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Effeminate behavior present in boys from childhood: Ten additional years of follow-up
Effeminate Behavior Present in Boys From Childhood: Ten Additional Years of Follow-Up Bernard
Zuger
T
HIS IS AN ACCOUNT of the results of IO years of further follow-up of 16 boys with early effeminate behavior first reported in 1966.’ The longer follow-up has yielded more definitive data on outcome as to homosexuality as well as a better delineation of the natural history of the syndrome. MATERIALS
AND METHODS
The sources of the cases, reasons for original referral, and details of early symptoms are given in the initial report (four additional cases were separated out at that time because they differed in certain respects from the others: follow-up on these will be reported at another time).’ The early manifestations of effeminacy in these children, as indicated in Table I. included dressing in women’s clothes, using female adornments, and expressing a desire to have been born a girl. The boys often assumed the gesturing and posturing of females. displaying no interest in or actually disliking boys’ games and sports. These symptoms have been shown to be less common, fewer in number. of shorter duration. and significantly different in other aspects when they occurred in noneffeminate children.‘.:’ Ten of the children were first seen at 8 years of age or younger, 2 ds ’ early as 4 years-3 months of age. Five other children were first seen between I I and 16 years of age. but good early histories were obtained from the parents of all of these children except one and. with the permission of the parents. additional data on previous behavior were obtained for several children from the records of schools and social agencies. As for the remaining child, the parents were seen when he was 7 years old and at various intervals thereafter, but he himself was not seen until he was 20 years of age. His early symptoms were classically those of other effeminate boys. Follow-up was frequent for most of the cases. though at varying intervals for the different children. and the results recorded represent this cumulative experience. The procedure followed included interviews with parents and where relevant, with school counselors. psychologists and other physicians. Even when the boy was strongly suspected of being homosexual. the question could not always be put directly to him, lest the suggestion of what was being investigated be possibly traumatic. Disclosure came in various ways: from one boy. in a pathetic letter to his family when he was about 9 years of age. from another in an outburst of crying before his mother that he was “queer”. and from a third through his obvious feminine ways. continued preference for cross-dressing, and expressed intent to seek a sex change. Two boys admitted their homosexuality when caught involving others in their sex activities. Another boy, needing help for his drinking, admitted his predilection to his physician. In the case of two boys, their mannerisms, dyeing of their hair, dress, and relationship with close friends (e.g.. one boy wore one of a pair of earrings while his roommate, a known homosexual, wore the other one on the opposite ear) made the diagnosis fairly certain without the need for self-disclosure. In Table I. the age of each boy is given when last seen by me as well as when the latest data about him were obtained from others. Where appearance. dress. mannerisms. and interests generally pointed to a homosexual orienta-
Comprehensive
Psychiatry,
Vol. 19, No. 4 (July/August),
1978
363
6
7
1311
3 mo
llyr
97
4
+
+
ND
+
ND
+
ND
+
knew
6
+
+
+ wanted
+
?
before
school
dresses
exliked dancing
outcome
disliked
ex-
Transvestite?
and used lipstick;
to be a woman;
homosexual
uncertain;
cross-dressed
At 15 still preferred
probably
gym.
effeminate;
“artistic,”
uncertain At 13 continued
outcome
very much; still clung to mother;
cept at Halloween;
wearing
into a girl At 13 stopped
himself
been a joy to him”
dress-
etc.. since later childhood
hibitionistic,
said “My
had
mannerisms
Sexually attracted to boys; at 16 asked for an operation to change
ing table has always
Mother
a girl
mother
to be a girl;
said he always
wanted
Mother
of hair, ballet
yr of age; liked braiding
dressed
like a girl, 2-3
Came to nursery
of an invert;
be-
no cross-dressing.
takes both; walkand
from
active role but
yr of age; hated gym
prefers
homosexual
adjustment Confirmed
sexually to boys since 9
since
heterosexual
in
in a girl at
gestures;
ex-
at 15
some interests
ginning;
hair curled
feminine
2 yr of age; Attracted
Wanted
present; probably
interest
apparent
16; “introvert”;
questionable sports;
in
ing
interested
homosexual. At 17 occasional
gym;
gestures
cused from
feminine
hair-
decorator;
interior
dresser,
adjust-
interests;
to become
heterosexual
homosexual
At 12 wanted
ment
apparent
denied
inter-
Behavior
gestures;
heterosexual
Observations
ests; slight feminine
At 16 claimed
Interim
what a bride was wear-
7yr
+
+
ND
+
ND
being a
his hair to be like
a girl’s;
Wanted
mommy
in wom-
to cut off his
interest
an’s body,
penis;
Threatened
etc
their jewelry,
clothing,
with
play
liked to be with
adult females,
role;
to play mother’s
wanted
Other
of Boys Wiih Early Feminine-type
house taking
Always
4 mo
ND
ND
ND
Games
Boys’
6
+
+
+
+
+
+
ing
Play-
to
6
l-2
+
+
+
ND
+
ND
O$
+
+
NDt
0
+
Female
tures
Ges-
mates
stick
to be
Play-
Lip-
Doll
athy
Antip-
5
4 mo
13 yr
4
3-4
5%
7
3
+
+
2-3
4 v 3 mo
2
ing
+’
7
1
onset
Dress
inine
Desire
Girl
ing
inine
Fem-
Prefer
Wear-
Fem-
2-3
Seen
at
First
Case
Age (yr)
Age (yr)
Early Symptoms
Table 1. Later Sexual Orientation
16
29
29
21
29
Seen
Age (vr) Last
24
25
21
26
26
Others
from
Data
Latest
Age (vr)
Other Findings
sexual?
