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Effeminate behavior present in boys from early childhood
1098
1"he Journal of P E D I A T R I C S
Effeminate behavior present i. boy / om early childhood I. T h e c l i n i c a l s y n d r o m e a n d f o l l o w - u p
studies
An attempt is made to evaluate the possible relationship o[ effeminate behavior in boys during early childhood to subsequent sexual identification.
Bernard Zuger, M.D. ~" NEW
YORK~
N.
Y.
EFFEMINATE BEHAVIOR in young boys is often dismissed as inconsequential and as something that will be outgrown. There are, however, few long-term follow-up studies on which to base such a belief. This report concerns 16 such boys. All showed marked feminine-type behavior from early childhood. They were first seen between 1953 and 1964, and since some of them have been observed for 10 years or more some judgments can be made as to the significance of the early signs. A comparison is also made with a smaller group of 4 children seen during the same period whose earlier signs were not marked, and who are thought to differ in other ways. A study that closely parallels the present one is that of Green and Money, 1 who reported a 5 year follow-up on 10 such chil-
From the Department of Psychiatry and Neurology, New York University School of Medicine, New York, and The Children's Psychiatric Clinic, Greenwich Hospital, Greenwich, Conn. eAddress, Department o[ Psychiatry, New York University School of Medicine, 550 First Avenue, New York 16, N. Y.
dren, 5 of whom were over 14 years of age. Bender 2 reported on 12 boys, 9 of whom had early feminine behavior, but these were severely deprived children whose other problems beclouded the sexual ones. A retrospective study by Holemon and Winokur a on prisoners with a history of homosexual activity is also relevant in that it deals with the prior occurrence of early effeminacy in one group, the later onset of homosexual behavior in another group, and the homosexual practices of a third group whose members were not homosexuals. S O U R C E OF C A S E S A N D M E T H O D S
The 20 patients herein reported came from three sources: 12 from the Children's Service of the Psychiatric Division of the Greenwich Hospital, Greenwich, Connecticut; 6 from the author's private practice in New York City; and two referred by a family agency to the author for psychiatric consultation. All of the initial pediatric and psychiatric histories and psychiatric examinations, as
Volume 69 Number 6
well as the follow-up examinations, were done by the author. With respect to the patients from the Greenwich Hospital, the usual information obtained by tile social worker and psychologist was also available. In addition, with the permission of the parents, there was access to earlier observations recorded by nursery and grade school teachers on several of the children. Of the 6 patients from private practice, contact with 4 has been frequent and has extended over a long period of time. In the fifth patient, only the parents were seen initially and at followup, and in the sixth the period since the initial interview" and commencement of treatment has been short. As with other patients, there was relevant consultation with tile pediatricians, psychologists, and other workers involved. For the two boys from the family agency, there were available complete social histories as well as medical data obtained from their respective pediatricians. Subsequent follow-up included a review of the detailed psychological and treatment records of the treating agency and personal exchange with the therapist of one of the children. Nine of the 20 patients were originally referred primarily for feminine behavior, while 7 were seen mainly for other symptoms or a combination of them. These 16 patients are listed in the tables as belonging to Group A. The 4 remaining patients, subsequently considered as Group B, were first seen exclusively for problems other than feminine-type behavior. There was at that time-little evidence of abnormal sexual tendencies. In 3 of these 4 patients the homosexuality was disclosed spontaneously by the patients themselves. The homosexuality of the fourth came to light when he was apprehended by the police. Information on earlier symptoms was then obtained retrospectively. I N C I D E N C E IN A BOYS' PSYCHIATRIC POPULATION
A continuous register has been kept by the writer since May, 1951, of all patients under 18 years of age referred to him from the three sources mentioned above. From
Effeminate behavior in boys
1 09 9
that date to the referral of the last of the 20 boys in November, 1964, the total number of boys seen was 407. With the possible exception of 2 patients taken out of order on the clinic list, the others may be considered randomly distributed in the given population, indicating an approximate incidence of 1 in 20 such patients in a population of boys referred for psychiatric evaluation. D E S C R I P T I O N OF T H E CLINICAL MATERIAL
The 20 cases are presented in Table I. The earliest age at which a child was seen was 4 years and 3 months (2 children) ; the oldest was 16 yeats of age (2 patients). Notes on the behavior in the first grade of one of the latter were available. The ages at onset may be summarized from Table I as follows: before 3 years of age in 6 patients, and before 6 years of age in all cases of group A, except perhaps one. The mothers of several of the children and some of the children themselves felt that they had been effeminate as far back as they could remember. The realization that a child is different in this respect would, of course, occur to mothers at different times. In any event, it is apparent that symptoms must have begun very early, almost as soon as motor and speech development allowed their manifestation. It would seem that, in contrast to Group A, the patients in Group B had the onset of symptoms at a later age, 8 to 10 years in 3 and uncertain in the fourth. To none of the mothers did the idea occur that their children were effeminate, and 3 of them continued to be unaware of their boys' homosexual leanings. The symptoms present before frank homosexual attraction were disclosed by the patients themselves, or were observed directly by the author. The more common symptoms of effeminacy are recerded in Table I. These included the wearing of articles of women's dress, the use of lipstick, a preference for playing with girls, asserting a desire to be a girl or a woman, feminine gesturing, 'playing with dolls, and exhibiting a lack of interest in or
1 1 O0
Zuger
December 1966
Table I. Age at onset and symptoms
of boys with feminine-type
behavior
Early symptoms
Case no.
Age when first seen
Age at onset
l Preference AntipFern- Wear- for Fernathy inine ing I girl Desire inine Doll to dress- lip- play- to be ges- play. boys" ing stick ]mates :emale turing ing games
Other
Group A 1
7 yr.
2-3 yr.
+~
nd{
2
4 yr., 3 mo.
2-3 yr.
+
+
+
+
+
+
+
Always w a n t e d to p l a y house t a k i n g m o t h e r ' s role. L i k e d to be w i t h a d u l t females. L i k e d playing with women's jewelry, c l o t h i n g , etc.
nd
+
O~t
+
+
T h r e a t e n e d t o c ut off his penis. I n t e r e s t in w o m a n ' s body, b e i n g
a mommy 3
7 yr.w
5 I ~ yr.
+
0
nd
+
+
nd
+
W a n t e d his h a i r to be l i ke a girl's. I n t e r e s t e d in w h a t a b r i d e was wearing
4
13 yr., 4 mo.
3-4 yr.
+
+
+
nd
nd
nd
+
W a n t e d h a i r c u r l e d since 2 years of age. A t t r a c t e d s e x u a l l y to boys a t 9 years of age. H a t e d gym.
5
8 yr.
1-2 yr.
+
nd
+
+
+
+
+
C a m e to n u r s e r y school dressed l i ke a girl, 2 to 3 y e a r s of age. L i k e d b r a i d i n g of ha i r. L i k e d ballet
6
7 yr., 4 mo.
? (before 6 yr.)
+
0
+
+
+
+
+
M o t h e r said he a l w a y s w a n t e d to be a girl. K n e w m o t h e r h a d wanted a girl
7
11 yr., 3 too.
