cling to it as the hours passed. The infant monkey could easily see the familiar baby bottle no more than a few feet away on the other dummy. Many hours passed. Although growing increasingly distraught and hungry, the infants in these studies would not release their hold on the soft cloth of the foodless dummy. It was soon apparent that the young monkeys would likely dehydrate and starve before abandoning the terry cloth surrogate mother.

As the isolated monkeys grew older, they were observed to display a highly predictable constellation of behavioral symptoms, even when they were later reunited with their mother and social group. They included highly unusual patterns of self-clasping and self-orality; idiosyncratic patterns of repetitive stereotyped activity; an almost total lack of gregariousness or interest in exploring the environment; timidity and withdrawal from virtually all social situations, with concomitant self-directed stereotyped behaviors; obvious aversion to physical contact with others; hyperaggressivity; gross abnormalities in sexual behaviors; and, later in adulthood, the inability to nurture offspring, with failure to nurse, neglect, and abusive behaviors being highly predictable. In addition, negative physical health consequences and hormonal imbalances were noted in these primate studies.

Additional studies by the Harlow team and others clearly demonstrated that the psychoanalytic "wisdom" of the day was incorrect in its assumptions regarding mother-child attachment. At least with infant and young monkeys, there appeared to be a hunger more powerful than the craving for food. It was science's first view of the pervasiveness and intensity of "touch hunger."

Beginning in the same general era as the Harlow investigations was another direction of research in the area of mother-child attachment. These attachment-theory studies were conducted by the British scientist Bowlby and his American colleague, Ainsworth. As a major extension of the work of Lorenz, their investigations focused directly on the ways human mothers and infants succeeded or failed to bond to one another. In general, Bowlby and Ainsworth discovered that there are highly predictable outcomes to the differing styles of early mother-child attachment patterns. More than two decades of scientific research on human parents and their offspring has generated a wealth of vital information regarding essential requirements for normal human development. Affectionate touch versus neglect or punishing touch is a central theme of attachment theory, and much of this work may be viewed as the human research counterpart to the Harlow studies.

Long before infants develop a useful vocabulary, they employ innate and powerful methods to communicate moods, interests, and needs to their caretakers. This is accomplished with a splendid and increasingly sophisticated variety of sounds, movements, and facial expressions. It is a difficult struggle for any infant to teach its parents about himself or herself. However, we know that babies are universally good "teachers." Sadly though, it has been discovered that most parents and caretakers in the United States are less than adequate "students." As with all good teachers, if you have a poor student the teacher must work harder to help the student learn.

Bowlby and Ainsworth learned that, for healthy parent-child attachments, the parent was a good "student." These parents usually noticed, understood, and responded appropriately to the "lessons" offered by the infant or toddler. Almost all the infants' lessons involved touch. They signal to their parents to "pick me up, hold me, feed me, burp me, soothe me, stimulate me, change me, and make the pain or discomfort go away." Of course, occasionally the signal was, "I'm overstimulated, so please leave me alone for a few minutes." These healthy "parent students" and "child teachers" are synchronized to each other, communicating and learning in a rhythm of increasing complexity.

It was found that, for the "inadequately attached" parent and child, there is a great deal of obvious neglect of the offspring by the parent. The parent "students" usually are uninterested in the lessons offered by their daughter or son and generally ignore the signals of the child. When the infant "teacher" tries even harder to interest these parents, the mother or father usually responds with even more neglect or with verbal or physical abuse. These infants rapidly become impatient teachers and the home "classroom" is filled with the turmoil of rapidly escalating frustration of teacher and student. Within the first year or two, these children eventually give up most efforts to "teach," learn to suppress their signals for attention, and are likely to become sullen, chronically miserable, or ill. Whichever child responses occur, the outcome is commonly devastating on many levels for the child, the parent-child attachment, and subsequent relationships as the child grows to adulthood. Grade schools and high schools are filled with severely withdrawn and troublesome, acting-out children and teens who have given up hope of affectionate pleasure and happiness.

Ainsworth's third category of the "anxiously attached" child is not a median category somewhere between the "adequate" and "inadequate" attachment classifications. The parent of the anxiously attached child may sometimes appear to be a "supermom" or "superdad," in that they tend to hold and give just as much, or more, attention to their child than do the parents of the healthy attachment children. The primary difference is that these, like the inadequate attachment parents, are also very poor parent "students." They and their child are, more often than not, out of synchronization with one another. This frequently "overinvolved" parent is not actually responding to the signals of the child, but instead responds to his or her own personal needs and desires. Because these parents are busily working at trying to care for the child, the toss of the dice says that the parent and child will occasionally be in synch and the child's needs will be met. When this occurs, it confuses the child into believing that the parent is finally "getting it," only to be followed by the majority of situations in which the child's signals are unanswered (or incorrectly answered). The randomly reinforced and anxiously attached child usually does not give up, even though it may be in her or his best interest. In a frustrated and disconsolate manner, the child continues to try to get through to the unreceptive parent and will likely continue these patterns into adulthood with poor choices of enabling relationships.

These studies reveal that the potential for a great deal of psychological human damage occurs at a very early age. Essential aspects of development, including, most importantly, sexual-affectional development, is arrested or severely damaged. In the United States, some researchers estimate that only about 25 percent of children come from a functional home in which adequate attachment occurs.

In the early 1970s, Prescott had been engaged in brain research studying the effects of touch deprivation on laboratory animals. He suspected that neurological deterioration, which had been found to be a predictable sequela to touch deprivation, was also a central and etiological agent in the expression of the violent behavior, as noted by Harlow.

Using the Human Relations Area Files, he examined some 400 societies and concluded that those societies that lavish affectionate touch on their infants and children, and also are tolerant or encouraging of adolescent sexual-affectional behaviors, were the least violent societies on earth, with the converse also being true. His findings, however, remain controversial because the data in the files do not usually give the kind of information he sought, and others who examined them did not classify the data the same way. Still, the fact that American society is often violent as well as one of the least openly physically affectionate societies on this planet might give some support to Prescott's ideas. We do not lavish affectionate touch on our infants and children; we push them aside into high chairs, playpens, car seats, baby beds, their rooms, the backyard, and so forth. We throw toys to them, and we expect television and video games to occupy their time. Moreover, in the United States, we have endless proscriptions against adolescent sexual-affectional behaviors. From very early childhood, the parental admonition, "Don't touch!" has been a powerful one. But just when the pubescent child begins the important physiological changes of puberty and the psychological separation-individuation task, our society warns, "Don't touch anyone, don't let anyone touch you, and don't touch yourself."

Since the normally developing adolescent is increasingly less interested in parental touch and more interested in touch and other forms of interaction with his or her peers, the obedient girl or boy is therefore effectively sentenced to several years of extreme touch deprivation and arrested psychological development. That the majority of teenagers eventually, to some degree, ignore these parental and societal warnings actually results in placing today's teens at higher risk for anxiety, depression, unwanted pregnancy, and sexually transmitted diseases due to "sex guilt." Research by Mosher and his colleagues demonstrates that sex guilt is powerfully related to the avoidance of self-care as well as lower self-esteem. In the United States, we have decided, with no data whatsoever, to support our strongly held beliefs that adolescents are "too immature" to deal with a sexual-affectional relationship. Actual developmental research has largely avoided this topic, although opinions are abundant.

Other researchers have found that the affectional touch climate in the subject's family of origin and parental religiosity are the major psychosocial variables related to a person's current sexual attitudes and behaviors, as well as nongenital affectional behaviors with a partner. Subjects who originated from physically affectionate families were more likely to enjoy more pleasurable, and more frequent, experiences in the sexual-affectional aspects of their adult relationships. These studies clearly demonstrate that adults who experienced rejection and touch deprivation in their childhood tend to treat their adult partners and their own offspring in a similar manner.

The rich findings of the Harlow and Bowlby-Ainsworth research teams, coupled with the reports of Spitz and Prescott, have complemented, and in many ways paralleled, each other. The outcomes of these studies provide clear facts regarding the most central components of human development and relationships. Whether in part or taken as a whole, the results from these findings lead to one inescapable conclusion. That is, the quality of our relationships throughout our lives is massively affected by the quality of our attachments in infancy and early childhood. The quality of these early attachments is primarily influenced by specific aspects of the communication and touch relationship between the child and his or her primary caretakers.

Developmental Neuropsychology of Touch

On the day of our birth, we entered the world with an intense touch hunger. Of all of our neonate senses, neural pathways subserving cutaneous sensation and responses to somasthetic stimulation are the first to develop in the human fetus and infant. Physiological primatologists instruct that the organism's biological systems that are first to develop are those most necessary to survival. A substantial proportion of the central and peripheral nervous systems is dedicated to the reception and processing of somatosensory information and make up what have been labeled "topographic maps" of nervous system utilization. The neonate derives the vast majority of useful information for the first several months of life through his or her skin.

