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Archives of Sexual Behavior, Vol. 27, No. 5, 1998

Preferential Rap e in the Th eory of Cou rtship Disorder Kurt Freun d, M.D., D.Sc.1 an d Mich ael C. Seto, Ph .D.1,2

The theory of courtship disorder suggests voyeurism , exhibition ism , frotteurism , an d preferential rape (a paraphilic preference for coercive sex) are expression s of a comm on un derlyin g distu rbance. Previou s research has dem on strated that voyeurism , exhibition ism , an d frotteu rism are relatively likely to co-occur; however, their associations with rape are weaker. One explanation is that rapists are m ore heterogeneou s and may not always be m otivated by a paraphilic interest in coercive sex. Paraphilic interests can be identified using phallom etric testing, but the sensitivity of the test is attenuated by volu ntary control over erectile respon din g. Anoth er approach is to look for a behavio ral m arker associated with paraph ilic rape-pron eness. Freun d (1990) has argued that exhibitionism m ay be the “hu b ” of cou rtship disorder because exposin g one’s genitals to a stran ger is rare in control subjects. We predicted that rapists who also engaged in exhibitionistic activity would be m ore likely than other rapists to also engage in other expression s of courtship disorder, i.e., voyeurism and frotteurism . To rule ou t the possibility that rapists who report exhibitionistic activity on ly differ in their willin gness to report anom alous sexual behavior, we also pred ic ted n o d ifferen c e betw een th e gro u ps in th eir self-reported involvem ent in other paraphilic activities such as sadism or m asoch ism , or paraphil ic target preferen ces such as fetish ism or transvestism . Fin ally, we predicted no difference between groups in their willingness to adm it to attempting or com mitting rape. The results supported our predictions, and lend credence to the notion of preferential rape as an expression of courtship disorder. Moreover, these results su ggest that the presen ce of an oth er paraph ilia, particu larly exhibitionism , m ay be useful as a behavioral m arker for paraphilic rape-proneness. KEY WORDS: courtship disorder; paraphilias; rapist heteroge neity; rape . 1

Forensic Division, Clarke Institute of Psychiatry, 250 College Street, Toronto, O ntario, Canada, M5T 1R8. (e-mail: setom@ cs.clarke-inst.on.ca) 2 To whom correspondence should be addresse d. 433 0004-0002/98/1000-0433$ 15.00/0

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1998 Plenum Publishing Corporation

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INTRODUCTION The Parap h ilias The paraphilias can be broadly divide d into two cate gorie s, those involving anomalous targe t pre fe rence s and those involving anomalous activity preference s. In the former, there is a sexual pre fe rence for targets other than physically mature persons, as e videnced by persistent thoughts, urges, or behaviors; in the latter, there is a sexual preference for sexual activitie s that are uncommon for people who erotically prefer physically mature targets. Major activity paraphilias include sadism, masochism, voye urism, exhibitionism, tele phone scatalogia (obscene te lephone calling) , frotte urism, and pre fe re ntial rape (or paraphilic rape -prone ne ss, a pre fe rence for coercive sexual activity) . Prefere ntial rape is conside re d to be diffe rent from sadism in the relative importance of physical pain, injury, and suffe ring in sadistic fantasie s and be havior. Unlike the othe r paraphilias, prefere ntial rape is not recognize d in the late st edition of the Diagnostic an d Statistical Man ual of Mental Disorders (DSM-IV: American Psychiatric Association, 1994) , although the re was discussion about including it unde r the labe l of “ paraphilic coercive disorde r.”

Th e Cou rtship Disorder Hyp oth esis Fre und (1990) has argue d that voye urism, exhibitionism, frotte urism, and preferential rape can be vie wed as e xpre ssions of a disturbance in a common re gulatory system. These e xpre ssions can be viewed as distortions of the normal courtship process in male s, describe d in an idealize d re fe rence syste m by Freund and Kolá ºský (1965) . The te rm “ courtship ” is take n from the ethological lite rature , and re fe rs to the seque nce of dyadic behavioral inte ractions that pre cede and initiate sexual intercourse (se e Pe rper, 1989) . The refere nce syste m propose d by Freund and Kolá ºský involve s four phase s: ( i) a finding phase , consisting of locating and appraising a pote ntial partne r; (ii) an affiliative phase , characte rize d by nonve rbal and verbal ove rtures such as looking, smiling, and talking to a pote ntial partne r; (iii) a tactile phase , in which physical contact is made; and (iv) a copulatory phase , in which se xual inte rcourse occurs. 3 According to the the ory of courtship disorde r, voye urism, e xhibitionism, frotteurism, and prefere ntial 3

This is not to sugge st that female s are passive re ce ivers of male e fforts; in fact, there is an emerging body of evidence on female s’ active participation in the courtship proce ss (e.g., Givens, 1978; Gree r and Buss, 1994; Pe rpe r, 1989).