4 yr.
+
+
+
+
+
+
+
" M y dre s s i ng table has a l w a y s been a j o y to h i m , " m o t h e r said
8
13 yr. H
? 9 yr.
+
+
nd
+
nd
nd
+
9
16 yr.
4 yr.
+
+
nd
nd
nd
nd
+
H a s a l w a y s w a n t e d to "fuss" w i t h his ha i r, a c c o r d i n g to m o t h e r
10
16 yr.
4-5 yr.
+
nd
+
+
nd
+
nd
F r o m t e a c h e r ' s notes a t a ge 5 years: " . . . likes to p l a y i n t he doll corners . . . w i l l dress i n a n old hat, heels a n d old p e t t i coat. H e orga ni z e s t e a parties, washes a n d irons clothes a n d cares for the b a b y . . . "
11
6yr., 4 too.
? (before 6 yr.)
nd
+
nd
+
0
+
+
H i g h - p i t c h e d voice
12
5 yr., 7 too.
2 yr.
+
+
+
+
+
+
+
W a n t e d to b a k e a n d dust, like mother. D a n c i n g in a girlish way
~Present. "~nd, no data. :~0, absent. w not seen; information from parents. IIMother dead; complete history not available. 82 four patients had been seen or were being seen for other problems. Patient 17 disclosed homosexual prolems at 18 years of age. Patient 18 was apprehended by police for sexual practices at 15 years of age. Patient 19 requested interview at 22 years of age regarding homosexuality, after regular visits were discontinued. Patient 20 disclosed homosexuality at 12 years of age.
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Number 6
Effeminate behavior in boys
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T a b l e I. C o n t ' d Early symptoms Preference
no.
Antipfor Fernathy girl Desire inine Doll to znzne zng dress- lip- play- to be ges- play- boys' ing stick mates 'emale turing ing games Fem- Wear-
Age when Case] first
Age at
seen
onset
Other "Passion" for dancing. Very observant as to what mother wearing. Strutting and swinging of hips
2 yr.
+
+
+
+
+
+
+
5 yr., 10 mo.
2-3 yr.
+
+
+
+
+
+
+
Wearing scarf and sweater over shoulders like a woman
15
8 yr., 7 mo.
3-4 yr.
+
+
+
+
+
+
-I-
Has wanted to be a hair-dresser
16
5 yr., 10 mo.
3-4 yr.
+
+
-t-
+
+
+
+
Liked to use perfume. Good at gymnastics
? 8yr.
nd
nd
+
+
nd
nd
+
Called faggot by other boys in boarding school
0
0
0
+
0
+
Liked knitting as a child
nd
+
nd
nd
+
Attracted to boy at 10 years of age
0
0
0
0
+
Feels attraction to boys. Excused from gym
13
4 yr., 3 mo.
14
Group B82 17 14yr. 18
12 yr.
?
0
19
14 yr., 8 mo.
? 8 yr.
nd
20
6 yr., 9 mo.
? 10 yr.
0
nd 0
outright dislike of boys' games a n d sports. O t h e r feminine propensities more or less peculiar to each patient are also mentioned. As m a y be seen from the chart, most of the c o m m o n manifestations were shared by the boys of G r o u p A. Symptoms were m u c h fewer in the 4 patients of G r o u p B. I t would seem unlikely that if more had been present they would not have been detected, especially in the 3 whose parents were competent observers. T h e variations a n d the n a t u r a l history of some of the feminine manifestations were interesting. T h e articles of women's dress sought out by the boys included panties, petticoats, dresses, sweaters, high-heeled shoes, hats, jewelry, a n d other adornments, handbags, a n d umbrellas. These were worn or carried as part of ';dressing-up," playing house, going through a mock wedding in which the boy would take the bride's role, etc. This behavior was carried out at first without self-consciousness, a n d the criticism
of other boys was n o t a deterrent. If prohibited, the practices we:re often continued i n a covert a n d furtive fashion, a n d might come out into the open in Halloween dressups or in the taking of girls' parts in school plays. While some boys lost this need, it r e m a i n e d strong in others and its practice c o n t i n u e d into late adolescence. Apparently the association of the articles of clothing with a particular person was not i m p o r t a n t ; clothing belonging to mother, sister, or an u n k n o w n female, or stolen from a store, appeared to be equally satisfactory for meeting the child's needs. T h e mothers often described tile joy their boys exhibited in playing "dress-up," m u c h greater, it seemed, t h a n would have been expected of little girls engaging in such play. O n e boy, 15 years of age, would dress up a n d use lipstick when he was anxious , imagi n i n g he was a lovely lady, slim, a n d about the size of his stepmother; after 'this he would feel relaxed.
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Zuger
December 1966
T a b l e II. S u b s e q u e n t s e x u a l o r i e n t a t i o n i n b o y s w i t h e a r l y f e m i n i n e - t y p e b e h a v i o r
Case first Age no.
seen
Age at onset
Psychotherapy
Age at last followup
Status at follow-up
Comment
Group A 1
7 yr.
2-3 yr.
4 yr., 2-3 yr. 1110.
Claims heterosexual interests Apparent heterosexual 69 sessions, 7 through 10 18 yr. and objectives. Slight fernadjustment years of age. Parents inine gestures. Denies hoseen simultaneously mosexual interests Treated 1 2 ~ to 13 years of age, once weekly. Parents seen
18 yr., At 17 years of age occasional 6 too. feminine gestures. No interest in girls. "Introvert." Has developed interest in sports. At 18 years of age questionable interest in a girl
Apparent heterosexual adjustment
21 yr. Confirmed homosexual. PreAt 13 years of age, fers active role, but takes weekly for 1 year. both. Walk and mannerSome participation of isms of an invert. No mother cross-dressing, etc., since later childhood
Homosexual. ? Invert
Consultations and several interviews
16 yr., Sexually attracted to boys. 4 mo. Asked for an operation to make himself into a girl
Homosexual. Invert. Transvestite
Consultation and 4 in? terviews between 7 (before and 11 years of age 6 yr.)
12 yr., Stopped wearing dresses ex11 too. cept for Halloween. Likes dancing very much. Still clings to mother
Outcome uncertain
7 yr. 5 ~ yr. None, except advice at initial consultation
13 yr., 3-4 yr. 4 mo.
8 yr. i-2 yr.
7 yr.
7 to 8 years of age for 1 year. Again for 5 months when 11 years of age.
13 yr. Continues artistic, exhibition- Probably homosexual istic, effeminate. Dislike for gym
Seen once weekly, 13 to 15 years of age
15 yr. Still prefers to be a woman, cross-dresses. Uses lipstick
Outcome uncertain. Transvestite
16yr. 4yr.
Weekly interviews, 8 months at 16 years of age
17 yr. No interest sexually in girls. In appearance and manner, feminine. Wants to be hairdresser
Homosexual. Invert
16 yr. 4-5 yr.
Consultation and a few 18 yr. Homosexual activity, both interviews at 16 years passive and active roles; prefers passive. Peroxides of age his hair
11 yr., 4 yr. 3 mo.
13yr.