Touch deprivation and somasthetic stress (e.g., pain and "touch trauma") are rapidly followed by dramatic elevations in pituitary-adrenal plasma cortisol levels, while affectionate and soothing touch are associated with low serum plasma cortisol levels. Plasma cortisol levels have been shown to be a reliable physiological indicator of an organism's detection of environmental change or stress. Further, it has been shown that with chronic imbalances of plasma cortisol and other hormones and neurochemicals, there results abnormal brain tissue development as well as the destruction of previously normal brain tissue. In other words, frequent pleasurable touch results in positive changes in brain tissue, and chronic touch deprivation or trauma results in measurably significant brain damage.

Beyond the study of body chemicals and neural tissue, it has been discovered that pleasurable touch is associated with enhanced learning, improved IQ, language acquisition, reading achievement, memory, general neonate development, preterm infant development, reduced self-mutilating behavior in the severely mentally retarded, expanded external awareness in autistic patients, improved geriatric health, decreased childhood clinginess and fears of exploring the environment, elimination of inappropriate self-stimulation and public masturbation behavior in children, and improved visual-spatial problem solving. Hospitalized patients recover more rapidly from injury and physical or psychiatric illness with attention to touch needs. Current thinking defines touch as the primary organizer (or, in the case of neglect and abuse, "disorganizer") of normal human development when viewed at biological, psychological and even social levels. A person's sense of self apparently originates in body awareness, body functions, and body activities that center around the sense of touch.

For this reason, the writer often refers his partnerless and isolated psychotherapy clients to a masseuse or massage therapist whenever appropriate. Couples in treatment are usually instructed and assigned touch and massage homework exercises, even for the non - sex therapy clients. Although Masters and Johnson borrowed extensively from researched therapy techniques developed by others when constructing their broad sex therapy treatment regimen, the unique technique they called sensate focus was one of their most important contributions. Perhaps unknowingly borrowing from the treatment methods of physical therapists and speech therapists who deal with their patient's neurological damage, Masters and Johnson devised a method of graduated, lengthy, and redundant touch exercises for their patients.

The neurological damage discussed in this chapter is, by definition, permanent damage since the brain produces no new nerve cells beyond about age five. Fortunately, if the neurological damage is not too severe, the remaining healthy portions of the brain may be "taught" to recover functioning, given the appropriate treatment method. The highly motivated individual or couple can begin to engage in specific graduated and frequent touch exercises to improve receptivity, sensation, and functioning. Masters and Johnson and the large body of subsequent sex therapy research provides potentially important solutions to a large and multiaxial problem for those individuals and societies that seek answers to repairing the damage. Of course, the most obvious solution would be to change the child-rearing practices of those same individuals and societies. To say, "All we need is to be receptive and affectionate with our children," though correct, may miss the greatest obstacle to this major change. That most parents are not neurologically receptive to reciprocal affectionate touch with their child is only one, though important, dilemma.

An Obstacle to Affection

In its most rigid and fundamentalist form, the Judeo-Christian philosophy is staunchly antitouch, antibody, antipleasure, and antisexual. To our not-so-distant ancestors, the formula touch equals sex equals sin was a bromide to live by. This nonequation is now our cultural heritage in the United States. Some may argue that this is an overstatement of the present-day importance of a dying or changing philosophy. Some may feel a bit smugly insulated because their upbringing did not include a highly fundamentalist or highly orthodox religiosity.

One of the outcomes of prolonged touch deprivation and the resulting neurological deterioration is a hypersensitivity to touch. Some researchers propose that the average person's experience with affectionate touch in the United States and several other countries is so inadequate that it is almost a certainty that the majority of the citizens suffer from some degree of significant neurological impairment. This is especially true if you are male, since males in the United States tend to receive far less affectionate touch from birth than do females. By early adulthood, most of these males have as much or more experience with overstimulating, aversive, painful, and traumatic touch than with soothing and affectionate touch. Even though they move through life with a growing touch hunger, most of these males can tolerate prolonged physical contact with another human only if forced or if they are sexually aroused.

So the cultural philosophy that may have initiated our ancestor's avoidance of touch may not be as important a maintaining factor as some might believe. It is possibly not the direct impact of religious philosophies today that causes a culture to be relatively touch phobic but, rather, a long history of parents who, due to the neurological damage unknowingly inflicted by their parents, were hypersensitive to touch and therefore did not nurture their offspring with the necessary somatosensory stimulation. Highly religious homes tend to provide significantly less affectionate touch (and more punishing touch), beginning in late childhood as the child approaches puberty and more overt sexuality.

For many adults, highly fundamentalist religions probably become an attraction for those who are most touch and sex phobic. The child of the high-religiosity parent or parents will likely experience significantly more difficulty with affectionate touch and sexuality in their adult relationships, even if the offspring no longer subscribe to their parents' beliefs.

We are beginning to understand many more of the developmental issues that impact on our attempts at healthy sexuality and relationships. Touch experiences in childhood appear to be powerful determining influences.

Many people tell of their highly interested and attentive lovers (mostly male) who seem to disappear very soon after orgasm occurs. He or she rolls away, goes to sleep, or gets up, grabs a beer, and goes to the den to watch the ball game—without even saying goodbye. Without the benefit of continuing high levels of sexual arousal, he can no longer tolerate prolonged tactile contact. One report of touch-deprived women revealed that only a tiny percent had ever had an orgasm. A study of touch-deprived men revealed that when given the hypothetical choice between giving up their recreational drugs and alcohol and giving up sex and orgasm, almost all of them said they would give up sex and orgasm. It seems that those who harbor these conflicts between a strong desire for touch and the confusing discomfort with it resolve the conflict by avoiding the difficulties and discomforts associated with touch and finding a replacement in the form of behaviors and chemicals, prescription and nonprescription. Such palliatives ultimately pile brain damage upon brain damage.

Virtually everyone has an intense need to be held and soothed and stimulated, but we find ourselves receptive at relatively brief moments of our lives. If we are not receptive to a given touch, the effect is deleterious rather than beneficial. So it is that we do not hold our partners or our infants for very long or very often.

In addition, the United States culture has created handy myths and philosophical constructs that merely serve our touch discomforts. Most parents are too easily convinced that they will "spoil" the child if they run to her "too quickly" when she cries or hold him "too often" or for "too long." We find a substantial percentage of parents who justify their homophobia by withdrawing meager affectionate touch from their toddlers and young children, stating, "Well, I don't want him to turn out homosexual." Some of our incorrect theories of the past are still with us, perhaps doing more damage than ever. Antitouch and antisexual societies have spawned fathers who panic if they happen to experience sexual arousal with their child squirming on their lap, and essentially punish the child severely by withdrawing physical affection from his daughter or son. Worse still is the father who acts on his sexual arousal, using the child as the defenseless object.

REFERENCES

Ainsworth, M.D.S., M.C. Blehar, E. Waters, and S. Wall. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, N.J.: Erlbaum, 1978.

Ainsworth, M.D.S., and B.A. Wittig. Attachment and Exploratory Behavior of One Year Olds in a Strange Situation. In B.M. Foss, ed., Determinants of Infant Behavior. Vol. 4. London: Methuen, 1969.

Barnard, K.E., and T.B. Brazelton, eds. Touch: The Foundation of Experience. Madison, Conn.: International Universities Press, 1990.

Bowlby, J. Attachment and Loss. 3 vols. London: Hogarth Press, 1969, 1973, 1980.

Bowlby, J. Some Pathological Processes Set in Train by Early Mother-Child Separation. Journal of Mental Science, Vol. 99 (1953), pp. 265-72.

Brown, C.C., ed. The Many Facets of Touch. Skillman, NJ.: Johnson and Johnson, 1984.

Colton, H. Touch Therapy. New York: Kensington, 1983.

Diamond, M.C. Cortical Change in Response to Environmental Enrichment and Impoverishment. In C. C. Brown, éd., The Many Facets of Touch. Skillman, NJ.: Johnson and Johnson, 1984.

Diamond, M.C. Evidence for Tactile Stimulation Improving CNS Function. In K.E. Barnard and T.B. Brazelton, eds., Touch: The Foundation of Experience. Madison, Conn.: International Universities Press, 1990.

Diamond, M.C., R.E. Johnson, and C.A. Ingham. Morphological Changes in the Young, Adult, and Aging Rat Cerebral Cortex, Hippocampus, and Diencephalon. Behavioral Biology, Vol. 14 (1975), pp. 163-74.

Diamond, M.C., F. Law, B. Lindner, M.R. Rosenweig, D. Krech, and E.L. Bennett. Increases in Cortical Depth and Glial Numbers. Journal of Comparative Neurology, Vol. 128 (1966), pp. 117-26.

Emde, R.N., and RJ. Harmon, eds. The Development of Attachment and Affiliative Systems. New York: Plenum Press, 1982.

Fisher, J.D., and S.J. Gallant. Effect of Touch on Hospitalized Patients. In N. Gunzenhauser, ed., Advances in Touch: New Implications in Human Development. Skillman, NJ.: Johnson and Johnson, 1990.

Fisher, S., and S.F. Cleveland. Body Image and Personality. 2d ed. New York: Dover, 1968.

Freud, S. The Development of the Sexual Function. In An Outline of Psychoanalysis. New York: W.W. Norton, 1949.