trans-
Transvestite;
Homosexual
Homosexual
Transsexual
Homosexual
Married
children
Work with retarded
suicide
for sex
Art student
change;
paring
Drug addict;
pre-
addict; attempt
drug suicide
Musician;
student
S%llal
unaggres-
social
sive; sociology
Gentle,
worker
Effeminate;
teacher
hetero
Probably
Homosexual
Heterosexual
Orientation
Not effeminate;
Follow-up
SBX
Present
6yr
11
?
4-5
5yr
dead;
complete
history
old; early data from
+
T
-
+
not available..
of symptom.
+
+
+
+
+
+
+
NO
Mother
absence
4
+
+
+
+
ND
+
+
i
ND
ND
+
of symptom.
+
+
+
-f
+
ND
+
+
5 Patient not seen until 20 years
jlndicates
t ND, no data.
presence
3-4
5 Yr 10 mo
16
‘Indicates
3-4
2-3
2
2
6 Yr 7 mo
10 mo
5w
2 mo
4yr
7 ma
15
14
13
12
16
IO
4
4 mo before 6
16
9
parents
+
+
+
+
+
0
ND
ND
*
+
+
+
+
+
+
ND
+
!
+
+
+
ND
f dresser
washes
tea and
to be a hair-
at gymnastics
Liked to use perfume; good
in
over shoulders
scarf and
Has wanted dresser
wears;
and swinging
like a woman
sweater
Wearing
of hips
strutting
mother
as to
for dancing;
way
dancing
very observant
“Passion”
a girlish
what
.”
to bake and dust
like mother;
Wanted
for the baby High-pitched voice
irons clothes, and cares
parties,
he organizes
heels and old petticoat
interest
more
symptoms according
ges-
use; other
no cross-
in symp
feminine
to parents
in symptom%
or less present
or llpstick
dressing
At 6 improvement
6 months
improvement
At 3 years
tools
turing;
by
more covert)
little sister
At 7 only occasional
but be-
(feminine
“sissy”
walk;
in boys games;
generally
liked dressing
some
behavior
At 7 no cross-dressing
peers
to be called
deviously; ginning
earlier ,‘swishy”
At 6 continued
homosex-
homosex-
from
practices,
probably
ual, transvestite
plays with
ual activity;
his hair
suspicious
in a boy; excused
gym; wrote
interest
Put on sister’s clothing;
ferred passive; peroxided
will dress in an old hat,
both
roles, pre-
activity,
the doll corners
At 16 homosexual
to be hair-
passive and active
notes at
wanted
age 5; “likes to play in
From teacher’s
feminine;
fin girls; in
and manner
At 17 no interest sexually
to mother
to “fuss” appearance
wanted
with his hair. according
Always
16
17
17
18
24
19
26
16
20
17
17
18
28
of depres-
em-
uncertain
Homosexual
sexual Homosexual
homo-
Probably
Actor
Art student
art
design-
Plans to studv
“theatre”
ing and
clothing
on interests include
occasion;
fain
in attire
female
Still dresses ““Cer-
Outcome
acting
biology, in all sex; outcome
ests -teaching,
inter-
attempt Effeminate?
suicide
ployment;
regular
no
Tom”; psychotic;
“Peeping
sion; hairdresser
Periods
gro-
suicide
cery clerk
attempts;
Alcoholic;
disinterest
Professes
sexual
homo-
Probably
Homosexual
Homosexual
$I
Cii z
z
; zz
BERNARD
366
ZUGER
tion in the absence of self-disclosure or outside confirmation of the fact. the outcome was considered as “probably homosexual.” It was considered “uncertain” when no clear evidence was present of either a homosexual or heterosexual orientation.