I0
11
15 yr., Feminine gestures and man- Probably homosexual 3 too. nerlsms. No interest in girls. At 12 years of age, wanted to become hairdresser or interior decorator. Had himself excused from gym
?9yr.
17 yr. Puts on sister's clothing. SusSeen 6 to 7 years once 6 yr., picious interest in a boy. weekly for 5 months. 4 too. (before Excused from gym. Writes Again at 16 years once 6 yr.) plays with homosexual weekly for 6 months activity
Homosexual. Probably invert
Probably homosexual. Transvestite
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Effeminate behavior in boys
1 1 03
Table II. Cont'd
Case Age first no.
seen
Age at onset
Psychotherapy
Age at last followup
Status at follow-up
Comment
12
5 yr., 2 yr. 7 mo.
Seen biweekly from 6 years to time of follow-up
7 yr., Still continues earlier pracNo improvement in 11 mo. tices, b u t now deviously. symptoms "Swishy" walk. Beginning to be called "sissy" by peers
13
4 yr., 2-3 yr. 3 too.
Seen 14 times from 4 to 6 years of age
6 yr., No cross-dressing (feminine 11 mo. behavior generally more covert). Some interest in boys' play. Likes dressing little sister
No improvement in symptoms. Later outcome uncertain
14
5 yr., 2-3 yr. 10 mo.
7 yr., Only occasional gesturing
Improvement in symptoms. Later outcome uncertain
15
8 yr., 3-4 yr. 7 mo.
16
5 yr., 3-4 yr. 10 mo.
Seen once weekly for several months at 5 to 6 years
1 too.
Seen by social worker at 7 years of age for 1 year once a week
9 yr., No cross-dressing or lipstick; Improvement in symp6 too. other symptoms more or toms. Later outcome less present uncertain
Seen 5 times after consultation
6 yr. Improvement, according to parents
Later outcome uncertain
Group B 23 yr. Attracted to men. No interest Homosexual, nonpracin women. Very passive ticing (?). Masturbation fantasies with males
17
14yr. ? 8 y r .
Seen at long intervals after 14 years of age
18
13 yr.
Seen once weekly at 13 22 yr. Preference for genital contact Homosexual with young boys to 14 years. Residential treatment 16 to 18 years
19
14 yr., ? 8 y r . 8 mo.
20
?
26 yr. Married with children. Voice Homosexual Seen at 14 years for high-pitched. Gestures short time. Residential somewhat feminine. Present school 2 years, then occupation one that genonce or twice a year erally has high percentage of homosexuals
6 yr., ? 10 yr. Seen once weekly for 9 mo. 3 to 4 years from 11 to 14 years of age
15 yr. Attracted to boys
There was often a general preoccupation with the female body and clothing, usually t h e m o t h e r ' s . E v e n t h e v e r y y o u n g ones would comment on what their mothers were w e a r i n g a n d h o w t h e y looked. I n t h e o l d e r o n e s t h e r e p e r s i s t e d a n excessive i n t e r e s t i n clothing, both masculine and feminine. In t h e i r l a t e r p l a t o n i c r e l a t i o n s h i p s w i t h girls, t h e boys o f t e n a d v i s e d t h e m r e g a r d i n g t h e i r clothing.
Homosexual
U s e of lipstick, n a i l p o l i s h a n d p e r f u m e , and preoccupation with their own hair (or t h e i r m o t h e r ' s o r a n o t h e r f e m a l e ' s ) w e r e also e a r l y s y m p t o m s . T h e i n t e r e s t i n h a i r led t o experimenting with their own hair, later to i n c l u d e d y e i n g it, d r e s s i n g t h e h a i r of t h e i r girl f r i e n d s or of t h e i r m o t h e r , a n d o f t e n to c h o o s i n g h a i r d r e s s i n g as a n o c c u p a t i o n . A p r e f e r e n c e f o r p l a y i n g w i t h girls w a s p r e s e n t e v e n w h e n boys of s i m i l a r a g e w e r e
1 I 04
Zuger
available, though some parents chose to explain this tendency as being due to a scarcity of other boys in the neighborhood. Actually, the other boys had different interests and would not play the games or accept the roles assigned to them by the effeminate children. The mothers often described their effeminate boys as "bossy." As will be indicated in a subsequent paper, it is striking that almost without exception these children at an early age had difficulties in playing with other boys. The later relationships these boys had with girls often deluded the parents and others into thinking that they did have girl friends. They could, in fact, be extremely popular with girls in high school because of their interest in dancing and music. Each of the boys in Group A for whom there are data said at one time or another that he wanted to be a girl or to be like "mommy," or asked why he was not born a girl. Some liked to associate closely with other adult women as well as with their own mothers. The feminine gestures included the body carriage, which was noted in one patient as early as 4 to 5 years of age, feminine speech and expressions, "sashaying like a prima donna," strutting, preening, and primping before the mirror, etc. Many of the children were very fond of dancing and liked to watch ballet on television. One child stole a pair of ballet slippers from a store. I n all except possibly one of the patients of Group A, and this was true as well for Group B, there was a lack of interest in competitive sports and in boys' games such as playing with guns. In most instances many unsuccessful attempts had been made, usually by the father, to get the boys interested in sports. As they grew older, the boys disliked gym more and more, and toward adolescence many developed panic at the prospect of undressing in the locker rooms. FOLLOW-UP STUDIES
As these children grew older, follow-up became more difficult. One could be more
December 1966
certain of the outcome when it was homosexual than when it was apparently heterosexual. The initial openess in behavior and expression of preferences were replaced by subterfuge, or the telltale symptoms of effeminacy were suppressed as a confirmed orientation toward homosexuality was taking place. Often enough the individual made no attempt to hide his leanings. When this was not the case, however, his other interests, the choice of an occupation, the dread of attending gym, the group he associated with, or information from home and other sources gave important clues. Nevertheless, in some instances, one could come to only a presumptive conclusion as to the sexual orientation. In Table I I the results of the follow-up studies done in 1964-1965 are presented. Ten of the 16 boys of Group A were then over 13 years of age, and 6 of these were 17 years of age or older. One was almost 13 and the remaining 5 were less than 10 years of age. Of the 10 older boys, 2 were making apparent heterosexual adjustments, 4 were confirmed homosexuals, 3 were probably homosexuals~ and sexual status in the remaining one (Case 8) was uncertain. Even in the cases of the 2 boys considered to be making heterosexual adjustments, some doubts remained. One of the boys (Case 1), when seen at 18 years of age, claimed he was in love with a girl in whom he was physically interested, and that he wanted to get married. H e said he was having night emissions, sometimes dreaming about a girl, sometimes not. He denied homosexual interests. His voice was masculine though his gestures were somewhat effeminate. His parents were not worried about him. H e planned to become a teacher like his father. In drawing a person he did not know whether he was drawing a boy or a girl, though when requested to give the person a name, it was a man's name. The figure had large eyes with prominent eyelashes, a sign considered by some 4 to be indicative of homosexuality. The second boy (Case 3), whose development also seemed to be going in a heterosexual direction, was the one not seen directly but
Volume 69 Number 6
Effeminate behavior in boys