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rape can be vie wed as distortions or e xtreme inte nsifications of each courtship phase , where the othe r phase s are eithe r skippe d or retaine d in a ve stigial way. In othe r words, voye urism can be vie wed as a distortion of the finding phase , exhibitionism as a distortion of the affiliative phase , frotte urism as a distortion of the tactile phase , and rape as a distortion of the copulatory phase . A possible relationship betwee n the se paraphilias was observe d by early writers in sexology: Krafft-Ebing (1886/1978) calle d frotteurism a form of exhibitionism, while Freud (1925) coine d the term “ scoptophilia ” to indicate his belief that voye urism and e xhibitionism were intrinsically related. Others have note d an empirical association be tween the se paraphilias: Taylor (1947) describe d the co-occurre nce of e xhibitionism and frotte urism. Grassbe rge r (1964) found that 12% of individuals arreste d for inde cent exposure had committed othe r sexual offenses, particularly rape . According to Gebhard et al. (1965) , one in ten incarce rated e xhibitionists they studie d had also committed rape . Abel et al. (1988) found a high de gre e of co-ocurre nce in paraphilic behavior for a group of 561 male outpatie nts. For example , 28% of the 142 men primarily reporting exhibitionistic activity also reported voye uristic activity; conve rsely, 63% of the 62 men primarily reporting voye uristic activity also reporte d e xhibitionistic activity. In Abe l et al.’s sample of 126 rapists, 28% reporte d exhibitionistic activity, 18% reporte d voye uristic activity, and 11% re porte d frotte uristic activity. Finally, Bradford et al. (1992) reporte d on the co-occurre nce of the se paraphilic activitie s in a sample of 443 men unde rgoing a forensic psychiatric asse ssment. O f the 115 men reporting voye uristic activity (the largest single paraphilic category in their study), 66% had engage d in frotteuristic activity, 52% had engage d in exhibitionistic activity, and 47% had committed rape . O f the 56 men who attempte d to commit rape , 23% reporte d voye uristic activity, 13% reported exhibitionistic activity, and 31% reporte d frotteuristic activity. Of the 30 men who committe d rape , 12% re porte d voye uristic activity, 7% re ported exhibitionistic activity, and 16% reporte d frotte uristic activity. Previous reports by Freund and his colle ague s have de monstrate d that the activity paraphilias include d in the the ory of courtship disorde r are re latively like ly to co-occur (e .g., Fre und, 1990; Freund et al., 1983; Freund and Watson, 1990). The most recent inve stigation, using conditional probabilitie s that anothe r paraphilic activity would be pre sent give n the prese nce of a particular activity, supporte d the the ory of courtship disorde r with regard to voye urism, exhibitionism, and frotte urism (Freund et al., 1997) . These paraphilic activitie s were more like ly to co-occur with each othe r than with sadism or masochism. Howe ver, the strengths of association between the se expre ssions of courtship disorde r and rape were smalle r. O ne possible e xplanation for this lower le ve l of co-occurre nce is that all rape

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case s were include d in the analyse s, including those that were nonparaphilic in nature . This argume nt is also true , presumably to a le sser extent, for the othe r activitie s. Anothe r possibility is that patie nts with an expression of courtship disorde r would be less willing to re port rape fantasie s or behavior compare d to the othe r activitie s, give n the severity of legal sanctions for rape .

Th e Heterogen eity of Rap ists Many clinicians and rese archers have argue d that rapists are a heteroge ne ous group (e .g., Barbare e et al., 1994; Marshall and Barbare e, 1990; Pre ntky and Knight, 1991; Se to and Barbare e , 1997) . There may be a varie ty of motivations for sexually aggre ssive be havior. At the same time , as note d by Abe l and Roule au (1990) , “ clinical inte rviews with rapists provide support for the classification of rape as a paraphilia, be cause many individuals re port having recurrent re petitive and compulsive urge s and fantasie s to commit rape . These offe nde rs atte mpt to control the ir urge s and fantasie s to commit rape s and the n fe el guilty afterwards with a temporary re du ction in urge s ” ( p. 18) . This de scriptio n me e ts the crite ria for paraphilias in the DSM-IV. Rapists are expe cted to be unwilling to report fantasie s or urge s about coercive sex, give n the possibility of le gal or social sanctions, so there is a need for an obje ctive marker of paraphilic rape . In a recent meta-analysis, Lalumi ère and Q uinse y (1994) de monstrate d that phallome tric testing, the measure ment of penile re sponse s to sexual stimuli presented in the laboratory, diffe rentiate s rapists from nonrapists. Howeve r, discrimination in the se studie s was not perfect; there was some ove rlap in the distributions of rapists ’ and nonrapists ’ deviance indice s (a measure of the re sponse to depictions of rape , relative to the re sponse to de pictions of consenting sex). Possible explanations for this overlap are voluntary control of sexual arousal by offe nde rs (Quinse y and Chaplin, 1988) or the use of non-optimal stimuli (Lalumi ère and Quinse y, 1994) . Regardle ss of the corre ct explanation, phallometric testing has lower se nsitivity than spe cificity among child mole ste rs and rapists, so the pre se nce of arousal to inappropriate stimuli is more informative than its abse nce (Fre und and Watson, 1991; Lalumi ère and Q uinse y, 1993) . Anothe r approach is to look for a behavioral marker of paraphilic rape , such as co-occurre nce of another expre ssion of the posite d courtship disorde r. An earlie r study found that the e xhibitionistic activity of exposing one ’s penis from a distance to an unsuspecting female stranger was rare ly reported by men recruited from the community (Freund et al., 1988). They compare d 150