Gunzenhauser, N., ed. Advances in Touch: New Implications in Human Development. Skillman, N.J.: Johnson and Johnson, 1990.

Harlow, H.F. The Heterosexual Affectional System in Monkeys. American Psychologist, vol. 17 (1962), pp.1-9.

Harlow, H.F. Lust, Latency, and Love: Simian Secrets of Successful Sex. Journal of Sex Research, Vol 11 (1975), pp. 79-90.

Harlow, H.F. The Nature of Love. American Psychologist, Vol. 13 (1958), pp. 673-85.

Harlow, H.F., et al. From Thought to Therapy. American Scientist, Vol. 59 (1971), pp. 538-49.

Harlow, H.F., and M.K. Harlow. The Effects of Rearing Conditions on Behavior. Bulletin of the Menninger Clinic, Vol. 26 (1962), pp. 213-24.

Harlow, H.F., and C. Mears. The Human Model: Primate Perspectives. Washington, D.C.: Winston, 1979.

Harlow, H.F., and M.A. Novak. Psychopathological Perspectives. Perspectives in Biology and Medicine, Vol. 16 (1973), pp. 461-78.

Harlow, H.F., and S.J. Suomi. Nature of Love: Simplified. American Psychologist, Vol. 25 (1970), pp. 161-68.

Hatfield, R.W. Sexual Intimacies and Affection in Adulthood as Determined by Family Religiousness and Child-rearing Practices. Ph.D. diss., University of Cincinnati, 1986.

Kinsey, A.C., W.B. Pomeroy, C.E. Martin, and P.H. Gebhard. Sexual Behavior in the Human Female. Philadelphia: Saunders, 1953.

Kinsey, A.C., W.B. Pomeroy, and C.E. Martin. Sexual Behavior in the Human Male. Philadelphia: Saunders, 1946.

Klaus, M.H., T. Leger, and M.A. Trause, eds. Maternal Attachment and Mothering Disorders. Skillman, NJ.: Johnson and Johnson, 1982.

Lorenz, K. King Solomon's Ring. London: Methuen, 1952.

Masters, W.H., and V.E. Johnson. Human Sexual Inadequacy. Boston: Little, Brown, 1970.

Masters, W.H., and V.E. Johnson. Human Sexual Response. Boston: Little, Brown, 1966.

Merzinich, M.M., and J.H. Kaas. Principles of Organization of Sensory-Perceptual Systems in Mammals. In J.M. Sprague and A.N. Epstein, eds., Progress in Psychobiology and Physiological Psychology, Vol. 9. New York: Academic Press, 1980.

Money, J., and A.A. Ehrhardt. Man and Woman, Boy and Girl. Baltimore: Johns Hopkins Univ. Press, 1972.

Montague, A. Touching: The Human Significance of the Skin. 2d ed. New York: Harper & Row, 1978.

Mosher, D.L. Measurement of Guilt in Females by Self-Report Inventories. Journal of Consulting and Clinical Psychology, Vol. 32 (1968), pp. 690-95.

Mosher, D.L. Sex Guilt and Sex Myths in College Men and Women. Journal of Sex Research, Vol. 15 (1979), pp. 224-34.

Novak, M.A., and H.F. Harlow. Social Recovery of Monkeys Isolated for the First Year of Life: 1. Rehabilitation and Therapy. Developmental Psychology, Vol. 11 (1975), pp. 453-65.

Prescott, J.W. Early Somatosensory Deprivation as an Ontogenic Process in the Abnormal Development of Brain and Behavior. In E. Goldsmith and J. Morr-Jankowski, eds., Medical Primatology. Basel: Karger, 1970.

Prescott, J.W. Somatosensory Affectional Deprivation (SAD) Theory of Drug and Alcohol Use. National Institute on Drug Abuse Research Monograph Series, no. 30, 1980.

Prescott, J.W., and D.H. Wallace. Body Pleasure and the Origins of Violence. Bulletin of the Atomic Scientists, Vol. 11 (1975), pp. 10-20.

Reite, M., and T. Fields, eds. The Psychobiology of Attachment. New York: Academic Press, 1987.

Shaver, P., C. Hazan, and D. Bradshaw. Love as Attachment. In R.J. Sternberg and M.L. Barnes, eds., The Psychology of Love. New Haven: Yale Univ. Press, 1988.

Spitz, R.A. Hospitalism: A Follow-up Report. In D. Fenichel, P. Greenacre, and A. Freud, eds., The Psychoanalytic Study of the Child, Vol. 2. New York: International Universities Press, 1947.

Spitz, R.A. The Psychoanalytic Study of the Child. 4 vols. New York: International Universities Press, 1945 - 49.

Suomi, S.J. The Role of Tactile Contact in Rhesus Monkey Social Development. In K.E. Barnard and T. B. Brazelton, eds., Touch: The Foundation of Experience. Madison, Conn.: International Universities Press, 1990.

Soumi, S. J., and H.F. Harlow. Abnormal Social Behaviors in Young Monkeys. In J. Hellmuth, ed., Exceptional Infant: Studies in Abnormality. Vol. 2. New York: Brunner/Mazel, 1971.

Sternberg, R.J., and M.L. Barnes. The Psychology of Love. New Haven: Yale Univ. Press, 1988.

Tribotti, S. J. Effects of Gentle Touch on the Premature Infant. In N. Gunzenhauser, ed., Advances in Touch: New Implications in Human Development. Skillman, N.J.: Johnson & Johnson, 1990.

Robert W. Hatfield
TOYS: SEX TOYS

Dildos
Vibrators
Ben-wa Balls
Other Sex Toys
The moniker "sex toys" has been in use less than two decades and even today is not in wide circulation. Broadly defined, it includes any object used to enhance sexual activity, whether or not the item was specifically designed or marketed for that purpose. By that broad definition, if a woman uses a hairbrush handle for vaginal stimulation, or a man masturbates with a silk handkerchief, the hairbrush and the handkerchief are sex toys. However, this discussion will be limited (with one significant exception) to objects designed, marketed, or primarily used for the purpose of sexual stimulation.

When these items are marketed in North America, they are typically called "sex aids" or "marital aids." Both of these terms suggest that potential customers need help with their sexuality, that the sex aids will make up for presumed inadequacy on the part of consumers. Use of the adjective "marital" is surely an attempt to add an air of respectability to use of these objects, the implication being that only married people actually engage in sexual activity. Because these terms were so widely used, it became a requirement of the Food and Drug Administration in the United States that certain sexual or marital aids be labeled "sold as a novelty only," assuring consumers that no therapeutic claims are being made for the use of any product so labeled.

The term "sex toys" was coined in the early 1970s at the same time women were starting to more openly acknowledge their interest in sex and were also becoming much more likely to purchase items previously usually bought for them by their husbands or male lovers. (For many years before that, cylindrical plastic battery-operated vibrators advertised and ostensibly used for facial "massage" had been sold directly to women through advertising in the backs of women's magazines.) The phrase is somewhat problematic, in that the word "toy" still refers in many people's minds exclusively to the playthings of children. Nevertheless, most people exposed to this term for the first time find it pleasing because it reintroduces playfulness into the sometimes all-too-somber sexual ideation of adults.

Dildos

Over time, the most widely recognized sex toy is the dildo, thought of by many as an artificial or substitute penis. Collectors of erotic objets d'art will be familiar with statues of male figures with often exaggerated erect penises, dating from ancient times, and similar objects produced up until the present day by certain indigenous groups in the Third World. It is unlikely that women (or men) use these carved figurines for self stimulation. A variety of cultures have produced dildos, or objects so representational of the penis that it is safe to assume that they were utilized by at least some persons for vaginal or anal stimulation. Female fertility figurines, by contrast, are much less likely to have exaggerated genitals, and there is no indication that carved or molded objects resembling vulvas were historically used as masturbation enhancers by men.

Most dildos available commercially today are mass-produced in Hong Kong (and to a significantly lesser extent in the United States, China, Germany, and Japan), and almost all of them are sold in so-called "adult" stores or by direct mail. Virtually all of them are made of malleable plastic, vinyl or latex stuffed with cotton. Some are very realistic, including a few molded from life, complete with realistic skin colors, bluish veins, and "testicles" that can be manipulated inside the "scrotum."

Some dildos are hollow and are marketed as penile prosthetic aids.

These PPAs—the term used for them in the sex industry—usually have a flimsy elastic strap at the base. The strap is worn around the hips in such a way that a man can, hypothetically, put his flaccid or semierect penis inside the dildo and engage in sexual intercourse. Since men do not readily discuss their sexual functioning with others, particularly if their sexuality is problematic, it is not known how often PPAs are employed in this manner.

Dildos come in many sizes, ranging in length from 4 inches to 12 inches and in diameter from three-quarters of an inch to two inches. Double or double-headed dildos are also available. A few specialty dildos are huge, and one is shaped like a forearm and fist. These extra-large sizes are used almost exclusively by men for anal insertion.