RESULTS
The sexual status in each case at the time of the last follow-up is noted in Table I and may be compared with the behavioral pattern manifested at varying times during the period of observation. The overall outcome for the entire group is summarized in Table 2. The age of the youngest patient at the present follow-up was 16 years, the oldest 29, and the mean age was 22.7k4.5 years. The time since first visit varied from 10 to 22 years, except in the instance of one case lost to follow-up after 3 years. For the whole group the mean elapsed time since first visit was 14.0t4.9 years. It may be seen from the tables that the sexual outcome in these 16 cases included heterosexuality, transvestism, homosexuality, and transsexualism. This varied outcome was not obviously related to the initial symptoms, either in age of onset or extent of manifestations. The child who later became a transsexual (case 5) preferred cross-dressing as early as l-2 years of age, but other cases, with different outcomes, manifested similar symptoms at about the same age. While some variation in symptomatology was bound to occur, dependent on such factors as how observant the parent was and the availability of the means of expression (e.g.. mother wearing lipstick), it was remarkably similar for all of the boys at onset regardless of later outcome. What distinguished the boy who became a transsexual and the one who became a transvestite (case 8) from the others was the persistence of the cross-dressing, as opposed to the occasional, sporadic resort to the practice by others. In general, these results parallel those of 10 years earlier in the older children, but they are more definitive for most of the younger ones. For the group as a whole, a deviant outcome was present in 12 (75%c) of the cases, a figure that may possibly be higher when the outcomes in the two uncertain cases become clearer. If the 11 cases seen at 8 years of age or younger are considered as a group, 7 (64%) became deviant. The category with the largest number of cases (IO-63%) was that of straightforward homosexuality. One patient was a classic transsexual, seeking sex change, and another was a transvestite. The latter had expressed his Table 2. Summary
of Later Sex Orientation Sex Orientation
Heterosexual Probably heterosexual Homosexual Probably homosexual Transsexual Transvestite Uncertain Total
of Boys With Early Feminine-type Number 1 1
8 2 1 1 2 16
Behavior
EFFEMINISM
IN BOYS
367
preference to be a woman as late as 1.5years of age, although he subsequently married. At the last follow-up, those who became homosexual were not exaggeratedly manneristic, except in three cases. Preference was generally for the passive sex role, although this varied to complement that of the partner and was often interchangeable. Choice of occupation favored the arts. Two were in art school and another was planning to attend art school. One was a musician. Three others were interested in becoming actors, one among them also considering architecture and interior decorating as possible professions. Two were engaged in some aspect of social work. One was a hairdresser, another a grocery clerk, and the work of one was not known. Of the two who developed heterosexually, one became a teacher and the other a sociologist. It should also be noted (Table I) that 4 of the I6 patients attempted suicide, one of them succeeding. DISCUSSION
This long-term prospective follow-up of boys with early and persistent effeminate behavior provides a beginning for a quantitative basis for estimating the probability of a deviant outcome in an individual with such early symptoms. If the five boys seen for the first time after they were I1 years of age are excluded because their sex orientation may already have been sufficiently fixed to produce a weighted bias, the ratio in children before the age of 9 years would be approximately 2 to I in favor of a deviant outcome (uncertain cases being included with the heterosexual ones). If the total group is taken, to make comparison possible with the results of other studies that will be discussed, the ratio of deviant to heterosexual outcome would be 3 to I. This is, of course, a small number of cases, and these figures may well have to be revised: it nevertheless indicates the seriousness of early effeminate behavior. as has been pointed out by 0thers.l Comparison with outcomes in other studies of early effeminate behavior is difficult to make because of differences in selection of cases and of ages when first seen and at follow-up. Bakwin” reported on 10 effeminate boys first seen when they were 5-17 years of age and at various ages later: he found 5 to be homosexual, 2 heterosexual, and the remaining 3 of uncertain sexual orientation. In a follow-up study by Lebovitz” of I6 cases, which included 8 cases with reported onsets at ages IO-16 years, 6 of the I6 manifested deviant sexual behavior: 3 were transsexuals, 2 were homosexuals, 1 was a transvestite, 4 were probably heterosexual, and the outcome in the remaining 6 was uncertain. some continuing to show remnants of effeminate symptoms. Green and Money’ and Green8 saw 5 boys at 5-10 years of age and again 12-15 years later and found 3 to be homosexual, one probably homosexual. and the fifth of uncertain sexual orientation. The outcome in deviant behavior in the above three studies is thus seen to have varied, approximately, from 40% to 80%. If one considers together the 3 1 cases of these authors, at least one-half of them later developed deviant behavior. This is somewhat less than the figure of 607~ (7 of I I)