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exhibitionists, 81 students, and 35 nonstudents in terms of their self-re ported exhibitionistic activity. Of the e xhibitionists, 49% admitte d showing their pe nis at a distance to a female stranger, and 31% admitte d showing both the ir penis and buttocks. In contrast, none of the stude nts or nonstude nts admitte d exposing their penis at a distance to a fe male stranger, and only 5 and 6% , respectively, admitte d showing both the ir penis and buttocks. Differe nce s in the self-reports of sexological patie nts and controls were smalle r for ite ms regarding voye uristic or frotte uristic activity, suggesting that exhibitionism could be a use ful marker for preferential rape .

Th e Curren t Stu dy We pre dicte d that rapists who also engage d in exhibitionistic activity would be more like ly than rapists who did not to exhibit the othe r expre ssions of courtship disorde r, i.e ., voye urism and frotte urism. To rule out the possibility that rapists who report exhibitionistic activity actually differ from those who do not in their willingne ss to re port se xually anomalous behavior, we also pre dicted the re would be no diffe rences between the two groups in terms of their involve ment in othe r paraphilic activitie s such as sadism, masochism, or paraphilic targe t prefere nce s such as fe tishism or transve stism. Finally, we predicte d there would be no diffe rence s be tween the two groups in their willingne ss to adm it to engaging in rape or atte mpte d rape .

METHOD Su bjects The clinical subje cts in the prese nt study were 127 men who had committe d or attempted rape , define d as sexual contact with a nonconse nting female, achie ve d through thre at or force . These perpe trators were referre d by psychiatrists or ge ne ral practitione rs and were seen by the first author ove r a 10-ye ar period. Their mean age was 25.6 years (SD = 6.9) , with a modal e ducation score of 2 on a 5-point scale (1 = le ss than Grade 8, 2 = Grades 9 to 12, 3 = high school graduation; 4 = some colle ge or unive rsity, 5 = colle ge or unive rsity graduation) . Control subje cts were recruited from local community colle ges and Canada Employme nt offices. Their mean age was 26.5 years (SD = 6.5), with a modal education score of 3 ( high school graduation) . Information on socioe conomic status was unavailable for many subje cts. Control subje cts were include d to provide a base line for the pre vale nce rate s of various activitie s.

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Materials A 385-ite m que stionnaire , the Erotic Prefere nces Examination Scheme (EPES), was use d in this study. This que stionnaire was give n to all sexological patie nts who could re ad and unde rstand English te xt. The EPES has 12 sections. The first se ction, comple te d by the first author, indicate s the numbe r of incide nts involving voye uristic, e xhibitionistic, frotteuristic, or sexually aggre ssive activity, and indicate s whethe r or not the patie nt admits to committing the offense(s). The remaining sections are comple ted by the subje cts, and contain que stions about his se xual intere sts and history, as well as ite ms about his early childhood and developme nt. The following self-report que stions, answe red ye s or no, were important to the pre sent study: 1. Since age 16, and apart from viewing picture s or movie s, have you eve r spe nt a substantial amount of time trying to observe females nude or partially nude , or to obse rve the m urinating, having inte rcourse with a man, or some othe r normally private act? 2. Since age 16, have you e ver masturbate d while watching or trying to obse rve a girl or woman who was unaware of your presence ? 3. Since age 16, have you ever shown your penis (from a distance ) to a female who was almost or totally a strange r to you? 4. Since age 16, have you e ver fondle d or atte mpte d to fondle the breasts or crotch of an unsuspe cting fe male who was almost or totally a strange r to you? 5. Since age 16, have you ever stood behind an unsuspe cting female who was almost or totally a strange r to you, and pressed (inte ntionally) your penis against he r buttocks? 6. Have you e ve r thre atened a strange r or almost unknown female into accepting se xual advance s from you or into carrying out some sexual activity? Items 1 and 2 toge the r indicate voye uristic activity, item 3 indicate s exhibitionistic activity, ite ms 4 and 5 toge ther indicate frotte uristic activity, and item 6 indicate s coe rcive se xual activity. Collate ral file information was available for 108 of the 127 pe rpe trators.