through his parents. At 17 years of age he still had some feminine gestures, showed no interest in girls, and was called an "introvert," though he had developed an interest in sports. At 18 years of age he showed an interest in a girl whom he later dropped; she had pushed the relationship in a sexual direction. In all other ways, according to his parents, nothing effeminate about him was noted except for an occasional slipping into high falsetto voice. The 4 considered to be confirmed homosexuals included 3 who were pretty much that way when first seen at 13, 15, and 16 years of age, respectively. The fourth was first seen at 8 years of age. Of the 6 patients under 13 years of age, the oldest one presented no outward signs of effeminacy though he continued to dress in women's clothing on Halloween. He was very fond of dancing, and was still very much attached to his mother. Of the youngest 5 patients, 2 showed some improvement in overt symptoms, 2 did not, and not enough time had elapsed since the fifth was first seen to expect much change. No conclusion can be drawn as to the final outcome in any of these children. In Group B the outcome wa% of course, predetermined in that the members were self-selected on the basis of homosexuality. TREATMENT
AND
OUTCOME
As may be seen from Table II, the amount of psychotherapy received and the age when it was initiated varied considerably. All parents were given guidance which it was thought would lead to a better masculine identification. They were advised to discourage effeminate activities and to reinforce masculine ones. The boy whose treatment was longest and was begun moderately early (Case 1) was one of the 2 who made an apparent heterosexual adjustment. The other boy (Case 3) was not seen, and guidance was given to the parents only. Of the group of 3 who were probably homosexual, one (Case 7) received more than one year of treatment and 2 (Cases 2
1 1 05
and 11) less than one year before their thirteenth birthdays. Obviously, in these cases, the amount of treatment at the ages given was not very effective. In general, the older boys in Group A showed no interest in receiving treatment and those already homosexually inclined did not want to change. This apparently was not the case for those of Group B, for 3 of them disclosed their homosexuality because they wanted help. It appears that with guidance or treatment some of the younger boys could be induced to suppress their effeminate behavior, though, as indicated, it often came out in covert and devious ways..What the eventual effect of such, suppression may be on the potential for homosexuality cannot be predicted. DISCUSSION
The clinical phenomenon dealt with in this paper adds up to something other than transvestism. Although prominent early in the children of Group A, the desire for wearing feminine things is only one part of a larger feminine-type behavior pattern. In the 2 patients with an apparent heterosexual adjustment, transvestism has no.t seemed to persist. In those boys for whom the outcome has been a homosexual one, unusual habits of dress are not always seen. On the other h a n d , in one of the older patients (Case 8), transvestism without a homosexual orientation may yet be the end result. In the younger children, the desire to play house with little gifts may be as compelling an urge as the wearing of feminine clothing. It is probably this total feminine direction of the interests of these children which brings them closer to the mother, and not the other way around. In the clinical experience of the writer, few children are brought to a psychiatric clinic for cross-dressing only. One cannot exclude the possibility that only those with more obvious feminine manifestations or with other behavioral symptoms are being seen. An attempt is now being made to obtain some idea of the incidence of feminine-type
1 1 06
Zuger
behavior in a random population of 7 to 8 year old boys. Preliminary data suggest that it is not at all common. Is there a justification for separating the 20 children into two groups? T h e children of Group B had few feminine symptoms, and the onset appeared to come later. There was no definite evidence of cross-dressing. More striking, and in contrast to the children of Group A, was the self-disclosure of homosexual leanings and the expression of a desire for help. The feminine orientation of the children of Group A seemed to be so much a part of the self that there was no desire for change. It may well be that Group B represents a larger group in the general population, and that only those who have other behavioral problems are seen. This group would thus represent a different type of homosexuality than the generally invert type encountered in the children from Group A. As they mature, both of these groups would differ from the group of boys who casually engage in homosexual activity, much or little, and for reasons other than that they are basically homosexual. Holemon and Winokur a defined three such groups retrospectively among prisoners with homosexual problems. The outcome of the patients in this study differs from that of Bender 2 but is similar to that reported by Green and Money? Bender dealt with psychotic and delinquent patients; in 4 of her 9 cases there is clear mention of the outcome as to sexual adjustment, and only one was effeminate homo:sexual. In the Green and Money patients, the symptoms of feminine-type behavior (referred to by them as cross-gender identity) tended to persist and were given up only gradually. Five of their patients were 14 years of age or older at the time of their last follow-up, and 3 of these could be considered as pretty definitely homosexual. This outcome is not unlike that reported in the present study. As one looks at this symptom complex, one is struck by the completeness of the feminine identification and how full sprung
December 1966
seems its development from the outset. There is a strikingly exaggerated feminine quality to it and its expression appears to be compulsive. Its most important characteristic may be its early appearance. Feminine behavior beginning early in childhood would seem to constitute a clinical entity, possibly carrying with it serious consequences for future sexual identification. SUMMARY
Two groups of boys were studied. The larger group of 16 boys showed symptoms of feminine-type behavior from very early childhood, including the wearing of articles of women's dress, the use of lipstick, a preference for playing with girls, the desire to be female, employing feminine gestures~ playing with dolls, and showing no interest in (or exhibiting an actual dislike of) boys' games and sports. Ten of these children at the time of follow-up were 13 years of age or older. Of these, 4 were homosexuals, 3 were probably homosexuals, 2 were apparently heterosexual, and in the remaining 1 the outcome was uncertain. It is thought that the symptoms shown by these children constitute a clinical entity, in the outcome of which the sexual identification of the child is at issue. The other group of 4 children showed few of the symptoms mentioned above, and differed in other ways, but later themselves indicated that they were homosexual. The question is raised as to whether this may constitute a different type of homosexuality. It was difficult to evaluate the results of psychologic treatment in the first group, though guidance of parents can apparently effect a suppression of the overt symptoms in some of the children. Dr. Bernard Benjamin, Brooklyn, New York, has made many valuable suggestions which have added to the clarity of the paper. Mrs. Thirza Howard, Mrs. Patsy Taylor, and Mrs. Margie Anderson, social workers in the Department of Psychiatry at the Greenwich Hospital at various times, have helped in the follow-up of the cases. Miss Marlene Van Slingerlandt, administrative assistant, has given valuable aid in many ways.
Volume 69 Number 6
REFERENCES
1. Green, R., and Money, J.: Prepubertal morphologically normal boys demonstrating signs of cross-gender identity, read at the annual meeting of the American Orthopsychiatric Association, Chicago, Ill., 1964. 2. Bender, L.: A Dynamic Psychopathology of Childhood, Springfield, Illinois, 1954, Charles C Thomas, Publisher, p. 152.
Effeminate behavior in boys
1 10 7
3. Holemon, R. E., and Winokur, G.: Effeminate homosexuality: A disease of childhood, Am. J. Orthopsychiat. 35: 48, 1965. 4. Levy, S.: Figure drawing as a projective test, in Abt, L. E., and Bellak, L., editors: Projective Psychology, New York, 1950, Alfred A. Knopf, Inc., See also Hammer, Emanuel: The Clinical Application of Projective Drawings, Springfield, Illinois, 1955, Charles C Thomas, Publisher.