Dildos molded of silicone are also being manufactured in very small quantities by a handful of craftspeople. Designed and manufactured primarily for direct sales to women, these dildos include a wider range of smaller sizes, and relatively few of them resemble peruses. Despite the fact they are considerably more costly than mass-produced plastic, vinyl, or latex dildos, they are quite popular because the material they are made of is very smooth, warms quickly to body temperature, and does not have an unpleasant "rubbery" odor. Throughout history, dildos produced in Japan have had fanciful designs; they are often molded to look like people or animals. One manufacturer of the new silicone dildos includes zucchini and corn cobs, along with dolphins, human figures, and cats, among her many dildo designs.

All the silicone dildos and a few mass-produced dildos flare at the base so that they can be worn in a harness that holds the dildo in place over the pubic bone so the wearer can simulate intercourse. Flimsy vinyl and elastic dildo harnesses have been available for many years at adult stores and through mail-order catalogs that sell adult novelties. People who use dildo harnesses regularly, however, prefer the sturdier all-leather or nylon webbing harnesses. The fact that silicone dildos and leather harnesses are in demand, even though they are considerably more costly than the mass-produced varieties, suggests that many consumers now expect better quality sex toys and are willing to pay higher prices for them.

Vibrators

Today, and presumably since the invention of the hand held massagers/vibrators powered by small electric motors, women have used these devices for clitoral stimulation to generate arousal and orgasm. However, since neither women or men typically discuss their masturbatory practices, both have assumed that a woman wanting to arouse herself would simulate intercourse with an artificial penis of some sort. Only recently have women openly acknowledged that they may use their dildo-shaped vibrators for clitoral stimulation.

The earliest vibrators, and by far the majority of vibrators sold today, are essentially dildos with a small battery-operated vibrating motor inside. The resemblance of most of these hard plastic devices to an erect human penis begins and ends in the fact that they are typically seven or eight inches in length and cylindrical in shape.

A considerable range of styles of battery-operated vibrators is available. In addition to smooth or ribbed hard plastic cylindrical vibrators and softer plain, "realistic" vinyl vibrators, there are egg- and bullet-shaped vibrators and several versions of the "butterfly." The butterfly is a vibrator designed for clitoral stimulation. It is held against a woman's genitals with lightweight elastic straps encircling her hips and thighs, freeing her hands and those of her partner for other activity. Certain vibrators originating in Japan have one "branch" molded to look like a person or animal and designed to be inserted into the vagina, and a shorter "branch," usually looking like an animal, for clitoral stimulation. Like several other vibrators mentioned here, these have a separate battery pack. When they are turned on, the longer branch swivels internally and the shorter one vibrates. Some anal plugs (dildos designed for anal stimulation) are equipped with battery-driven motors as well.

Because of the surreptitious or underground way in which these products are sold in the "adult" market, and because embarrassment usually prevents dissatisfied customers from demanding recourse, little is known about customer satisfaction with these products. But judging from the number of jokes in the culture about battery-powered vibrators malfunctioning "right at the crucial moment," it is safe to assume that for many they are not particularly satisfactory.

With the invention of the electric motor, or perhaps even earlier when exposed by accident or design to other kinds of vibrating equipment or appliances, women have experienced sexual pleasure and even orgasms. For example, the treadle sewing machines, which often involved pelvic movement, were in folklore regarded by some as an erotic stimulus. The historian Maines has recently provided a wealth of information about turn-of-the-century medical treatment of "hysteria" (believed in ancient Egypt and Greece to be the revolt of the uterus against sexual deprivation) using electric vibrators. Maines shows that "the electromechanical vibrator, introduced as a medical appliance in the 1880s and as a household appliance between 1900 and 1905, represented a deskilling and capital-labor substitution innovation designed to improve the efficiency of medical massage, a task performed since ancient times by physicians, midwives, and their assistants. Medical massage from the time of Hippocrates to that of Freud included the clinical production of orgasm in women and girls."

The object of that medical massage, whether performed with lubricated fingers or an electric vibrator, was the induction of a "hysterical paroxysm," manifested by "rapid respiration and pulse, reddening of the skin, vaginal lubrication and abdominal contractions." Apparently, not all physicians recognized these "paroxysms" as orgasms, but some medical authors through the ages commented on the morally ambiguous character of the treatment, including one physician who observed that genital massage should be reserved to "to those alone who have clean hands and a pure heart."

In 1869 and 1872, George Taylor, an American physician, patented a steam-powered massage and vibratory apparatus for treatment of female disorders, intended for supervised use to prevent overindulgence. By 1909, convenient portable models were available, permitting use on house calls. Until the end of the 1920s, vibrators were advertised in respectable women's magazines as home appliances, primarily as an aid to good health and relaxation. The sexual references in these ads were thinly disguised, since a typical ad reads, "All the pleasures of youth will throb within you."

Within a decade after that, vibrators had disappeared from doctors' offices and magazine advertisements, in part because doctors started to treat hysteria with psychotherapy, and in part because vibrators had started to appear in stag films. Seemingly, as soon as this treatment modality became associated in the popular culture with sexual arousal and pleasure, the embarrassed medical establishment turned away from its use. Since that time, line voltage, brand-name vibrators or massagers have been widely available on the shelves of many drug and department stores. Package inserts do not even hint of possible sexual uses. In fact, one brand's instruction sheet warns ominously, without explanation, "Do not use on genital areas of the body."

Three different types of line-voltage vibrators are currently on the market. One is the wand type, which has a long, cylindrical body or handle and a spherical vibrating head, attached to the body by a flexible "neck." Other vibrators are powered by an electromagnetic coil instead of a small electric motor. This type operates in virtual silence. It is shaped somewhat like a small hair dryer or a hairbrush, with the vibrating head perpendicular to the handle. It is packaged with four to six attachments, designed to massage different parts of the body. One brand-name vibrator of this type is packaged with an attachment ideal for clitoral stimulation, although that is certainly not specified in the packaging.

Vibrators that strap over the back of the hand or Swedish massagers are rarely chosen by women for sexual use, but they are strongly favored by the few men who regularly masturbate with vibrators. Presumably, this is because this is the vibrator most used by barbers for scalp and neck massage and most likely to have been found around the house when men who are now adults were children or adolescents and because the man using this kind of vibrator can do so in a manner very similar to the way he masturbates using his hand alone.

Ben-wa Balls

Ben-wa balls, two solid metal balls about three-quarters of an inch in diameter, are found in virtually every catalog of sex toys and adult stores. Though they are said to give orgasmic satisfaction when they are inserted into the vagina and the body is moved back and forth, many women say they are the most overrated of sex toys. Some report that once the balls are inserted into the vagina, they cannot be felt at all. Curiosity about ben-wa balls, like curiosity about some other sex toys, seems to persist in large measure because information about their ineffectiveness is generally not available to consumers.

Other Sex Toys

Dildos and dildo-vibrators frequently are used for anal stimulation. Safety is an important consideration here, as it is surprisingly easy for a lubricated dildo or vibrator to slip into the rectum. It is advisable to use instead an anal plug (a toy that widens in the middle and has a flared base so that it will neither fall out nor go in too far). Anal beads are a set of five or six small plastic beads strung onto a nylon cord. They are lubricated and fed into the anus one at a time and pulled out all together at the moment of orgasm to heighten the sensation.

Beyond the scope of this entry are the accessories and paraphernalia used by persons who engage in S/M sexual activities such as restraints, whips, nipple clamps, and paddles. They are mentioned here because in the S/M community, they are frequently referred to as toys.

REFERENCES

Blank, J. Good Vibrations: The Complete Guide to Vibrators. Burlingame, Calif: Down There Press, 1982, 1989.

Maines, R. Socially Camouflaged Technologies: The Case of the Electromechanical Vibrator. EEE Journal of Technology and Society, 8: 2 (June 1989), 3-11, 23.

Maines, R. The Vibrator and Its Predecessor Technologies. Paper presented at the Society for the Scientific Study of Sex, Pittsburgh, Oct. 1986.

Joani Blank
TRANSSEXUALISM

Introduction
Historical Perspective
Gender Dysphoria and the Spectrum of Gender Identity Disorders
Transsexualism and Body Image
Evaluation
Trial of Cross-Gender Living—The Real-Life Test
Hormone Therapy
Sex Reassignment Surgery for Primary Transsexuals
Conclusion
Introduction

The syndrome of transsexualism is characterized by a lifelong preference for the opposite gender role, predicated on the conviction of belonging to the opposite sex. This conviction is held and persists despite the painfully obvious fact of normal anatomy and genitalia, before and after puberty, and in the absence of delusional ideation or psychosis. Transsexuals are disgusted with the development of their primary and secondary sexual characteristics; the penis in males and breasts in females are perceived as the offensive organs, and their removal becomes a preoccupation for transsexual individuals. In addition, these desperately unhappy people seek the anatomical status of the opposite gender, and thus the hallmark of this syndrome is the request for change of sex or sex reassignment surgery (SRS). Feeling they belong to the opposite sex, they feel "unnatural" in a love relationship with someone of the opposite biological sex, considering this to be "homosexual." Perceiving themselves to be members of the opposite sex, they consider it appropriate to have a love relationship with an individual of the same biological sex but of the opposite gender identity. In recent years, we have become aware that some male-to-female transsexuals, after sex reassignment, prefer lesbian relationships with women. Only recently, this homogenderal, albeit biologically heterosexual, relationship has been described in the female-to-male situation. There is some evidence that the sexual activity per se, whether it be considered homosexual or heterogenderal, plays a minor or secondary role. Certainly, the primary goal of the transsexual is to pass successfully in society as a member of the opposite sex. Transsexuals are often sufficiently convincing in their ability to pass that some have lived for many years as members of the opposite sex, even without contrary hormone therapy or SRS. Other transsexuals are not so confident or fortunate, and they present to the physician requesting hormonal and surgical treatment in the hope that this will permit them to realize their lifelong goal of being accepted as members of the opposite sex.