RESULTS The re was no significant diffe re nce in age be tween the rapists and controls, t(621) = ¯0.86, ns. Howe ver, the controls were significantly be tter educate d, Mann-Whitne y z = ¯7.99, p < .0001. Approximate ly 3% of the controls admitte d to coe rcing a fe male strange r into some kind of sexual

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Table I. Proportions of Rapists or Controls Admitting to an Activity Consistent with an E xpression of Courtship Disorder (Perce ntages) E xpression Voyeuristic E xhibitionistic Frotteuristic a Te lephone scatalogia

Rapists (n = 127)

Controls (n = 483)

c

22.0 22.0 18.1 17.3

10.8 6.6 9.7 10.6

11.23 c 26.97 b 6.95 4.37

2 c

a

Variant of e xhibitionism, according to Freund et al. (1983) . p < 0.01. c p < 0.001. b

activity. The 13 se xually coercive controls were exclude d from the following comparisons. As shown in Table I, rapists were more like ly than controls to admit voye uristic, exhibitionistic, or frotteuristic activity. Because exhibitionism is conside red to be the “ hub ” of courtship disorde r (Freund et al., 1997) , and because the large st group diffe rence s were found for exhibitionistic activity, rapists we re divide d into those who admitte d engaging in exhibitionistic activity (22% ) and those who did not (78% ). A similar patte rn of results was obtaine d if rapists were divide d according to voye uristic or frotte uristic activity, but there was less discrimination betwee n groups in te rms of othe r paraphilic activitie s. The re was no significant diffe rence be twe en the rapists with or without the marke r in terms of mean age (25.7 vs. 25.6 years, re spe ctive ly) , t(125) = ¯0.11, ns, or e ducation, Mann-Whitne y z = ¯0.66, ns. As shown in Table II, the 28 rapists who also admitte d e ngaging in exhibitionistic activity were much more like ly than the othe r 99 rapists to also admit engaging in voye uristic or frotteuristic activity. Note that the proportions of none xhibitionistic rapists who did admit to e ngaging in voye uristic or frotte uristic activity were similar to the corresponding proportions in the control sample . There was also a significant diffe re nce in the proportion of rapists who admitte d e ngaging in both voye uristic and frotteuristic activity; 39.3% of the rapists who admitte d e ngaging in exhibitionistic activity also admitted to both voye uristic and frotteuristic activity, while none of the othe r rapists did so, c 2(1) = 37.76, p < 0.0001. O f the 13 sexually coercive subje cts recruited from the community, 6 also admitte d to e ngaging in voye uristic activity, 6 admitte d to exhibitionistic activity, and 10 admitte d frotte uristic activity. These proportions were significantly highe r than those found in the re st of the control sample ; in contrast, only the proportion admitting to frotteuristic activity was significantly highe r than that found in the rapist sample .

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Freun d an d Seto Table II. Self-Reported or Docume nted Involve ment of the Rapist Groups in Other Sexually Anomalous Activities or Targets (Pe rcentage s Indicating “ Ye s” ) Activity or target Voye uristic a E xhibitionistic Frotteuristic a Attempte d rape a Rape b Fetishistic Sadistic b Masochistic b Transvestic b Te lephone scatalogia Not otherwise specified

Rapists with marker (n = 28)

Other rapists (n = 99)

82.1 75.0 53.6 90.0 89.5 7.1 3.6 0.0 3.6 39.3 7.1

7.1 0.0 8.1 82.7 84.1 1.0 14.1 0.0 3.0 11.1 3.0

c

2 c

68.18 c 83.61 c 30.41 3.18 <1 3.56 2.34

¯ <1 c 12.10 <1

a

Percentage adm itting to an activity indicate d by collate ral information such as charges. For e xample, 75% of rapists who had engaged in exhibitionistic activity admitte d to it. b Based on se lf-report only. c p < 0.001.

As mentione d, collate ral information was available for 108 of the rapists and inte rview information was available for all 127 cases. Exce pt for te le phone scatalogia, which Freund et al. (1983) have argue d is a variant of exhibitionism, rapists who admitte d to e ngaging in exhibitionistic activity did not diffe r from those who did not in te rms of othe r self-reporte d or docume nte d sexually anomalous activitie s (see Table II). The rapist groups also did not diffe r in the proportion who admitte d to attempting or committing rape . Looking at othe r EPES ite ms about voye uristic or exhibitionistic inte rests, rapists who admitte d engaging in e xhibitionistic activitie s differe d significantly from those who did not in an e xpe cted manne r (Table III). While the diffe re nces were smalle r for the two items about voye uristic inte rest, the groups diffe red greatly on items about exhibitionistic intere st. In particular, none of the none xhibitionistic rapists reporte d masturbating to orgasm while exposing himse lf from a distance , and only two of the se rapists reporte d masturbating to orgasm while imagining that he was exposing himself from a distance .