1"he Journal of P E D I A T R I C S
Effeminate behavior present i. boy / om early childhood I. T h e c l i n i c a l s y n d r o m e a n d f o l l o w - u p
studies
An attempt is made to evaluate the possible relationship o[ effeminate behavior in boys during early childhood to subsequent sexual identification.
Bernard Zuger, M.D. ~" NEW
YORK~
N.
Y.
EFFEMINATE BEHAVIOR in young boys is often dismissed as inconsequential and as something that will be outgrown. There are, however, few long-term follow-up studies on which to base such a belief. This report concerns 16 such boys. All showed marked feminine-type behavior from early childhood. They were first seen between 1953 and 1964, and since some of them have been observed for 10 years or more some judgments can be made as to the significance of the early signs. A comparison is also made with a smaller group of 4 children seen during the same period whose earlier signs were not marked, and who are thought to differ in other ways. A study that closely parallels the present one is that of Green and Money, 1 who reported a 5 year follow-up on 10 such chil-
From the Department of Psychiatry and Neurology, New York University School of Medicine, New York, and The Children's Psychiatric Clinic, Greenwich Hospital, Greenwich, Conn. eAddress, Department o[ Psychiatry, New York University School of Medicine, 550 First Avenue, New York 16, N. Y.
dren, 5 of whom were over 14 years of age. Bender 2 reported on 12 boys, 9 of whom had early feminine behavior, but these were severely deprived children whose other problems beclouded the sexual ones. A retrospective study by Holemon and Winokur a on prisoners with a history of homosexual activity is also relevant in that it deals with the prior occurrence of early effeminacy in one group, the later onset of homosexual behavior in another group, and the homosexual practices of a third group whose members were not homosexuals. S O U R C E OF C A S E S A N D M E T H O D S
The 20 patients herein reported came from three sources: 12 from the Children's Service of the Psychiatric Division of the Greenwich Hospital, Greenwich, Connecticut; 6 from the author's private practice in New York City; and two referred by a family agency to the author for psychiatric consultation. All of the initial pediatric and psychiatric histories and psychiatric examinations, as
Volume 69 Number 6
well as the follow-up examinations, were done by the author. With respect to the patients from the Greenwich Hospital, the usual information obtained by tile social worker and psychologist was also available. In addition, with the permission of the parents, there was access to earlier observations recorded by nursery and grade school teachers on several of the children. Of the 6 patients from private practice, contact with 4 has been frequent and has extended over a long period of time. In the fifth patient, only the parents were seen initially and at followup, and in the sixth the period since the initial interview" and commencement of treatment has been short. As with other patients, there was relevant consultation with tile pediatricians, psychologists, and other workers involved. For the two boys from the family agency, there were available complete social histories as well as medical data obtained from their respective pediatricians. Subsequent follow-up included a review of the detailed psychological and treatment records of the treating agency and personal exchange with the therapist of one of the children. Nine of the 20 patients were originally referred primarily for feminine behavior, while 7 were seen mainly for other symptoms or a combination of them. These 16 patients are listed in the tables as belonging to Group A. The 4 remaining patients, subsequently considered as Group B, were first seen exclusively for problems other than feminine-type behavior. There was at that time-little evidence of abnormal sexual tendencies. In 3 of these 4 patients the homosexuality was disclosed spontaneously by the patients themselves. The homosexuality of the fourth came to light when he was apprehended by the police. Information on earlier symptoms was then obtained retrospectively. I N C I D E N C E IN A BOYS' PSYCHIATRIC POPULATION
A continuous register has been kept by the writer since May, 1951, of all patients under 18 years of age referred to him from the three sources mentioned above. From
Effeminate behavior in boys
1 09 9
that date to the referral of the last of the 20 boys in November, 1964, the total number of boys seen was 407. With the possible exception of 2 patients taken out of order on the clinic list, the others may be considered randomly distributed in the given population, indicating an approximate incidence of 1 in 20 such patients in a population of boys referred for psychiatric evaluation. D E S C R I P T I O N OF T H E CLINICAL MATERIAL
The 20 cases are presented in Table I. The earliest age at which a child was seen was 4 years and 3 months (2 children) ; the oldest was 16 yeats of age (2 patients). Notes on the behavior in the first grade of one of the latter were available. The ages at onset may be summarized from Table I as follows: before 3 years of age in 6 patients, and before 6 years of age in all cases of group A, except perhaps one. The mothers of several of the children and some of the children themselves felt that they had been effeminate as far back as they could remember. The realization that a child is different in this respect would, of course, occur to mothers at different times. In any event, it is apparent that symptoms must have begun very early, almost as soon as motor and speech development allowed their manifestation. It would seem that, in contrast to Group A, the patients in Group B had the onset of symptoms at a later age, 8 to 10 years in 3 and uncertain in the fourth. To none of the mothers did the idea occur that their children were effeminate, and 3 of them continued to be unaware of their boys' homosexual leanings. The symptoms present before frank homosexual attraction were disclosed by the patients themselves, or were observed directly by the author. The more common symptoms of effeminacy are recerded in Table I. These included the wearing of articles of women's dress, the use of lipstick, a preference for playing with girls, asserting a desire to be a girl or a woman, feminine gesturing, 'playing with dolls, and exhibiting a lack of interest in or
1 1 O0
Zuger
December 1966
Table I. Age at onset and symptoms
of boys with feminine-type
behavior
Early symptoms
Case no.
Age when first seen
Age at onset
l Preference AntipFern- Wear- for Fernathy inine ing I girl Desire inine Doll to dress- lip- play- to be ges- play. boys" ing stick ]mates :emale turing ing games
Other
Group A 1
7 yr.
2-3 yr.
+~
nd{
2
4 yr., 3 mo.
2-3 yr.
+
+
+
+
+
+
+
Always w a n t e d to p l a y house t a k i n g m o t h e r ' s role. L i k e d to be w i t h a d u l t females. L i k e d playing with women's jewelry, c l o t h i n g , etc.
nd
+
O~t
+
+
T h r e a t e n e d t o c ut off his penis. I n t e r e s t in w o m a n ' s body, b e i n g
a mommy 3
7 yr.w
5 I ~ yr.
+
0
nd
+
+
nd
+
W a n t e d his h a i r to be l i ke a girl's. I n t e r e s t e d in w h a t a b r i d e was wearing
4
13 yr., 4 mo.
3-4 yr.
+
+
+
nd
nd
nd
+
W a n t e d h a i r c u r l e d since 2 years of age. A t t r a c t e d s e x u a l l y to boys a t 9 years of age. H a t e d gym.
5
8 yr.
1-2 yr.
+
nd
+
+
+
+
+
C a m e to n u r s e r y school dressed l i ke a girl, 2 to 3 y e a r s of age. L i k e d b r a i d i n g of ha i r. L i k e d ballet
6
7 yr., 4 mo.
? (before 6 yr.)
+
0
+
+
+
+
+
M o t h e r said he a l w a y s w a n t e d to be a girl. K n e w m o t h e r h a d wanted a girl
7
11 yr., 3 too.
4 yr.