The reader is referred to the original articles listed in the references, which describe in greater detail the adult manifestations of these syndromes in the male-to-female (M-F) and the female-to-male (F-M) situation. Transsexualism as now defined in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III-R) has the following diagnostic criteria:

1. Persistent discomfort and sense of inappropriateness about one's assigned sex (feeling trapped in the wrong body).
2. Persistent preoccupation for at least two years with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex (a request for hormone treatment and/or SRS).

3. The person has reached puberty (otherwise, the diagnosis of gender identity disorder of childhood would be made).

In addition, the DSM-III-R defines a gender identity disorder of adolescence or adulthood, nontranssexual type (GIDAANT). This condition is the same as transsexualism, with persistent cross-dressing (but not for the purpose of sexual excitement) but without the persistent preoccupation with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex. Finally, the DSM-III-R lists the criteria for the diagnosis of childhood gender identity disorder in boys and girls. These include the persistent desire to be a girl (boy) and the insistence that the individual actually is a girl (boy). Also, there is a repudiation of one's anatomical sexual status and strong preference for the role, activities, dress, name, and social status of the opposite sex, all with onset prior to puberty. In DSM-IV the term "transsexualism" was removed and replaced by the generic term "gender disorder."
Transsexualism as now defined is clearly more prevalent than previously thought. At least 1 in 50,000 individuals over the age of 15 years is likely to be transsexual. It would appear that the male/female ratio is probably close to 1: 1 in most cultures. If a higher male preponderance is present, this could reflect a more negative bias in that culture toward male homosexuality, or it could reflect a lack of availability in that culture for surgical sex reassignment for F-M transsexuals. Whatever the real statistics may turn out to be, this disorder carries more significance than the actual prevalence might indicate. Perhaps there is some gender dysphoria in all of us, no matter how repressed or latent. Certainly, our culture is struggling with issues of women's liberation and equality. Most important, the study of the normative process of gender identification has been well served by our research into the etiology and prevalence of transsexualism.

Historical Perspective

The concept of gender-role reversal has been known since it was first described in the early classic literature from Herodotus to Shakespeare. The first mention of gender dysphoria in the medical literature as an example of a clinical or pathological syndrome was from the German literature. Historical descriptions of various forms of gender dysphoria came from the French and German literature in the 19th century. In the early part of the 20th century, the focus of scientific research on this topic shifted from Europe to the United States. The term "transsexualism" was coined by an American sexologist, D.O. Cauldwell, and was popularized by the pioneering efforts of Harry Benjamin. The publicity surrounding the famous Christine Jorgenson case ushered in what the author has referred to as the modern era of the gender identity movement. The details of this movement are reported elsewhere, but suffice it to say that currently there is a small cadre of researchers in the gender identity field who report their findings every other year at the Harry Benjamin International Gender Dysphoria Association meeting.

Research in this field was facilitated by the inclusion of transsexualism and gender identity disorders in the American Psychiatric Association's Diagnostic and Statistical Manual, third edition, in 1980. To some extent, this inclusion has legitimized these gender identity disorders and defines the criteria for the diagnosis of transsexualism. Further elaboration occurred with the publication of DSM-III-R, in 1988, although gender identity disorders are somewhat concealed in the section dealing with conditions that have their onset in childhood or adolescence. Currently, the work group looking at the fourth edition of the Diagnostic and Statistical Manual is hoping to find an appropriate and unique section for gender identity disorders. In any event, it is fair to say that these conditions are now well-known in medical and psychiatric circles, even though their prevalence and incidence are quite rare. This gender identity movement has spawned a new medical subspecialty dedicated to furthering understanding and knowledge of the normative process of gender identification and disorders thereof.

Gender Dysphoria and the Spectrum of Gender Identity Disorders

Thus far, this article has emphasized the most extreme manifestation of gender identity misidentification, namely, transsexualism. However, there is clearly a spectrum or continuum along which each and every individual might assume his or her place. The process of gender identification, as a normative development sequence, is only beginning to come under scientific scrutiny. The nature-nurture, genetic-environmental dichotomies are still in contention in attempting to understand this normal developmental process, let alone the problems that arise when normality is not achieved. Certainly, the very early onset (age three to four years) of strong preference for the gender role incongruent with the individual's apparently normal biological sex causes one to consider a biological force, either genetic or hormonal. Unfortunately, the promise of such an early genetic determinant of gender dysphoria, as determined by the H-Y antigen test, appears to have been repudiated. The role of hormone imbalance, probably prenatal, influencing the central nervous system, has been suggested as an important predisposition towards contrary sex-role behavior and gender identity. Money places transsexualism at the extreme end of the cross-gender identity spectrum, with transvestism and homosexuality as less extreme manifestations, all three having their origins in hormonal imbalance during some critical period of development.

In contrast to this hormonal or biological view of the etiology of gender identity disorders are various social or intrafamilial forces that have been postulated to explain this phenomenon. Pauly, Stoller, and Lothstein have underscored the significance of intrafamily dynamics and relationships in the etiology of both M-F and F-M transsexualism. The influence of societal factors, especially the rigidity of society with reference to sex roles, sexual equality, and homosexuality, also has been hypothesized as an etiological factor in the development of transsexualism. In fact, Ross, et al., attempt to prove this hypothesis by comparing the frequency and sex ratio of transsexualism in two different cultures, Sweden and Australia. Although their results suggest significant societal factors bearing on the etiology and development of transsexualism, the authors are quick to point out the limitations of such research. Suffice it to say that hard data in this field are only beginning to emerge. Therefore, the precise cause is far from clear. There may well be multiple factors that operate in sequence, with a biological predisposition being augmented by intrafamily and social forces.

Returning to the issue of variability of behavior among humans, it is sometimes difficult to be sure when gender behavior is sufficiently atypical to warrant evaluation or treatment. Certainly, gender roles are stereotyped and tend to be dimorphic in most Western cultures. In the extreme, there is less uncertainty, and pretranssexual boys and girls behave in a sufficiently crossgenderal fashion that their families have good reason for concern. These effeminate boys, often labeled as "sissies" by their peers, come in for much more abuse than their female counterparts, whose tomboyish behavior is better tolerated. Even so, very young boys are brought to the physician for evaluation of their gender-role behavior. Follow-up studies suggest these young boys with atypical gender-role behavior grow up to demonstrate atypical gender role or atypical sexual preference as adults. Green underscores the fact that effeminate behavior in young boys is a developmental stage in the natural history of male homosexuality. Young girls are less often referred for atypical gender behavior, unless there is an extreme repudiation and denial of their femaleness, in which case the diagnosis of gender identity disorder of childhood is warranted. Suffice it to say, there are a broad range of gender behaviors, which are quite well tolerated by society, unless they become extremely pronounced. Although gender-role behavior is dimorphic, there is some overlap, which makes early detection quite difficult. Also, there appears to be a movement toward less rigidity and stereotyping and more acceptance of atypical gender-role behavior. Whether this unisexed concept will develop to such an extent that individuals will feel less inclined to have to resort to SRS in order to feel comfortable remains to be seen.

As these children grow up into adolescents and adults, they identify themselves as feeling uncomfortable with their biological sex and prefer the opposite gender identity. Often, they try to adjust to the genderal expectations of them by parents and society. However, at one point, the internal pressure to "be myself' intensifies, and the individual makes the disclosure, which results in professional evaluation. Clearly, not everyone who feels that a sex-change operation is the solution to their problems is a good candidate for the procedure. The term "gender" dysphoria syndrome" has emerged as the generic name for all those individuals who present with some form of gender discomfort. Under this umbrella term, "gender dysphoria," fall other diagnostic categories, the common denominator of which is displeasure or discomfort with the original genital anatomy and a desire or demand for SRS. Laub and Fisk list the following diagnostic possibilities:

1. Classic Transsexualism of Benjamin—lifelong history of desire to be a member of the gender opposite his or her biological sex.
2. Transvestism—cross-dresser who receives erotic stimulation from wearing female clothing as a prelude to heterosexual activity.

3. Effeminate Homosexuality (Male) or Masculine Lesbianism (Female)—erotically attracted to same biologically sexed individuals and gives history of enjoying the use of their genitalia in homosexual lovemaking.

4. Psychosis—discomfort regarding one's gender identity in the face of a psychotic decompensation only, and does not endure when patient is over the acute episode.