DISCUSSION Rapists were more like ly than controls to re port engaging in any expression of courtship disorde r. The small subse t of 13 se xually coe rcive men identifie d in the control sample were also more like ly than the ir counte r-

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Table III. Affirmative Re sponses to Self-Report Items Re garding Voyeuristic or E xhibitionistic Activity (Perce ntages)

Self-report item Prefer secre tly watching some one over se xual contact Masturbate d to orgasm while se cre tly watching someone (not movies, etc.) Sometimes e xpe rience desire to show penis Had urge to e xpose penis Masturbate d to orgasm while e xposing Masturbate d to orgasm while imagining exposing a

Rapists with marker (n = 26)

O ther rapists (n = 99)

c

2

34.6

21.6

1.3

46.2

11.2

16.59

a

67.9

7.1

49.54

a

76.9 34.6 46.2

8.2 0.0 2.0

51.71 a 31.93 a 39.92

a

p < 0.0001.

parts to re port voye uristic, exhibitionistic, or frotteuristic activity. As predicted, rapists who engage d in e xhibitionistic activity were much more like ly to engage in voye uristic or frotte uristic activity than those who did not, as indicate d by se lf-re port or collate ral information. The two groups also differed in the proportion who reporte d engaging in obsce ne te lephone calling (see Freund et al., 1983) . Contrary to the alte rnative interpre tation that the two rapist groups actually diffe re d in te rms of their willingne ss to re port sexually anomalous behavior, the two rapist groups did not significantly differ in the ir re porte d rate s of sadistic, masochistic, fetishistic, or transve stic activity, although the re was a te nde ncy for rapists who engage d in exhibitionistic activity to report more involve ment in these activitie s. Anothe r finding that sugge sts the diffe rence betwee n the rapist subgroups is not solely attributable to a re porting bias is the lack of differe nce in the proportion who adm itted to atte mpting or committing rape . The prevale nce of voye uristic, e xhibitionistic, and frotteuristic activitie s in the control sample sugge sts (i) the se activitie s are more common than thought in normal populations; (ii) the control sample in the prese nt study diffe rs from the general male population; or (iii) more extre me forms of the se activitie s should be use d to diffe re ntiate true paraphilic activitie s from topographically similar but nonparaphilic activitie s (e.g., the distinction between purpose fully going into crowded public place s in order to touch or rub one ’s pe nis against an unsuspe cting female vs. doing so opportunistically). First, e pide miological data are difficult to obtain, so the pre vale nce of paraphilias is unknown (for a review, se e Se to & Barbare e, in pre ss). With regard to the se cond alte rnative , a numbe r of studie s have shown that volunte e rs for sex research diffe r from nonvolunte ers in terms of the ir sexual expe rience (e.g., Strassbe rg and Lowe , 1995; Wolchik et al., 1985) .

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Regarding the third possibility, Lang et al. (1987) have sugge ste d that orgasm in the context of a sexual activity is the distinguishing feature of a paraphilic preference . In the prese nt study, se lf-report items re garding masturbating to orgasm while exposing or imagining that one was exposing had highe r spe cificitie s (but lower sensitivitie s) than othe r se lf-report items that did not re fe r to masturbation and orgasm. The main results of this study support the notion that engaging in exhibitionistic activity is a useful behavioral marker for preferential rape, especially whe n phallome tric te sting is unavailable . More over, exhibitionistic activity is more useful in this regard than either voye uristic or frotteuristic activity, because exhibitionistic activity is relative ly rare in nonoffe nding controls and gre ate r discrimination betwe en groups was achie ved whe n it was use d as the marker, compare d to voyeuristic or frotteuristic activity. Unfortunate ly, we were not able to determine if rapists who engage d in exhibitionistic activity are re lative ly more responsive to depictions of rape than rapists who do not engage in this activity. Such a finding would confirm the validity of using exhibitionistic activity as a behavioral marker to identify paraphilic rapists, with implications for risk asse ssment and case manage ment.

ACKNOWLEDGMENT Kurt Freund died shortly after comple ting his work on this manuscript. I thank Martin Lalumi ère for helpful comments on an earlie r draft.

REFERENCES Abe l, G. G., Be cke r, J. V., Cunningham-Rathner, J., Mittelman, M., and Rouleau, J. L. (1988) . Multiple paraphilic diagnose s among se x offende rs. Bull. Am . Acad. Psychiat. Law. 16: 153-168. Abe l, G. G., and Rouleau, J. J. (1990) . The nature and e xtent of sexual assault. In Marshall, W. L., Laws, D. R., and Barbaree , H. E. (eds.), Handbook Of Sexual Assault: Issues, Theories, And Treatm ent Of The Offender, Plenum Press, Ne w York, pp. 9-21. Ame rican Psych iatric Association. (1994) . Diagn o stic an d Statistical Man u al of Men tal Disorders, 4th e d., Ame rican Psychiatric Association, Washington, DC. B arbare e , H. E ., Se to, M. C., Se rin, R. C., Am os, N. L., and Pre ston, D. L. ( 1994) . Comparisons betwe en sexual and non-sexual rapist subtype s: Sexual arousal to rape , offense precursors and offense characte ristics. Crim . Justice Behav. 21: 95-114. Bradford, J. M. W., Boulet, J., and Pawlak, A. (1992) . The paraphilias: A multiplicity of deviant behaviors. Can. J. Psychiat. 37: 104-108. Freud, S. (1938) . Three contributions to the theory of se x. In Brill, A. A. (ed.), The Basic Writings of Sigm und Freud, Random House, New York, pp. 553-579. (O riginally published, 1905)