+
+
+
+
+
+
+
" M y dre s s i ng table has a l w a y s been a j o y to h i m , " m o t h e r said
8
13 yr. H
? 9 yr.
+
+
nd
+
nd
nd
+
9
16 yr.
4 yr.
+
+
nd
nd
nd
nd
+
H a s a l w a y s w a n t e d to "fuss" w i t h his ha i r, a c c o r d i n g to m o t h e r
10
16 yr.
4-5 yr.
+
nd
+
+
nd
+
nd
F r o m t e a c h e r ' s notes a t a ge 5 years: " . . . likes to p l a y i n t he doll corners . . . w i l l dress i n a n old hat, heels a n d old p e t t i coat. H e orga ni z e s t e a parties, washes a n d irons clothes a n d cares for the b a b y . . . "
11
6yr., 4 too.
? (before 6 yr.)
nd
+
nd
+
0
+
+
H i g h - p i t c h e d voice
12
5 yr., 7 too.
2 yr.
+
+
+
+
+
+
+
W a n t e d to b a k e a n d dust, like mother. D a n c i n g in a girlish way
~Present. "~nd, no data. :~0, absent. w not seen; information from parents. IIMother dead; complete history not available. 82 four patients had been seen or were being seen for other problems. Patient 17 disclosed homosexual prolems at 18 years of age. Patient 18 was apprehended by police for sexual practices at 15 years of age. Patient 19 requested interview at 22 years of age regarding homosexuality, after regular visits were discontinued. Patient 20 disclosed homosexuality at 12 years of age.
Volume 69
Number 6
Effeminate behavior in boys
1 10 1
T a b l e I. C o n t ' d Early symptoms Preference
no.
Antipfor Fernathy girl Desire inine Doll to znzne zng dress- lip- play- to be ges- play- boys' ing stick mates 'emale turing ing games Fem- Wear-
Age when Case] first
Age at
seen
onset
Other "Passion" for dancing. Very observant as to what mother wearing. Strutting and swinging of hips
2 yr.
+
+
+
+
+
+
+
5 yr., 10 mo.
2-3 yr.
+
+
+
+
+
+
+
Wearing scarf and sweater over shoulders like a woman
15
8 yr., 7 mo.
3-4 yr.
+
+
+
+
+
+
-I-
Has wanted to be a hair-dresser
16
5 yr., 10 mo.
3-4 yr.
+
+
-t-
+
+
+
+
Liked to use perfume. Good at gymnastics
? 8yr.
nd
nd
+
+
nd
nd
+
Called faggot by other boys in boarding school
0
0
0
+
0
+
Liked knitting as a child
nd
+
nd
nd
+
Attracted to boy at 10 years of age
0
0
0
0
+
Feels attraction to boys. Excused from gym
13
4 yr., 3 mo.
14
Group B82 17 14yr. 18
12 yr.
?
0
19
14 yr., 8 mo.
? 8 yr.
nd
20
6 yr., 9 mo.
? 10 yr.
0
nd 0
outright dislike of boys' games a n d sports. O t h e r feminine propensities more or less peculiar to each patient are also mentioned. As m a y be seen from the chart, most of the c o m m o n manifestations were shared by the boys of G r o u p A. Symptoms were m u c h fewer in the 4 patients of G r o u p B. I t would seem unlikely that if more had been present they would not have been detected, especially in the 3 whose parents were competent observers. T h e variations a n d the n a t u r a l history of some of the feminine manifestations were interesting. T h e articles of women's dress sought out by the boys included panties, petticoats, dresses, sweaters, high-heeled shoes, hats, jewelry, a n d other adornments, handbags, a n d umbrellas. These were worn or carried as part of ';dressing-up," playing house, going through a mock wedding in which the boy would take the bride's role, etc. This behavior was carried out at first without self-consciousness, a n d the criticism
of other boys was n o t a deterrent. If prohibited, the practices we:re often continued i n a covert a n d furtive fashion, a n d might come out into the open in Halloween dressups or in the taking of girls' parts in school plays. While some boys lost this need, it r e m a i n e d strong in others and its practice c o n t i n u e d into late adolescence. Apparently the association of the articles of clothing with a particular person was not i m p o r t a n t ; clothing belonging to mother, sister, or an u n k n o w n female, or stolen from a store, appeared to be equally satisfactory for meeting the child's needs. T h e mothers often described tile joy their boys exhibited in playing "dress-up," m u c h greater, it seemed, t h a n would have been expected of little girls engaging in such play. O n e boy, 15 years of age, would dress up a n d use lipstick when he was anxious , imagi n i n g he was a lovely lady, slim, a n d about the size of his stepmother; after 'this he would feel relaxed.
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Zuger
December 1966
T a b l e II. S u b s e q u e n t s e x u a l o r i e n t a t i o n i n b o y s w i t h e a r l y f e m i n i n e - t y p e b e h a v i o r
Case first Age no.
seen
Age at onset
Psychotherapy
Age at last followup
Status at follow-up
Comment
Group A 1
7 yr.
2-3 yr.
4 yr., 2-3 yr. 1110.
Claims heterosexual interests Apparent heterosexual 69 sessions, 7 through 10 18 yr. and objectives. Slight fernadjustment years of age. Parents inine gestures. Denies hoseen simultaneously mosexual interests Treated 1 2 ~ to 13 years of age, once weekly. Parents seen
18 yr., At 17 years of age occasional 6 too. feminine gestures. No interest in girls. "Introvert." Has developed interest in sports. At 18 years of age questionable interest in a girl
Apparent heterosexual adjustment
21 yr. Confirmed homosexual. PreAt 13 years of age, fers active role, but takes weekly for 1 year. both. Walk and mannerSome participation of isms of an invert. No mother cross-dressing, etc., since later childhood
Homosexual. ? Invert
Consultations and several interviews
16 yr., Sexually attracted to boys. 4 mo. Asked for an operation to make himself into a girl
Homosexual. Invert. Transvestite
Consultation and 4 in? terviews between 7 (before and 11 years of age 6 yr.)
12 yr., Stopped wearing dresses ex11 too. cept for Halloween. Likes dancing very much. Still clings to mother
Outcome uncertain
7 yr. 5 ~ yr. None, except advice at initial consultation
13 yr., 3-4 yr. 4 mo.
8 yr. i-2 yr.
7 yr.
7 to 8 years of age for 1 year. Again for 5 months when 11 years of age.
13 yr. Continues artistic, exhibition- Probably homosexual istic, effeminate. Dislike for gym
Seen once weekly, 13 to 15 years of age
15 yr. Still prefers to be a woman, cross-dresses. Uses lipstick
Outcome uncertain. Transvestite
16yr. 4yr.
Weekly interviews, 8 months at 16 years of age
17 yr. No interest sexually in girls. In appearance and manner, feminine. Wants to be hairdresser
Homosexual. Invert
16 yr. 4-5 yr.
Consultation and a few 18 yr. Homosexual activity, both interviews at 16 years passive and active roles; prefers passive. Peroxides of age his hair
11 yr., 4 yr. 3 mo.
13yr.