5. Psychopathic or Sociopathic Personality—individuals who wish to achieve notoriety or financial gain from SRS, and who are not sincere or truthful in their protestations of cross-gender identification.

The primary distinguishing characteristic of the above differential diagnosis is the age of onset and the stability and persistence of the gender dysphoria. This is sometimes difficult to ascertain, since the clinician is at the mercy of the patient's truthfulness and reliability as a historian. Also, most of the intelligent gender dysphoric individuals have become very familiar with literature on this topic and know what the criteria for the genuine article are considered to be. Person and Ovesy make a similar point by distinguishing primary from secondary transsexualism. To confirm the transsexual's history that the gender identity problem originated in early childhood, it is essential to have contact with the parents or other family members. For primary transsexuals, parents do confirm the patient's history that cross-gender identification has persisted since early childhood. However, when either the patient or the family member reports that the individual had developed a comfortable gender identity that was congruent with their biological sex, then one should begin to consider secondary forms of transsexualism or gender dysphoria. Many authors have underscored the multiplicity of diagnostic and personality characteristics of those who request SRS.
Transsexualism and Body Image

The concept of body image has particular relevance to the phenomenon of transsexualism and gender dysphoria. Body image has come to mean not only the way one perceives his or her own body but also the way he or she feels about these perceptions. As such, it is an important part of one's overall self-concept. The transsexual is unable to form a satisfactory body image because of the dissonance between his or her anatomic sex and his or her gender identity. Thus, the reality of the transsexual's body does not conform to the preferred or desired body image. The result is a disturbance in the formation of a complete and consistent self-concept.

The transsexual attempts to reduce this dissonance through a variety of means, the effects of which are to bring the physical form of the body into line with the preferred gender concept. The male transsexual cross-dresses, wears a wig, obtains electrolysis to remove facial hair or covers it up with make-up, uses bra padding, and so forth in an attempt to correct his body image dissatisfaction. In addition to these outward attempts to pass in society as a woman, the male transsexual assumes the preferred body image in fantasies and daydreams. Likewise, the female transsexual dresses in a masculine manner, cuts "his" hair short and in a masculine fashion, flattens "his" breasts, and places padding in "his" crotch to simulate the presence of a penis. Finally, however, the transsexual seeks the alteration of the actual body form, through endocrinological and surgical means, to bring the body into harmony with the preferred body image. This last step is the hallmark of the syndrome of transsexualism, and it is this request for hormone therapy and SRS that brings the transsexual to the physician. Thus, it is only natural that body image becomes one of the conceptual frameworks within which transsexualism can be studied and understood.

In 1975, Lindgren and Pauly introduced a Body Image Scale, which they felt might help in the evaluation and treatment of transsexualism. This 30-item list of body parts asks each respondent to rate his or her feeling about that part of their body on a five-point scale from very satisfied (1) to very dissatisfied (5). Among other things, this research revealed that transsexuals invariably scored certain body parts as (5) or "very dissatisfied," and these body parts were called primary genderal characteristics. For the M-F transsexual, these primary genderal characteristics are the penis, scrotum, testicles, facial hair, body hair, and breasts. For the F-M transsexual, the most hated parts of the anatomy are the breasts, vagina, clitoris, ovaries-uterus, chest, voice, and facial hair (or lack of it). This pattern of dissatisfaction is thought to be quite specific in identifying those gender-dysphoric individuals who are correctly diagnosed as primary transsexuals. Also, the Lindgren-Pauly Body Image Scale has been shown to be useful in following transsexuals from their initial pretreatment phase through hormone therapy and finally SRS. A statistically significant reduction in the overall score indicates that, in well-evaluated cases, this approach is successful in reducing the transsexual's negative body image. The body image scores come down as this sex reassignment treatment continues, so as to closely approximate a normal control group's body image score.

Body image is a useful parameter in the study and evaluation of individuals with a serious gender identity problem, and it allows one to characterize the primary transsexual and distinguish him or her from the secondary transsexual or other gender-dysphoric individuals, who would not be appropriate candidates for sex reassignment. The author has been gratified to find that another researcher, from South Africa, applying the Lindgren-Pauly Body Image Scale, has independently confirmed its usefulness in distinguishing "effectively between pre-operative transsexuals and homosexuals." Dutch workers have also used this instrument to follow transsexuals through hormone treatment and SRS and have confirmed the previous impression that the body image scale is a useful instrument as an objective measure of the individual transsexual's status as he or she progresses through hormone treatment and SRS.

Evaluation

Since transsexualism and gender dysphoria are considered psychiatric disorders, their evaluation requires a fully certified mental health professional, that is, a psychiatrist or psychologist. Individuals requesting SRS do not necessarily agree that their condition is of psychogenic origin, and they usually present to the surgeon or internist. The nonpsychiatric physician is well advised to refer such gender-dysphoric patients to the psychiatrist before recommending any form of treatment. This is not to say that physicians might not wish to perform a medical evaluation (i.e., physical examination, endocrinological studies, including testosterone or estrogen levels, and so forth). Even if the physician is convinced of the patient's sincerity and would like to alleviate his or her suffering, there are good reasons for not responding directly. Not the least of these reasons is the fact that some such patients have changed their minds, after hormone therapy and SRS, and have implicated their treating physicians in malpractice suits. Even if the physician is convinced that transsexualism is not a psychiatric disorder but rather a biological phenomenon, the fact remains that some psychotic individuals do request SRS. The nonpsychiatric physician is skating on thin ice if he or she attempts to make this distinction.

Once the individual comes to the attention of the psychiatrist, the evaluation process is not dissimilar to other clinical evaluations. A very careful past history is required, so that the intensity, duration, and stability of the gender dysphoria can be determined. As has been made clear in the previous section, primary transsexualism is a lifelong identification with the gender role of the opposite biological sex. Since the patient is highly invested in the outcome of the evaluation, he or she may not be entirely candid or truthful. Transsexuals are usually well-read and know what and what not to reveal to their evaluators. However, this dilemma is not unfamiliar to the clinician and need not negate the value of obtaining a careful history. The standards of care recommend that such an evaluation extend over a significant period of time and that an independent source of information about the patient be sought. It would be well to interview the parents or other family members or friends who have known the patient over time. Unfortunately, this is not always possible, since the patient may be estranged from his or her family. In such cases, it is more important to have had even longer contact with the person requesting SRS before a recommendation is made.

A careful mental status examination is required, primarily to rule out the possibility of an underlying psychotic condition, even though the patient may appear quite sane. Thus, it is important to inquire about delusions, auditory hallucinations, and other grandiose or bizarre ideation. Quite apart from the issue of psychosis, the evaluator needs to be alert to the possibility of depression and suicidal ideation. Many gender-dysphoric patients are quite desperate. They have experienced rejection and ridicule, and may regard this attempt at obtaining help as their "last chance." Many investigators have pointed out the prevalence of depression and suicidal ideation in the transsexual prior to the transsexual's undergoing sex reassignment treatment. Obviously, the diagnosis of gender dysphoria or transsexualism need not be the only psychiatric diagnosis. Affective disorders, primarily depression, with or without psychotic features, may also be present. An accurate assessment of IQ is also important, since the evaluator must document that the patient has sufficient capacity and competence to understand the implications and consequences of hormone therapy and SRS.

Trial of Cross-Gender Living—The Real-Life Test

One of the requirements prior to recommending in favor of hormone therapy or SRS is the so-called real-life test. Actually, many primary transsexuals have already passed this test, since they may have lived for some time in the opposite gender role before seeking hormones or SRS. If this is the case, the author would submit that this fact is correlated positively with a favorable outcome from SRS. The fact that the individual had been able to pass successfully without hormone therapy speaks positively to the applicant's confidence in being able to pass in society in the gender role opposite to the sex of birth. This is particularly impressive when the individual was quite young at the time when cross-gender living commenced. Quite often, such individuals have formed close interpersonal relationships during this time and are well accepted by their lovers or partners. The transsexual is perceived by his or her partner as belonging to the gender that the transsexual is portraying. Neither partner sees either the self or the other as homosexual. For these reasons, DSM-III-R's designations of homosexual or heterosexual types are confusing and misleading. The author has suggested the term "hetero-genderal" in lieu of homosexual and "homogenderal" in place of heterosexual as appropriate terms designed to overcome this confusion.

For others, however, cross-gender living is only considered after the recommendation of the evaluation or support of the therapist. Despite the standards of care, which advise cross-gender living of at least three months prior to recommendation for hormone therapy, some transsexuals require the additional help of hormones first. This deviation from the standards of care should not be undertaken by the novice and certainly not without a second opinion. The author has found this trial of cross-gender living not only important to the evaluator, but more so to the individual transsexual. Sometimes, the fantasy of living in the opposite gender role is enjoyed more mentally than in reality. Anxiety over one's ability to pass convincingly must be confronted sooner or later. No matter how strong the opposite gender identification, not all transsexuals are able to pass. Thus, experiencing the long sought after wish to live as a member of the opposite sex may or may not enhance the transsexual's motivation. In some cases, the real-life test is passed quite readily and the individual thrives, feeling much happier that he or she is on the way toward the solution to the gender problem.