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Freund, K., and Kol á sº ký, A. (1965) . Grundzuge e ines e infachen Bezugsystems fur die Analyse sexue ller Deviationen [A simple re fere nce system for the analysis of sexual de viations]. Psychiat. Neurol. Med. Psychol. 17: 221-225. Freund, K., and Watson, R. (1990) . Mapping the boundaries of courtship disorder. J. Sex Res. 27: 589-606. Fre und, K., and Watso n, R. ( 1991) . Asse ssme nt of the se nsitivity and spe cificity of a phallometric test: An update of phallometric diagnosis of pedophilia. Psychol. Assess. 3: 254-260. Freund, K., Scher, H., and Hucker, S. (1983) . The courtship disorders. Arch Sex Behav. 12: 369-379. Freund, K., Scher, H., Racansky, I. G., Campbell, K., and Heasman, G. (1986) . Males disposed to commit rape. Arch. Sex. Behav. 15: 23-35. Fre und, K., Watson, R., and Rienzo, D. (1988) . The value of self-reports in the study of voyeurism and e xhibitionism. Ann. Sex Res. 1: 243-262. Fre und, K., Seto, M. C., and Kuban, M. (1997). Frotteurism and the theory of courtship disorde r. In Laws, D. R., an d O ’Don ohue , W. T. ( e ds.), Sexual Devian ce: Theory, Assessm ent And Treatm ent, Guilford, Ne w York, pp. 111-130. Gebhard, P. Gagnon, J., Pomeroy, W., and Christenson, C. (1965) . Sex Offenders, Harper, Ne w York. Give ns, D. B. (1978) . The nonve rbal basis of attraction: Flirtation, courtship, and seduction. Psychiatry 41: 346-359. Grassberger, R. (1964) . Der E xhibitionismus (Exhibitionism). Kriminal. Österreich, 18: 557-562. Greer, A. E ., and Buss, D. M. (1994) . Tactics for promoting sexual e ncounters. J. Sex Res. 31: 185-201. Krafft-E bing, R. ( 1978) . Psychopath ia Sexualis, Ste in an d Day, Ne w York. ( O riginally published, 1886) Lalumi ère, M. L., and Quinsey, V. L. (1993) . The sensitivity of phallometric me asure s with rapists. Ann. Sex Res. 6: 123-138. Lalumi ère, M. L., and Quinsey, V. L. (1994) . The discriminability of rapists from non-sex offenders using phallometric measures: A me ta-analysis. Crim. Justice Behav. 21: 150-175. Lang, R. A., Langevin, R., Checkley, K. L., and Pugh, G. ( 1987) . Genital e xhibitionism: Courtship disorder or narcissism? Can. J. Behav. Sci. 19: 216-232. Marshall, W. L., and Barbaree, H. E. (1990) . An integrate d theory of the etiology of sexual offending. In Marshall, W. L., Laws, D. R., and Barbare e, H. E. (eds.), Handbook Of Sexual Assault: Issues, Theories, And Treatm ent, Ple num Press, Ne w York, pp. 257-275. Perper, T. (1989) . Theories and observations on se xual selection and fe male choice in human beings. Med. Anthropol. 11: 409-454. Prentky, R. A., and Knight, R. A. (1991) . Identifying critical dimensions for discriminating among rapists. J. Consult. Clin. Psychol. 59: 643-661. Quinsey, V. L. and Chaplin, T. C. (1988) . Preventing faking in phallometric assessments of sexual prefere nce. An n. N.Y. Acad. Sci. 528: 49-58. Se to, M. C., and Barbare e , H. E . ( 1997) . Se xual aggre ssion as antisocial beh avior: A deve lopmental model. In Stoff, D., Breiling, J., and Maser, J. D. (eds.), Handbook of Antisocial Behavior, Wiley, Ne w York, pp. 524-533. Se to, M. C., and Barbaree , H. E. (in press). Paraphilias. In Van Hasselt, V. B., and Hersen, M. (eds.), Aggression And Violence: An Introductory Text, Allyn and Bacon, New York. Strassberg, D. S., and Lowe, K. (1995) . Volunteer bias in sexuality research. Arch. Sex. Behav. 24: 369-382. Taylor, F. H. (1947) . Observations on some cases of exhibitionism. J. Mental Sci. 93: 631-638. Wolchik, S. A., Braver, S., and Jensen, K. (1985). Volunteer bias in erotica research: Effects of intrusiveness of measure and sexual background. Arch. Sex. Behav. 14: 93-107