368
BERNARD
ZUGER
reported here for the group seen at an early age, and is much less than the overall figure of 75% (I2 of 16) found if all the cases are grouped together. The particular form of deviant behavior that ultimately appears is not readily predictable from a consideration of the symptoms of child effeminacy. The symptoms noted here were also seen early by Paulyg to be present in those who later became transsexuals. Presumably, if these symptoms-cross-dressing, feminine gestures, wanting to be a girl, etc .-continued unabated in all of the children, they would all end up presenting the clinical picture of transsexualism, which, however, generally occurs in only a fraction of cases. What seems to be happening, as one follows these children, is a kind of “decay” or burning out of these symptoms, completely in some, partially in others, and not at all in a few. There then results the spectrum of conditions we actually see develop even in such small series of cases as the present one and that of Lebovitz,6 viz., heterosexuality, transvestism, homosexuality, and transsexualism, as well as intermediate forms. Such a view would shift emphasis from postnatal environmental factors thought to generate these conditions, as in the studies of Bieber et al.‘O and Stoller,ll to prenatal and possibly postnatal events involving hormonal factors. Such speculation would be consistent with the massive amount of experimental data on the prenatal and/or postnatal hormonal sexualization of the brain in animals (reviewed by Phoenix et al.lZ and Goy13). A possible indication that prenatal developmental factors may be important in early persistent effeminate behavior was the finding by the author14 of evidence of prenatal disturbances manifested by increased rates of congenital inguinal hernia, enuresis, testicular maldescent, and possibly speech impairments in such children. However, not all the children were so affected. The findings obviously need confirmation. More needs to be said on the type of homosexuality that develops in these children. Clinically, it is like that commonly seen in practice and diagnosed as such. It is not marked behaviorally in all cases by undue effeminacy. and, in sex relations, by a passive role. Choice of occupation was that frequently associated with homosexuals. Saghir and Robins I5 found that two-thirds of their group of non-hospitalized homosexuals gave a history of what resembles early effeminate behavior. In a random group of 20 adult male homosexuals seen clinically by the author,“j more than three-fourths of them presented histories of early effeminate behavior. We are therefore dealing, in the syndrome of effeminate behavior in early childhood, with what may well be the commonest form of onset of homosexuality. SUMMARY
This is a IO-year further follow-up of 16 boys with early effeminate behavior, a group of cases first reported in 1966. The average age at this follow-up was 22 years, and the average number of years elapsed since first seen was 14 years. Twelve of the 16 cases developed some form of deviant behaviorhomosexuality in 10, transvestism in 1, and transsexualism in 1. Two of the cases were heterosexually oriented, and in the remaining two, no decision could be reached as to their sexual orientation.
EFFEMINISM
369
IN BOYS
ACKNOWLEDGMENT Thirza Howard, M.S.W., formerly with the Greenwich Hospital. helped in the follow-up of the cases. Dr. Bernard Benjamin, Brooklyn. N.Y.. critically read the manuscript and made valuable suggestions.
REFERENCES I. Zuger B: Effeminate behavior present in boys from early childhood: I. The clinical syndrome and follow-up studies. J Pediatr 69: 1098-l 107, 1966 2. Zuger B, Taylor P: Effeminate behavior present in boys from early childhood: Il. Comparison with similar symptoms in noneffeminate boys. Pediatrics 44:375-380, 1969 3. Green R: One-hundred ten feminine and masculine boys: Behavioral contrasts and demographic similarities. Arch Sex Behav 5:425-446. 1976 4. Stoller RJ: “It’s only a phase.” JAMA 201:98. 1967 5. Bakwin H: Deviant gender role behavior in children: Relation to homosexuality. Pediatrics 41:620-629, 1968 6. Lebovitz PS: Feminine behavior in boys: Aspects .of its outcome. Am J Psychiatry 1’8: 103-109. I972 7. Green R. Money J: Incongruous gender role: Nongenital manifestations in prepubertal boys. J Nerv Ment Dis 130:160-168, 1960 8. Green R: Sexual Identity Conflict in Children and Adults. New York. Basic Books, 1974, p 243
9. Pauly IB: The current status of the change of sex operation. J Nerv Ment Dis 147:460-47 I. I968 IO. Bieber I. Dain JD. Dince PR. et al: Homosexuality: A Psychoanalytic Study. New York. Basic Books. 1962 I I. Staller RJ: Male childhood transsexualism. J Am Acad Child Psychiatry 7: lY3209, 1968 I?. Phoenix CH. Goy RW. Young WC, et al: Sexual behavior: General aspects. in Martini L, Ganong WF teds): Neuroendocrinology. New York. Academic, 1967. p 163 Hormonally induced RW: 13. Goy pseudohermaphroditism and behavior, in Motulsky AG, Lentz W (eds): Birth Defects. Proceedings of the Fourth International Conference. Vienna. Austria, 1973. New York. American Elsevier. 1974. p I55 14. Zuger B: Effeminate behavior in boys. Parental age and other factors. Arch Gen Psychiatry 30: 173-177, 1974 IS. Saghir MT, Robins E: Male and Female Homosexuality: A Comprehensive Investigation. Baltimore, Williams & Wilkins, 1973. p I8 16. Zuger B: Unpublished data
Zuger
T