For others, however, the real-life test is a painful confrontation that cross-gender living is not really possible, if they are to enjoy any kind of meaningful social interaction. As painful as this confrontation may be, certainly it is better to appreciate this reality before any irreversible physical changes or SRS have occurred. One hopes that the transsexual who is unsuccessful in this trial will have greater motivation to search for a psychotherapeutic approach to his or her gender dysphoria.

It is recommended by some that this real-life test continue for at least two years. In most true transsexuals, this period is often very rewarding, especially if the transsexual finds he or she passes easily and well. Often, the patient is supported through this period with hormone therapy, which helps to reduce negative body image problems and reassures the patient that progress is being made. With or without psychotherapy, with or without hormone therapy, the clinician-evaluator is able to ascertain if the individual is functioning better in the cross-gender role. This assessment should include some substantiation from sources other than the patient alone. In particular, it is important to document the ability to work or be gainfully employed. The ability to relate socially and develop a support system is also important during this period. And finally, it is essential that the patient be able to cope with less anxiety and depression than before cross-gender living. If these hoped-for changes do not occur during this trial of cross-gender living, the evaluator should be quite reluctant to recommend hormone therapy or SRS. Often, the individual will become aware of the inadvisability of proceeding with SRS and, possibly, elect to pursue a nonsurgical approach. Even if he or she is somewhat successful in the role of the opposite gender, perhaps the individual will realize that the reality of the situation is not as exciting as the fantasies about it. Second thoughts may arise that beg the individual to reconsider. It is important for the evaluator-therapist to take a neutral role during this process. By this is meant that the therapist be neither advocate nor detractor. The therapist should offer support and attempt to work through issues but not be prematurely invested in determining in favor of or against proceeding with SRS.

Hormone Therapy

The aim of endocrine treatment in the transsexual patient of either sex is dual: suppression of the existing sexual features (hormonal castration), and development and maintenance of sexual features belonging to the other sex ("paradoxical hormone therapy"). The recommended medications have not changed very much in the last 20 years: Estinyl (ethinyl estradiol) 0.15 - 0.5 milligrams per day for the M-F transsexual. To this may be added Provera (medroxy-progesterone acetate) 10 milligrams per day. For the F-M transsexual, depo-testosterone 200 milligrams by injection every two weeks is suggested. Hormone therapy reduces the dissonance between the transsexual's actual body configuration and his or her idealized body image.

Hormone therapy is recommended only after careful evaluation and not simply on request or on demand from the self-diagnosed transsexual. Certain irreversible changes, such as testicular atrophy in the male and permanent voice changes and clitoral enlargement in the female, should be explained in detail. A baseline endocrinological evaluation, together with baseline liver function studies, should precede hormone therapy. Administration of hormone therapy in adolescence should be avoided, especially in the female, where testosterone might prematurely close the epiphyses and prevent bone growth and attainment of the optimal height. However, once a careful evaluation has concluded that the individual is a good candidate for SRS and preliminary baseline studies have occurred, hormone therapy becomes the next step in the process of evaluation, after cross-gender living. Most genuine, primary transsexuals "pass" this test, are delighted with the physical changes that improve their body image, feel more self-confident in their ability to pass, and are encouraged with the progress they are making toward their goal. However, some self-select or are selected out of continuing toward SRS by their evaluators, for a variety of reasons.

For an update on hormone therapy for both M-F and F-M transsexuals, the reader is referred to more recent publications by Pauly and Steiner. It should be apparent that this treatment is best provided by an endocrinologist or specialist in the evaluation and treatment of transsexual pa-dents. Suffice it to say that hormone therapy is highly acclaimed by the transsexual, as moving in the correct direction of his or her cherished goal of complete sex reassignment.

Sex Reassignment Surgery for Primary Transsexuals

Those gender-dysphoric individuals who demonstrate a fixed and consistent cross-gender identification, using the above-mentioned criteria, are candidates for SRS. They establish themselves as primary transsexuals and successfully pass the real-life test of cross-gender living and hormone therapy for one to two years. Some are actively engaged in psychotherapy before and during this trial period, but they are all still involved in the evaluation process by a member of the mental health profession. Then, and only then, is it appropriate to recommend the patient to an experienced surgeon for SRS. Again, the specifics of SRS are highly technical and are reviewed elsewhere. Clearly, SRS is more advanced for the M-F transsexual than for the F-M transsexual. Despite this fact, F-M transsexuals report at least as much satisfaction with SRS as do M-F clients.

The genital surgical procedure in the M-F transsexual involves the removal of the penis, scrotum, and testicles and the creation of a functional neovagina. It should be emphasized that a successful outcome is largely dependent on a good functional result. The ability to engage in sexual intercourse without pain or discomfort is highly correlated with postoperative satisfaction as judged by the transsexual. In addition, the breast enlargement secondary to estrogen therapy is usually not sufficient to preclude breast augmentation mammoplasty. This procedure is not essentially different from that requested by nontranssexual women who wish to enhance the size of their breasts. Other forms of plastic surgery are occasionally requested to improve the feminine appearance, such as facial surgery, rhinoplasty, and thyroid cartilage shave to reduce the size of the Adam's apple. When one compares the pretreatment male transsexual's scores on the Body Image Scale (3.76/5.0) with the postsurgical scores (1.46/5.0), one sees a significant improvement (p =.001).

With reference to the F-M transsexuals, the surgical techniques are not as well developed. Certainly, it is easy enough to remove the breasts by mastectomy. These procedures can be accomplished through a small subareolar, key-hole incision in female transsexuals endowed with small breasts. However, larger inframammary incisions are required for large-breasted female transsexuals. Usually, these postoperative F-M transsexuals are quite pleased with their flat chests and thankful that they no longer have to resort to the use of Ace bandages around their chests to minimize the size of their breasts.

With reference to genital surgery in the F-M situation, total hysterectomy, salpingooophorectomy, and vaginectomy are performed initially. The creation of an artificial penis is a very complicated multistage procedure. Emphasis is placed on obtaining surgical results that will (1) allow the patient to stand to void, (2) permit sexual intercourse, (3) provide a presentable male appearance, and (4) be accomplished in a minimum number of operative steps. Although requests for SRS are currently coming equally from male and female patients, most of the attention in the surgical literature has been given to M-F transsexuals. Clearly, the difficulties inherent in the surgical construction of a cosmetically and functionally satisfactory male-appearing perineum have not yet been alleviated to the point where this is readily available. Until this has been accomplished to the same degree as with the M-F transsexual, it will be difficult to achieve a completely favorable outcome from SRS for female transsexuals.

The outcome of SRS is a complicated and difficult subject for review. The author has attempted on several occasions to review these results. The early data were reported in 1965 and 1968. In collaboration with Swedish colleagues, a more recent update was done. Finally, the most recent review of this topic is in collaboration with one of the most prominent and distinguished American surgeons. Nonetheless, SRS is still considered by some to be at least controversial, if not totally contraindicated. There is little question that the vast majority of those evaluated after SRS claim satisfaction with their surgical reorientation and indicate they would pursue such a course if they had it to do again. Satisfaction with SRS is present in 71.4 percent to 87.8 percent of M-F transsexuals, with only 8.1 percent to 10.3 percent expressing dissatisfaction. Likewise, some 80.7 percent to 89.5 percent of F-M transsexuals express satisfaction with SRS, compared with only 6.0 percent to 9.7 percent who do not. This difference between M-F and F-M transsexuals does not reach statistical significance. Blanchard, et al., report a smaller percentage of positive outcomes in heterosexual male transsexuals compared with homosexual male transsexuals, and they recommend caution in referring male transsexuals for SRS who have a history of sexual arousal toward women. More recent studies tend to confirm the transsexuals' satisfaction with SRS.

Conclusion

The study of transsexuals and other gender-dysphoric individuals has resulted in a new sub-specialty in medicine. Although only in its infancy, this field is developing into an important basic science helping to define the normative process of gender identification and the disorders thereof. Although considerable attention has been given to the evaluation and treatment of gender identity problems, all would agree that transsexualism and gender dysphoria are better prevented than treated. There is some hope that research in this gender identity field will lead to sufficient understanding of this developmental process so that such gender identity problems can be prevented. Short of this, we must continue to assess what is appropriate for those individuals who are currently dealing with their gender dysphoria and provide the very best treatment available.

REFERENCES

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, D.C.: American Psychiatric Association, 1980.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, D.C.: American Psychiatric Association, 1988.

Barlow, D.H., G.G. Abel, and E.B. Blanchard. Gender Identity Change in Transsexuals: Follow-up and Replications. Archives of General Psychiatry, Vol. 36 (1979), pp. 1001-07.

Benjamin, H. Transvestism and Transsexualism. International journal of Sexology, Vol. 7 (1953), pp. 12-14.

Benjamin, H. The Transsexual Phenomenon. New York: Julian Press, 1966.

Benjamin, H. For the Practicing Physician: Suggestions and Guidelines for the Management of Transsexuals. In R. Green and J. Money, eds., Transsexualism and Sex Reassignment. Baltimore: The Johns Hopkins Press, 1969.