I0
11
15 yr., Feminine gestures and man- Probably homosexual 3 too. nerlsms. No interest in girls. At 12 years of age, wanted to become hairdresser or interior decorator. Had himself excused from gym
?9yr.
17 yr. Puts on sister's clothing. SusSeen 6 to 7 years once 6 yr., picious interest in a boy. weekly for 5 months. 4 too. (before Excused from gym. Writes Again at 16 years once 6 yr.) plays with homosexual weekly for 6 months activity
Homosexual. Probably invert
Probably homosexual. Transvestite
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Number 6
Effeminate behavior in boys
1 1 03
Table II. Cont'd
Case Age first no.
seen
Age at onset
Psychotherapy
Age at last followup
Status at follow-up
Comment
12
5 yr., 2 yr. 7 mo.
Seen biweekly from 6 years to time of follow-up
7 yr., Still continues earlier pracNo improvement in 11 mo. tices, b u t now deviously. symptoms "Swishy" walk. Beginning to be called "sissy" by peers
13
4 yr., 2-3 yr. 3 too.
Seen 14 times from 4 to 6 years of age
6 yr., No cross-dressing (feminine 11 mo. behavior generally more covert). Some interest in boys' play. Likes dressing little sister
No improvement in symptoms. Later outcome uncertain
14
5 yr., 2-3 yr. 10 mo.
7 yr., Only occasional gesturing
Improvement in symptoms. Later outcome uncertain
15
8 yr., 3-4 yr. 7 mo.
16
5 yr., 3-4 yr. 10 mo.
Seen once weekly for several months at 5 to 6 years
1 too.
Seen by social worker at 7 years of age for 1 year once a week
9 yr., No cross-dressing or lipstick; Improvement in symp6 too. other symptoms more or toms. Later outcome less present uncertain
Seen 5 times after consultation
6 yr. Improvement, according to parents
Later outcome uncertain
Group B 23 yr. Attracted to men. No interest Homosexual, nonpracin women. Very passive ticing (?). Masturbation fantasies with males
17
14yr. ? 8 y r .
Seen at long intervals after 14 years of age
18
13 yr.
Seen once weekly at 13 22 yr. Preference for genital contact Homosexual with young boys to 14 years. Residential treatment 16 to 18 years
19
14 yr., ? 8 y r . 8 mo.
20
?
26 yr. Married with children. Voice Homosexual Seen at 14 years for high-pitched. Gestures short time. Residential somewhat feminine. Present school 2 years, then occupation one that genonce or twice a year erally has high percentage of homosexuals
6 yr., ? 10 yr. Seen once weekly for 9 mo. 3 to 4 years from 11 to 14 years of age
15 yr. Attracted to boys
There was often a general preoccupation with the female body and clothing, usually t h e m o t h e r ' s . E v e n t h e v e r y y o u n g ones would comment on what their mothers were w e a r i n g a n d h o w t h e y looked. I n t h e o l d e r o n e s t h e r e p e r s i s t e d a n excessive i n t e r e s t i n clothing, both masculine and feminine. In t h e i r l a t e r p l a t o n i c r e l a t i o n s h i p s w i t h girls, t h e boys o f t e n a d v i s e d t h e m r e g a r d i n g t h e i r clothing.
Homosexual
U s e of lipstick, n a i l p o l i s h a n d p e r f u m e , and preoccupation with their own hair (or t h e i r m o t h e r ' s o r a n o t h e r f e m a l e ' s ) w e r e also e a r l y s y m p t o m s . T h e i n t e r e s t i n h a i r led t o experimenting with their own hair, later to i n c l u d e d y e i n g it, d r e s s i n g t h e h a i r of t h e i r girl f r i e n d s or of t h e i r m o t h e r , a n d o f t e n to c h o o s i n g h a i r d r e s s i n g as a n o c c u p a t i o n . A p r e f e r e n c e f o r p l a y i n g w i t h girls w a s p r e s e n t e v e n w h e n boys of s i m i l a r a g e w e r e
1 I 04
Zuger
available, though some parents chose to explain this tendency as being due to a scarcity of other boys in the neighborhood. Actually, the other boys had different interests and would not play the games or accept the roles assigned to them by the effeminate children. The mothers often described their effeminate boys as "bossy." As will be indicated in a subsequent paper, it is striking that almost without exception these children at an early age had difficulties in playing with other boys. The later relationships these boys had with girls often deluded the parents and others into thinking that they did have girl friends. They could, in fact, be extremely popular with girls in high school because of their interest in dancing and music. Each of the boys in Group A for whom there are data said at one time or another that he wanted to be a girl or to be like "mommy," or asked why he was not born a girl. Some liked to associate closely with other adult women as well as with their own mothers. The feminine gestures included the body carriage, which was noted in one patient as early as 4 to 5 years of age, feminine speech and expressions, "sashaying like a prima donna," strutting, preening, and primping before the mirror, etc. Many of the children were very fond of dancing and liked to watch ballet on television. One child stole a pair of ballet slippers from a store. I n all except possibly one of the patients of Group A, and this was true as well for Group B, there was a lack of interest in competitive sports and in boys' games such as playing with guns. In most instances many unsuccessful attempts had been made, usually by the father, to get the boys interested in sports. As they grew older, the boys disliked gym more and more, and toward adolescence many developed panic at the prospect of undressing in the locker rooms. FOLLOW-UP STUDIES
As these children grew older, follow-up became more difficult. One could be more
December 1966
certain of the outcome when it was homosexual than when it was apparently heterosexual. The initial openess in behavior and expression of preferences were replaced by subterfuge, or the telltale symptoms of effeminacy were suppressed as a confirmed orientation toward homosexuality was taking place. Often enough the individual made no attempt to hide his leanings. When this was not the case, however, his other interests, the choice of an occupation, the dread of attending gym, the group he associated with, or information from home and other sources gave important clues. Nevertheless, in some instances, one could come to only a presumptive conclusion as to the sexual orientation. In Table I I the results of the follow-up studies done in 1964-1965 are presented. Ten of the 16 boys of Group A were then over 13 years of age, and 6 of these were 17 years of age or older. One was almost 13 and the remaining 5 were less than 10 years of age. Of the 10 older boys, 2 were making apparent heterosexual adjustments, 4 were confirmed homosexuals, 3 were probably homosexuals~ and sexual status in the remaining one (Case 8) was uncertain. Even in the cases of the 2 boys considered to be making heterosexual adjustments, some doubts remained. One of the boys (Case 1), when seen at 18 years of age, claimed he was in love with a girl in whom he was physically interested, and that he wanted to get married. H e said he was having night emissions, sometimes dreaming about a girl, sometimes not. He denied homosexual interests. His voice was masculine though his gestures were somewhat effeminate. His parents were not worried about him. H e planned to become a teacher like his father. In drawing a person he did not know whether he was drawing a boy or a girl, though when requested to give the person a name, it was a man's name. The figure had large eyes with prominent eyelashes, a sign considered by some 4 to be indicative of homosexuality. The second boy (Case 3), whose development also seemed to be going in a heterosexual direction, was the one not seen directly but
Volume 69 Number 6
Effeminate behavior in boys