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

Mon thly Measures of Salivary Testosteron e Predict Sexual Activity in Adolescent Males Carolyn Tucker Halp ern, Ph.D.,1,2 J. Richard Udry, Ph.D.,1 an d Chirayath Su chin dran , Ph.D.1

Strong relationships between on e-tim e serum testosteron e (T) m easures and sexual activity have been demon strated in cross-sectional an alyses of adolescen t m ales. However, a subsequ ent lon gitu din al study of a separate ad olescen t sam ple, usin g semian nual plasm a m easu res, failed to replicate cross-section al findings. The present study reexam ined the relationship between T and sexual activity usin g m ore frequently collected m easu res of salivary T and behavior. Saliva sam ples an d weekly behavior checklists were collected over a 2-year period from the sam e pan el sam ple of m ales on which semiann ual analyses were based. Saliva sam ples representin g m easures approxim ately every fou rth week of study participation were selected for T assay. The association between these m onthly salivary T m easu res and weekly reports of inciden ts of sexual activity was assessed with repeated m easures analyses. Higher levels of salivary T were significan tly associated with an in creasing hazard of coital in itiation, an d with m ore frequ ent coital an d noncoital activity. With in-individ ual chan ge an alyses dem onstrated th at in creases in salivary T were associated with increased sexual activity. Com parisons of m odels that varied specimen type, schedule of T m easu rement, an d type of behavioral report indicated that all th ree factors con tribu te to th e varyin g m agn itu de of h orm on e/beh avior relation sh ips that are dem on strated . These fin din gs are con sistent with a biosocial m odel of adolescen t sexual developm ent that pu bertal chan ges in T Research supported by re search grant (HD12806) from the National Institute of Child Health and Human Developme nt (NICHD) to J. Richard Udry, centers grants from NICHD to the Laboratorie s for Reproductive Biology (HD18968) and the Carolina Population Cente r (HD05798) , and a Clinical Research Unit Grant (RR00046) from the National Institutes of Health. 1 Carolina Population Center/Unive rsity of North Carolina at Chapel Hill, CB# 8120, Unive rsity Square, Chapel Hill, North Carolina 27516-3997. 2 To whom correspondence should be addresse d. 445 0004-0002/98/1000-0445$ 15.00/0

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1998 Plenum Publishing Corporation

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are a cau sal factor in the tim ing of sexual in itiation an d the frequ ency of activity during adolescenc e. KEY WORDS: salivary testosterone ; adolescen ce; se xual activity; longitudinal.

INTRODUCTION Experime ntal studie s of hypogonadal males have demonstrate d the importance of androge ns in maintaining sexual inte rest (Davidson et al., 1979; Luisi and Franchi, 1980; Skakke bae k et al., 1981; Salmimie s et al., 1982; O ’Carroll et al., 1985). However, cross-sectional analyse s of normal adult male s typically find no relationship betwe en normal variation in testoste rone (T) leve ls and sexual be havior (Raboch and Starka, 1973; Krae mer et al., 1976; Brown et al., 1978). These patte rns sugge st a dose -response relationship betwe en T and se xual inte rest at T le vels be low the normal adult range , and no additional effect within adult range s. What constitutes a threshold or ceiling may vary by individual, base d on variation in sensitivity to T. Male T le vels incre ase 10- to 20-fold during pube rty, and this increase is thought to provide a biological foundation for the incre ases in sexual inte re st and activity that occur during adole sce nce. Strong relationships have be en demonstrate d be twee n one -time se rum testosterone (T) measure s and multiple indice s of sexual behavior in a cross-sectional sample of adole scent males (Udry et al., 1985) . These findings supporte d the hypothe sis of a direct, motivational e ffect of hormone s on normal adole scent sexual de velopme nt that is distinct from social processe s associate d with obse rvable pube rtal de ve lopme nt. Howe ve r, cross-sectional data cannot demonstrate how sexual activity incre ases ove r time as a conse quence of changing biological influe nce. Subse que nt longitudinal analyse s of se parate adole scent male sample s followe d for 3 years as the y moved from pre pubertal to adult T leve ls faile d to re plicate cross-se ctional T/se xuality re lati on s h ips a fte r the ini tial r ou nd o f a ss e ss m e nt . Mor e i mp ort an t, within-individual change s in se miannual plasma T measure s were not significantly predictive of change s in semiannual reports of cumulative sexual expe rie nce over the 3-ye ar period (Halpe rn et al., 1993) . With the exception of repeated measure ment over time, the cross-sectional and pane l studie s were virtually ide ntical in variable measure ment and de sign protocol. Earlie r analyse s comparing the questionnaire reports of sexual activity among four similar groups of adole scent males (one of which is the current sample ), indicate d that more frequent asse ssment did not systematically affe ct semiannual reports of sexual intere st, motivation, or cumulative partne re d expe rience (Halpe rn et al., 1994a) . Differe nces in