Blanchard, R., S. Legault, and W. Lindsay. Vaginoplasty Outcome in Male-to-Female Transsexuals. Journal of Sex and Marital Therapy, Vol. 13 (1987), pp. 265-75.

Blanchard, R., B.W. Steiner, and L.H. Clemmensen. Gender Dysphoria, Gender Reorientation, and the Clinical Management of Transsexualism. Journal of Consulting and Clinical Psychiatry, Vol. 53 (1985), pp. 295-304.

Cauldwell, D.O. Psychopathia Transsexualis. Sexology, 16 (1949), pp. 274-80.

Eicher, W., M. Spoljar, H. Clere, J. Murken, K. Richter, and S. Stangel-Rutkowski. H-Y Antigen in Transsexuality. Lancet, II, No. 8152 (1979), pp. 1137-38.

Fisk, N. Gender Dysphoria Syndrome. In D. Laub and P. Gandy, eds.. Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome. Ann Arbor: Edwards Brothers, 1974.

Friedreich, J. Versuch Einer Literargeschichte der Pathologie und Therapie der Psychischen. Wurzburg: Krankheiten, 1830.

Green, R. Mythological, Historical, and Cross-cultural Aspects of Transsexualism. In H. Benjamin, The Transsexual Phenomenon. New York: Julian Press, 1966.

Green, R. Sexual Identity Conflicts in Children and Adults. New York: Basic Books, 1974.

Green, R. The Sissy Boy Syndrome. New Haven: Yale Univ. Press, 1987.

Green, R., and J. Money, eds. Transsexualism and Sex Reassignment. Baltimore: The Johns Hopkins Univ. Press, 1969.

Gorman, W. Body Image and the Image of the Brain. St. Louis: Warren H. Green, 1969.

Hamburger, C. Desire for Change of Sex as Shown by Personal Letters from 465 Men and Women. Acta Endocronologica, Vol. 14 (1953), pp. 361-75.

Hamburger, C. Endocrine Treatment of Male and Female Transsexualism. In R. Green and J. Money, eds., Transsexualism and Sex Reassignment. Baltimore: The Johns Hopkins Univ. Press, 1969, pp. 291-304.

Hamburger, C., G. Sturrup, and E. Dahl-Iverson. Transvestism. J.A.M.A., Vol. 152 (1953), pp. 391-96.

Hoenig, J., and J. Kenna. The Prevalence of Transsexualism in England and Wales. British Journal of Psychiatry, Vol. 124 (1974), pp. 181-90.

Hoopes, J. Operative Treatment of the Female Transsexual. In R. Green and J. Money, eds., Transsexualism and Sex Reassignment. Baltimore: The Johns Hopkins Univ. Press, 1969.

Kuiper, B., and P. Cohen-Kettenis. Sex Reassignment Surgery: A Study of 141 Dutch Transsexuals. Archives of Sexual Behavior, Vol. 17 (1988), pp. 439-58.

Laub, D., and N. Fisk. A Rehabilitation Program for Gender Dysphoria Syndrome by Surgical Sex Change. Plastic Reconstructive Surgery, Vol. 53 (1974), pp. 388-403.

Levine, S., and L. Lothstein. Transsexualism or the Gender Dysphoria Syndromes. Journal of Sexual and Marital Therapy, Vol. 7 (1981), pp. 85-114.

Lindemalm, G., D. Korlin, and N. Uddenberg. Long Term Follow-up of "Sex Change" in 13 Male-to-Female Transsexuals. Archives of Sexual Behavior, Vol. 15 (1986), pp. 187-210.

Lindgren, T., and I. Pauly. A Body Image Scale for Evaluating Transsexuals. Archives of Sexual Behavior, Vol. 4 (1975), pp. 639-56.

Lothstein, L. Sex Reassignment Surgery: Historical, Bioethical, and Theoretical Issues. American Journal of Psychiatry, Vol. 139 (1982), pp. 417-26.

Lothstein, L. Female-to-Male Transsexualism. Boston: Routledge & Kegan Paul, 1983.

Lundstrom, B., I. Pauly, and J. Walinder. Outcome of Sex Reassignment Surgery. Acta Psychiat. Scand., Vol. 70 (1984), pp. 289-94.

Meyer, J. Clinical Variants among Applicants for Sex Reassignment. Archives of Sexual Behavior, Vol. 3 (1974), pp. 527-58.

Money, J. Gay, Straight, and In-Between. Oxford: Oxford Univ. Press, 1988.

Money, J., and R. Ambinder. Two-year, Real-life Diagnostic Test: Rehabilitation Versus Cure. In H. Brady and J. Brody, eds., Controversy in Psychiatry. Philadelphia: Saunders, 1978.

Money, J., and A. Ehrhardt. Man and Woman: Boy and Girl. Baltimore: Johns Hopkins Univ. Press, 1972.

Money, J., and A. Russo. Homosexual Outcome of Discordant Gender Identity/Role m Childhood: Longitudinal Follow-up. Journal of Pediatric Psychology. Vol. 4 (1979), pp. 29-41.

Pauly, I. Male Psychosexual Inversion: Transsexualism. Archives of General Psychiatry, Vol. 13 (1965), pp. 172-81.

Pauly, I. The Current Status of the Change of Sex Operation. Journal of Nervous and Mental Diseases, Vol. 147 (1968), pp. 460-71.

Pauly, I. Adult Manifestations of Male Transsexualism. In R. Green and J. Money, eds., Transsexualism and Sex Reassignment. Baltimore: Johns Hopkins Univ. Press, 1969.

Pauly, I. Adult Manifestations of Female Transsexualism. In R. Green and J. Money, eds., Transsexualism and Sex Reassignment. Baltimore: Johns Hopkins Univ. Press, 1969.

Pauly, I. Female Transsexualism, Parts I and II. Archives of Sexual Behavior, Vol. 3 (1974), pp. 487-525.

Pauly, I. Sex and the Life Cycle. In H. Kaplan, A. Freedman, and B. Sadock, eds., Comprehensive Textbook of Psychiatry, 3rd ed. Baltimore: Williams and Wilkins, 1980.

Pauly, I. Outcome of Sex Reassignment Surgery for Transsexuals. Australian and New Zealand Journal of Psychiatry, Vol. 15 (1981), pp. 45-51.

Pauly, I. Gender Identity Disorders. InM. Farber, éd., Textbook of Human Sexuality. New York: Macmillan, 1985.

Pauly, I. Terminology and Classification of Gender Identity Disorders. Journal of Psychology and Human Sexuality, Vol. 5 (1993), pp. 1-14.

Pauly, I., and M. Edgerton. The Gender Identity Movement: A Growing Surgical-Psychiatric Liaison. Archives of Sexual Behavior, Vol. 15 (1986), pp. 315-29.

Pauly, I., and T. Lindgren. Body Image and Gender Identity. Journal of Homosexuality, Vol. 2 (1976), pp. 133-42.

Person, E., and L. Ovesey. The Transsexual Syndrome in Males: Parts I and II. American Journal of Psychotherapy, Vol. 28 (1974), pp. 4-20, 174-93.

Ross, M.W., J. Walinder, B. Lundstrom, and I. Thuwe. Cross-cultural Approaches to Transsexualism: A Comparison Between Sweden and Australia. Acta Psychiat. Scand. Vol. 63 (1981), pp.75-82.

Steiner, B., ed. Gender Dysphoria. New York: Plenum Press, 1985.

Stoller, R. Sex and Gender. New York: Science House, 1968.

Stoller, R. Near Miss: "Sex Change" Treatment and Its Evaluation. In R. Stoller, Presentations of Gender. New Haven: Yale Univ. Press, 1985.

Walinder, J. Transsexualism. Akademiforlaget, Goteborg, Sweden: Scandinavian University Books, 1967.

Walinder, J. Transsexualism: Definition, Prevalence, and Sex Distribution. Acta Psychiat. Scand. (Suppl.) Vol. 203 (1968), pp. 255-57.

Walinder, J. Incidence and Sex Ratios of Transsexualism in Sweden. British Journal of Psychiatry, Vol. 119 (1971), pp.195-96.

Walinder, J., B. Lundstrom, and I. Thuwe. Prognostic Factors in the Assessment of Male Transsexuals for Sex Reassignment. British Journal of Psychiatry, Vol. 132 (1978), pp. 16-20.

Walinder. J., and l. Thuwe. A Social-Psychiatric Follow-up Study of 24 Sex Reassigned Transsexuals. Goteborg, Sweden: Scandinavian Univ. Books, 1974.

Walker, P., et al. Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons. Archives of Sexual Behavior, Vol. 14 (1985), pp. 79-90.

Zucker, K.J. Cross-Gender Identified Children. In B.W. Steiner, éd., Gender Dysphoria: Development, Research, and Management. New York: Plenum, 1985.

Zuger, B. Homosexuality in Families of Boys with Early Effeminate Behavior: An Epidemiological Study. Archives of Sexual Behavior, Vol. 18 (1989), pp.155-66.

Ira B. Pauly