through his parents. At 17 years of age he still had some feminine gestures, showed no interest in girls, and was called an "introvert," though he had developed an interest in sports. At 18 years of age he showed an interest in a girl whom he later dropped; she had pushed the relationship in a sexual direction. In all other ways, according to his parents, nothing effeminate about him was noted except for an occasional slipping into high falsetto voice. The 4 considered to be confirmed homosexuals included 3 who were pretty much that way when first seen at 13, 15, and 16 years of age, respectively. The fourth was first seen at 8 years of age. Of the 6 patients under 13 years of age, the oldest one presented no outward signs of effeminacy though he continued to dress in women's clothing on Halloween. He was very fond of dancing, and was still very much attached to his mother. Of the youngest 5 patients, 2 showed some improvement in overt symptoms, 2 did not, and not enough time had elapsed since the fifth was first seen to expect much change. No conclusion can be drawn as to the final outcome in any of these children. In Group B the outcome wa% of course, predetermined in that the members were self-selected on the basis of homosexuality. TREATMENT
AND
OUTCOME
As may be seen from Table II, the amount of psychotherapy received and the age when it was initiated varied considerably. All parents were given guidance which it was thought would lead to a better masculine identification. They were advised to discourage effeminate activities and to reinforce masculine ones. The boy whose treatment was longest and was begun moderately early (Case 1) was one of the 2 who made an apparent heterosexual adjustment. The other boy (Case 3) was not seen, and guidance was given to the parents only. Of the group of 3 who were probably homosexual, one (Case 7) received more than one year of treatment and 2 (Cases 2
1 1 05
and 11) less than one year before their thirteenth birthdays. Obviously, in these cases, the amount of treatment at the ages given was not very effective. In general, the older boys in Group A showed no interest in receiving treatment and those already homosexually inclined did not want to change. This apparently was not the case for those of Group B, for 3 of them disclosed their homosexuality because they wanted help. It appears that with guidance or treatment some of the younger boys could be induced to suppress their effeminate behavior, though, as indicated, it often came out in covert and devious ways..What the eventual effect of such, suppression may be on the potential for homosexuality cannot be predicted. DISCUSSION
The clinical phenomenon dealt with in this paper adds up to something other than transvestism. Although prominent early in the children of Group A, the desire for wearing feminine things is only one part of a larger feminine-type behavior pattern. In the 2 patients with an apparent heterosexual adjustment, transvestism has no.t seemed to persist. In those boys for whom the outcome has been a homosexual one, unusual habits of dress are not always seen. On the other h a n d , in one of the older patients (Case 8), transvestism without a homosexual orientation may yet be the end result. In the younger children, the desire to play house with little gifts may be as compelling an urge as the wearing of feminine clothing. It is probably this total feminine direction of the interests of these children which brings them closer to the mother, and not the other way around. In the clinical experience of the writer, few children are brought to a psychiatric clinic for cross-dressing only. One cannot exclude the possibility that only those with more obvious feminine manifestations or with other behavioral symptoms are being seen. An attempt is now being made to obtain some idea of the incidence of feminine-type
1 1 06
Zuger
behavior in a random population of 7 to 8 year old boys. Preliminary data suggest that it is not at all common. Is there a justification for separating the 20 children into two groups? T h e children of Group B had few feminine symptoms, and the onset appeared to come later. There was no definite evidence of cross-dressing. More striking, and in contrast to the children of Group A, was the self-disclosure of homosexual leanings and the expression of a desire for help. The feminine orientation of the children of Group A seemed to be so much a part of the self that there was no desire for change. It may well be that Group B represents a larger group in the general population, and that only those who have other behavioral problems are seen. This group would thus represent a different type of homosexuality than the generally invert type encountered in the children from Group A. As they mature, both of these groups would differ from the group of boys who casually engage in homosexual activity, much or little, and for reasons other than that they are basically homosexual. Holemon and Winokur a defined three such groups retrospectively among prisoners with homosexual problems. The outcome of the patients in this study differs from that of Bender 2 but is similar to that reported by Green and Money? Bender dealt with psychotic and delinquent patients; in 4 of her 9 cases there is clear mention of the outcome as to sexual adjustment, and only one was effeminate homo:sexual. In the Green and Money patients, the symptoms of feminine-type behavior (referred to by them as cross-gender identity) tended to persist and were given up only gradually. Five of their patients were 14 years of age or older at the time of their last follow-up, and 3 of these could be considered as pretty definitely homosexual. This outcome is not unlike that reported in the present study. As one looks at this symptom complex, one is struck by the completeness of the feminine identification and how full sprung
December 1966
seems its development from the outset. There is a strikingly exaggerated feminine quality to it and its expression appears to be compulsive. Its most important characteristic may be its early appearance. Feminine behavior beginning early in childhood would seem to constitute a clinical entity, possibly carrying with it serious consequences for future sexual identification. SUMMARY
Two groups of boys were studied. The larger group of 16 boys showed symptoms of feminine-type behavior from very early childhood, including the wearing of articles of women's dress, the use of lipstick, a preference for playing with girls, the desire to be female, employing feminine gestures~ playing with dolls, and showing no interest in (or exhibiting an actual dislike of) boys' games and sports. Ten of these children at the time of follow-up were 13 years of age or older. Of these, 4 were homosexuals, 3 were probably homosexuals, 2 were apparently heterosexual, and in the remaining 1 the outcome was uncertain. It is thought that the symptoms shown by these children constitute a clinical entity, in the outcome of which the sexual identification of the child is at issue. The other group of 4 children showed few of the symptoms mentioned above, and differed in other ways, but later themselves indicated that they were homosexual. The question is raised as to whether this may constitute a different type of homosexuality. It was difficult to evaluate the results of psychologic treatment in the first group, though guidance of parents can apparently effect a suppression of the overt symptoms in some of the children. Dr. Bernard Benjamin, Brooklyn, New York, has made many valuable suggestions which have added to the clarity of the paper. Mrs. Thirza Howard, Mrs. Patsy Taylor, and Mrs. Margie Anderson, social workers in the Department of Psychiatry at the Greenwich Hospital at various times, have helped in the follow-up of the cases. Miss Marlene Van Slingerlandt, administrative assistant, has given valuable aid in many ways.
Volume 69 Number 6
REFERENCES
1. Green, R., and Money, J.: Prepubertal morphologically normal boys demonstrating signs of cross-gender identity, read at the annual meeting of the American Orthopsychiatric Association, Chicago, Ill., 1964. 2. Bender, L.: A Dynamic Psychopathology of Childhood, Springfield, Illinois, 1954, Charles C Thomas, Publisher, p. 152.
Effeminate behavior in boys
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3. Holemon, R. E., and Winokur, G.: Effeminate homosexuality: A disease of childhood, Am. J. Orthopsychiat. 35: 48, 1965. 4. Levy, S.: Figure drawing as a projective test, in Abt, L. E., and Bellak, L., editors: Projective Psychology, New York, 1950, Alfred A. Knopf, Inc., See also Hammer, Emanuel: The Clinical Application of Projective Drawings, Springfield, Illinois, 1955, Charles C Thomas, Publisher.