HIS IS AN ACCOUNT of the results of IO years of further follow-up of 16 boys with early effeminate behavior first reported in 1966.’ The longer follow-up has yielded more definitive data on outcome as to homosexuality as well as a better delineation of the natural history of the syndrome. MATERIALS
AND METHODS
The sources of the cases, reasons for original referral, and details of early symptoms are given in the initial report (four additional cases were separated out at that time because they differed in certain respects from the others: follow-up on these will be reported at another time).’ The early manifestations of effeminacy in these children, as indicated in Table I. included dressing in women’s clothes, using female adornments, and expressing a desire to have been born a girl. The boys often assumed the gesturing and posturing of females. displaying no interest in or actually disliking boys’ games and sports. These symptoms have been shown to be less common, fewer in number. of shorter duration. and significantly different in other aspects when they occurred in noneffeminate children.‘.:’ Ten of the children were first seen at 8 years of age or younger, 2 ds ’ early as 4 years-3 months of age. Five other children were first seen between I I and 16 years of age. but good early histories were obtained from the parents of all of these children except one and. with the permission of the parents. additional data on previous behavior were obtained for several children from the records of schools and social agencies. As for the remaining child, the parents were seen when he was 7 years old and at various intervals thereafter, but he himself was not seen until he was 20 years of age. His early symptoms were classically those of other effeminate boys. Follow-up was frequent for most of the cases. though at varying intervals for the different children. and the results recorded represent this cumulative experience. The procedure followed included interviews with parents and where relevant, with school counselors. psychologists and other physicians. Even when the boy was strongly suspected of being homosexual. the question could not always be put directly to him, lest the suggestion of what was being investigated be possibly traumatic. Disclosure came in various ways: from one boy. in a pathetic letter to his family when he was about 9 years of age. from another in an outburst of crying before his mother that he was “queer”. and from a third through his obvious feminine ways. continued preference for cross-dressing, and expressed intent to seek a sex change. Two boys admitted their homosexuality when caught involving others in their sex activities. Another boy, needing help for his drinking, admitted his predilection to his physician. In the case of two boys, their mannerisms, dyeing of their hair, dress, and relationship with close friends (e.g.. one boy wore one of a pair of earrings while his roommate, a known homosexual, wore the other one on the opposite ear) made the diagnosis fairly certain without the need for self-disclosure. In Table I. the age of each boy is given when last seen by me as well as when the latest data about him were obtained from others. Where appearance. dress. mannerisms. and interests generally pointed to a homosexual orienta-
Comprehensive
Psychiatry,
Vol. 19, No. 4 (July/August),
1978
363
6
7
1311
3 mo
llyr
97
4
+
+
ND
+
ND
+
ND
+
knew
6
+
+
+ wanted
+
?
before
school
dresses
exliked dancing
outcome
disliked
ex-
Transvestite?
and used lipstick;
to be a woman;
homosexual
uncertain;
cross-dressed
At 15 still preferred
probably
gym.
effeminate;
“artistic,”
uncertain At 13 continued
outcome
very much; still clung to mother;
cept at Halloween;
wearing
into a girl At 13 stopped
himself
been a joy to him”
dress-
etc.. since later childhood
hibitionistic,
said “My
had
mannerisms
Sexually attracted to boys; at 16 asked for an operation to change
ing table has always
Mother
a girl
mother
to be a girl;
said he always
wanted
Mother
of hair, ballet
yr of age; liked braiding
dressed
like a girl, 2-3
Came to nursery
of an invert;
be-
no cross-dressing.
takes both; walkand
from
active role but
yr of age; hated gym
prefers
homosexual
adjustment Confirmed
sexually to boys since 9
since
heterosexual
in
in a girl at
gestures;
ex-
at 15
some interests
ginning;
hair curled
feminine
2 yr of age; Attracted
Wanted
present; probably
interest
apparent
16; “introvert”;
questionable sports;
in
ing
interested
homosexual. At 17 occasional
gym;
gestures
cused from
feminine
hair-
decorator;
interior
dresser,
adjust-
interests;
to become
heterosexual
homosexual
At 12 wanted
ment
apparent
denied
inter-
Behavior
gestures;
heterosexual
Observations
ests; slight feminine
At 16 claimed
Interim
what a bride was wear-
7yr
+
+
ND
+
ND
being a
his hair to be like
a girl’s;
Wanted
mommy
in wom-
to cut off his
interest
an’s body,
penis;
Threatened
etc
their jewelry,
clothing,
with
play
liked to be with
adult females,
role;
to play mother’s
wanted
Other
of Boys Wiih Early Feminine-type
house taking
Always
4 mo
ND
ND
ND
Games
Boys’
6
+
+
+
+
+
+
ing
Play-
to
6
l-2
+
+
+
ND
+
ND
O$
+
+
NDt
0
+
Female
tures
Ges-
mates
stick
to be
Play-
Lip-
Doll
athy
Antip-
5
4 mo
13 yr
4
3-4
5%
7
3
+
+
2-3
4 v 3 mo
2
ing
+’
7
1
onset
Dress
inine
Desire
Girl
ing
inine
Fem-
Prefer
Wear-
Fem-
2-3
Seen
at
First
Case
Age (yr)
Age (yr)
Early Symptoms
Table 1. Later Sexual Orientation
16
29
29
21
29
Seen
Age (vr) Last
24
25
21
26
26
Others
from
Data
Latest
Age (vr)
Other Findings
sexual?
trans-
Transvestite;
Homosexual
Homosexual
Transsexual
Homosexual
Married
children
Work with retarded
suicide
for sex
Art student
change;
paring
Drug addict;
pre-
addict; attempt
drug suicide
Musician;
student
S%llal
unaggres-
social
sive; sociology
Gentle,
worker
Effeminate;
teacher
hetero
Probably
Homosexual
Heterosexual
Orientation
Not effeminate;
Follow-up
SBX
Present
6yr
11
?
4-5
5yr
dead;
complete
history
old; early data from
+
T
-
+
not available..
of symptom.
+
+
+
+
+
+
+
NO
Mother
absence
4
+
+
+
+
ND
+
+
i
ND
ND
+
of symptom.
+
+
+
-f
+
ND
+
+
5 Patient not seen until 20 years
jlndicates
t ND, no data.
presence
3-4
5 Yr 10 mo
16
‘Indicates
3-4
2-3
2
2
6 Yr 7 mo
10 mo
5w
2 mo
4yr
7 ma
15
14
13
12
16
IO
4
4 mo before 6
16
9
parents
+
+
+
+
+
0
ND
ND
*
+
+
+
+
+
+
ND
+
!
+
+
+
ND
f dresser
washes
tea and
to be a hair-
at gymnastics
Liked to use perfume; good
in
over shoulders
scarf and
Has wanted dresser
wears;
and swinging
like a woman
sweater
Wearing
of hips
strutting
mother
as to
for dancing;
way
dancing
very observant
“Passion”
a girlish
what
.”
to bake and dust
like mother;
Wanted
for the baby High-pitched voice
irons clothes, and cares
parties,
he organizes
heels and old petticoat
interest
more
symptoms according
ges-
use; other
no cross-
in symp
feminine
to parents
in symptom%
or less present
or llpstick
dressing
At 6 improvement
6 months
improvement
At 3 years
tools
turing;
by
more covert)
little sister
At 7 only occasional
but be-
(feminine
“sissy”
walk;
in boys games;
generally
liked dressing
some
behavior
At 7 no cross-dressing
peers
to be called
deviously; ginning
earlier ,‘swishy”
At 6 continued
homosex-
homosex-
from
practices,
probably
ual, transvestite
plays with
ual activity;
his hair
suspicious
in a boy; excused
gym; wrote
interest
Put on sister’s clothing;
ferred passive; peroxided
will dress in an old hat,
both
roles, pre-
activity,
the doll corners
At 16 homosexual
to be hair-
passive and active
notes at
wanted
age 5; “likes to play in
From teacher’s
feminine;
fin girls; in
and manner
At 17 no interest sexually
to mother
to “fuss” appearance
wanted
with his hair. according
Always
16
17
17
18
24
19
26
16
20
17
17
18
28
of depres-
em-
uncertain
Homosexual
sexual Homosexual
homo-
Probably
Actor
Art student
art
design-
Plans to studv
“theatre”
ing and
clothing
on interests include
occasion;
fain
in attire
female
Still dresses ““Cer-
Outcome
acting
biology, in all sex; outcome
ests -teaching,
inter-
attempt Effeminate?
suicide
ployment;
regular
no
Tom”; psychotic;
“Peeping
sion; hairdresser
Periods
gro-
suicide
cery clerk
attempts;
Alcoholic;
disinterest
Professes
sexual
homo-
Probably
Homosexual
Homosexual
$I
Cii z
z
; zz
BERNARD
366
ZUGER
tion in the absence of self-disclosure or outside confirmation of the fact. the outcome was considered as “probably homosexual.” It was considered “uncertain” when no clear evidence was present of either a homosexual or heterosexual orientation.
RESULTS
The sexual status in each case at the time of the last follow-up is noted in Table I and may be compared with the behavioral pattern manifested at varying times during the period of observation. The overall outcome for the entire group is summarized in Table 2. The age of the youngest patient at the present follow-up was 16 years, the oldest 29, and the mean age was 22.7k4.5 years. The time since first visit varied from 10 to 22 years, except in the instance of one case lost to follow-up after 3 years. For the whole group the mean elapsed time since first visit was 14.0t4.9 years. It may be seen from the tables that the sexual outcome in these 16 cases included heterosexuality, transvestism, homosexuality, and transsexualism. This varied outcome was not obviously related to the initial symptoms, either in age of onset or extent of manifestations. The child who later became a transsexual (case 5) preferred cross-dressing as early as l-2 years of age, but other cases, with different outcomes, manifested similar symptoms at about the same age. While some variation in symptomatology was bound to occur, dependent on such factors as how observant the parent was and the availability of the means of expression (e.g.. mother wearing lipstick), it was remarkably similar for all of the boys at onset regardless of later outcome. What distinguished the boy who became a transsexual and the one who became a transvestite (case 8) from the others was the persistence of the cross-dressing, as opposed to the occasional, sporadic resort to the practice by others. In general, these results parallel those of 10 years earlier in the older children, but they are more definitive for most of the younger ones. For the group as a whole, a deviant outcome was present in 12 (75%c) of the cases, a figure that may possibly be higher when the outcomes in the two uncertain cases become clearer. If the 11 cases seen at 8 years of age or younger are considered as a group, 7 (64%) became deviant. The category with the largest number of cases (IO-63%) was that of straightforward homosexuality. One patient was a classic transsexual, seeking sex change, and another was a transvestite. The latter had expressed his Table 2. Summary
of Later Sex Orientation Sex Orientation
Heterosexual Probably heterosexual Homosexual Probably homosexual Transsexual Transvestite Uncertain Total
of Boys With Early Feminine-type Number 1 1
8 2 1 1 2 16
Behavior
EFFEMINISM
IN BOYS
367
preference to be a woman as late as 1.5years of age, although he subsequently married. At the last follow-up, those who became homosexual were not exaggeratedly manneristic, except in three cases. Preference was generally for the passive sex role, although this varied to complement that of the partner and was often interchangeable. Choice of occupation favored the arts. Two were in art school and another was planning to attend art school. One was a musician. Three others were interested in becoming actors, one among them also considering architecture and interior decorating as possible professions. Two were engaged in some aspect of social work. One was a hairdresser, another a grocery clerk, and the work of one was not known. Of the two who developed heterosexually, one became a teacher and the other a sociologist. It should also be noted (Table I) that 4 of the I6 patients attempted suicide, one of them succeeding. DISCUSSION
This long-term prospective follow-up of boys with early and persistent effeminate behavior provides a beginning for a quantitative basis for estimating the probability of a deviant outcome in an individual with such early symptoms. If the five boys seen for the first time after they were I1 years of age are excluded because their sex orientation may already have been sufficiently fixed to produce a weighted bias, the ratio in children before the age of 9 years would be approximately 2 to I in favor of a deviant outcome (uncertain cases being included with the heterosexual ones). If the total group is taken, to make comparison possible with the results of other studies that will be discussed, the ratio of deviant to heterosexual outcome would be 3 to I. This is, of course, a small number of cases, and these figures may well have to be revised: it nevertheless indicates the seriousness of early effeminate behavior. as has been pointed out by 0thers.l Comparison with outcomes in other studies of early effeminate behavior is difficult to make because of differences in selection of cases and of ages when first seen and at follow-up. Bakwin” reported on 10 effeminate boys first seen when they were 5-17 years of age and at various ages later: he found 5 to be homosexual, 2 heterosexual, and the remaining 3 of uncertain sexual orientation. In a follow-up study by Lebovitz” of I6 cases, which included 8 cases with reported onsets at ages IO-16 years, 6 of the I6 manifested deviant sexual behavior: 3 were transsexuals, 2 were homosexuals, 1 was a transvestite, 4 were probably heterosexual, and the outcome in the remaining 6 was uncertain. some continuing to show remnants of effeminate symptoms. Green and Money’ and Green8 saw 5 boys at 5-10 years of age and again 12-15 years later and found 3 to be homosexual, one probably homosexual. and the fifth of uncertain sexual orientation. The outcome in deviant behavior in the above three studies is thus seen to have varied, approximately, from 40% to 80%. If one considers together the 3 1 cases of these authors, at least one-half of them later developed deviant behavior. This is somewhat less than the figure of 607~ (7 of I I)
368
BERNARD
ZUGER
reported here for the group seen at an early age, and is much less than the overall figure of 75% (I2 of 16) found if all the cases are grouped together. The particular form of deviant behavior that ultimately appears is not readily predictable from a consideration of the symptoms of child effeminacy. The symptoms noted here were also seen early by Paulyg to be present in those who later became transsexuals. Presumably, if these symptoms-cross-dressing, feminine gestures, wanting to be a girl, etc .-continued unabated in all of the children, they would all end up presenting the clinical picture of transsexualism, which, however, generally occurs in only a fraction of cases. What seems to be happening, as one follows these children, is a kind of “decay” or burning out of these symptoms, completely in some, partially in others, and not at all in a few. There then results the spectrum of conditions we actually see develop even in such small series of cases as the present one and that of Lebovitz,6 viz., heterosexuality, transvestism, homosexuality, and transsexualism, as well as intermediate forms. Such a view would shift emphasis from postnatal environmental factors thought to generate these conditions, as in the studies of Bieber et al.‘O and Stoller,ll to prenatal and possibly postnatal events involving hormonal factors. Such speculation would be consistent with the massive amount of experimental data on the prenatal and/or postnatal hormonal sexualization of the brain in animals (reviewed by Phoenix et al.lZ and Goy13). A possible indication that prenatal developmental factors may be important in early persistent effeminate behavior was the finding by the author14 of evidence of prenatal disturbances manifested by increased rates of congenital inguinal hernia, enuresis, testicular maldescent, and possibly speech impairments in such children. However, not all the children were so affected. The findings obviously need confirmation. More needs to be said on the type of homosexuality that develops in these children. Clinically, it is like that commonly seen in practice and diagnosed as such. It is not marked behaviorally in all cases by undue effeminacy. and, in sex relations, by a passive role. Choice of occupation was that frequently associated with homosexuals. Saghir and Robins I5 found that two-thirds of their group of non-hospitalized homosexuals gave a history of what resembles early effeminate behavior. In a random group of 20 adult male homosexuals seen clinically by the author,“j more than three-fourths of them presented histories of early effeminate behavior. We are therefore dealing, in the syndrome of effeminate behavior in early childhood, with what may well be the commonest form of onset of homosexuality. SUMMARY
This is a IO-year further follow-up of 16 boys with early effeminate behavior, a group of cases first reported in 1966. The average age at this follow-up was 22 years, and the average number of years elapsed since first seen was 14 years. Twelve of the 16 cases developed some form of deviant behaviorhomosexuality in 10, transvestism in 1, and transsexualism in 1. Two of the cases were heterosexually oriented, and in the remaining two, no decision could be reached as to their sexual orientation.
EFFEMINISM
369
IN BOYS
ACKNOWLEDGMENT Thirza Howard, M.S.W., formerly with the Greenwich Hospital. helped in the follow-up of the cases. Dr. Bernard Benjamin, Brooklyn. N.Y.. critically read the manuscript and made valuable suggestions.
REFERENCES I. Zuger B: Effeminate behavior present in boys from early childhood: I. The clinical syndrome and follow-up studies. J Pediatr 69: 1098-l 107, 1966 2. Zuger B, Taylor P: Effeminate behavior present in boys from early childhood: Il. Comparison with similar symptoms in noneffeminate boys. Pediatrics 44:375-380, 1969 3. Green R: One-hundred ten feminine and masculine boys: Behavioral contrasts and demographic similarities. Arch Sex Behav 5:425-446. 1976 4. Stoller RJ: “It’s only a phase.” JAMA 201:98. 1967 5. Bakwin H: Deviant gender role behavior in children: Relation to homosexuality. Pediatrics 41:620-629, 1968 6. Lebovitz PS: Feminine behavior in boys: Aspects .of its outcome. Am J Psychiatry 1’8: 103-109. I972 7. Green R. Money J: Incongruous gender role: Nongenital manifestations in prepubertal boys. J Nerv Ment Dis 130:160-168, 1960 8. Green R: Sexual Identity Conflict in Children and Adults. New York. Basic Books, 1974, p 243
9. Pauly IB: The current status of the change of sex operation. J Nerv Ment Dis 147:460-47 I. I968 IO. Bieber I. Dain JD. Dince PR. et al: Homosexuality: A Psychoanalytic Study. New York. Basic Books. 1962 I I. Staller RJ: Male childhood transsexualism. J Am Acad Child Psychiatry 7: lY3209, 1968 I?. Phoenix CH. Goy RW. Young WC, et al: Sexual behavior: General aspects. in Martini L, Ganong WF teds): Neuroendocrinology. New York. Academic, 1967. p 163 Hormonally induced RW: 13. Goy pseudohermaphroditism and behavior, in Motulsky AG, Lentz W (eds): Birth Defects. Proceedings of the Fourth International Conference. Vienna. Austria, 1973. New York. American Elsevier. 1974. p I55 14. Zuger B: Effeminate behavior in boys. Parental age and other factors. Arch Gen Psychiatry 30: 173-177, 1974 IS. Saghir MT, Robins E: Male and Female Homosexuality: A Comprehensive Investigation. Baltimore, Williams & Wilkins, 1973. p I8 16. Zuger B: Unpublished data