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the findings of the cross-se ctional analyse s and longitudinal analyse s of semiannual measure s have not bee n reconcile d to date . Although se miannual assessments of plasma T leve ls over seve ral years represe nt a methodological improve ment ove r a one -time assessment in a cross-sectional sample , the se miannual measure s re tain the disadvantage of having only a single spe cime n to inde x T le vels for a full 6-month period. In the pane l study, weekly saliva sample s and re ports of sexual be havior were colle cted in addition to the se miannual blood sample s and que stionnaire s. The present analyse s re examine the re lationship be tween pube rtal change s in T and se xual activity using these more fre quently colle cted measures for the same pane l sample .

METHOD Stu dy Particip an ts A list of all White males in Grades 7 and 8 was obtaine d from a county school district in a Southe astern state. At that time , the school district was a mixture of suburban and rural areas ce ntered on a medium-size city. Among the 12- and 13-ye ar-old boys listed, pote ntial participants were randomly selected and inte rviewers were sent to the ir homes to re quest the ir participation. Signe d conse nt was obtaine d first from a pare nt and then from the adole scent. The pare nts ’ and adole scents ’ informe d consent process include d a de taile d re view of all que stionnaire content, physical measure s, and study procedure s. Approximate ly half of the boys solicite d agre ed to participate ; re fusals were e venly split betwe en pare nts and adole scents. Many pare nts (40% ) and adole scents (49% ) who re fused were unwilling to spe cify a re ason for refusal. Among those who did, the most common re asons were they fe lt study content was too personal (45% of pare nts and 22% of adole scents offering a re ason) , or they were too busy to mee t the study’s time re quire ments (20% of pare nts and 49% of adole scents). Initially 127 boys agre e d to participate and comple ted at least one project que stionnaire or procedure . The ave rage age at study entry was 13.2 ye ars, with a range of about 1 ye ar. About 81% of re sponde nts who contribute d blood sample s had pre pube rtal (i.e ., < 250 ng/dl) plasma T le vels at study e ntry. The sample is ge ne rally middle class. Responde nts who agre ed to participate in the prese nt study are similar in demographic characte ristics, physical de ve lopme nt, and reporte d levels of sexual activity to adole scent sample s in e arlie r two-wave pane l studie s in this re search line that did not include physical and biological measure s and yielde d highe r

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recruitment rate s. (Se e Halpe rn et al., 1994a, for additional comparisons among these sample s of responde nts.) The se similaritie s sugge st that initial sample bias for the pre se nt study doe s not excee d that affe cting large r studie s of sexual behavior with highe r re cruitme nt rates and fe wer rounds of data colle ction. The original protocol calle d for participants to be followe d for 2 years. The availability of additional funding after comple tion of the second year allowed for a 3rd-ye ar follow-up approximate ly 1 year late r. O ne hundre d boys comple ted 2 ye ars of data collection and 82 boys comple ted all 3 years. The most common reasons for study withdrawal were families moving out of the county (19% ) and responde nts re porting being too busy or tired of study participation (52% ). The re were no reports from participants that they were withdrawing because of study conte nt. Hazard mode ls (Cox, 1972) were run to examine factors associate d with study withdrawal. Because participants had originally “ signe d on” for a 2-ye ar commitment and because the behavioral data to be used here focus on the first 2 years of participation, we examine attrition for that period. For comple tene ss, we also look at predictors of study withdrawal ove r the full 3-ye ar proje ct period. Responde nts whose mothe rs were colle ge graduate s and who made be tter grade s in school were less like ly to withdraw during the first 2 years. Boys who had highe r T le vels and who had sex by study e ntry were more like ly to withdraw. Paralle l analyse s base d on the 3-ye ar period also indicate d that boys with highe r T le vels and greater sexual e xperie nce were more like ly to withdraw. The variable s associate d with attrition are central to the analyse s presente d here. However, we have measure s for each of the se variables, typically at multiple rounds, for participants who e ventually drop out. The refore respondents who le ft the study can be include d in all models of sexual behavior. If the re is an e ffect of responde nt loss associate d with this set of variable s, the effect should be to make our re sults more conse rvative . That is, it should be more difficult to detect re lationships be tween T and sexual activity. Respondents who make bette r grade s and who have highe r socioeconomic backgrounds are more like ly to stay in the study. The se two variable s are associate d with a lower like lihood of coital initiation. If highe r T leve ls are associate d with the initiation or freque ncy of sexual activity, then the loss of participants with highe r T levels will diminish the like lihood of detecting relationships. Loss of sexually active participants would have the same effect.

Data Collection Typ e an d Sequ ence Boys com ple te d a se lf-adm iniste re d, confide ntial que stionnair e in each of five se miannual inte rvie ws and comple te d a sixth questionnaire 1

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ye ar late r; the time be twe e n the first and sixth inte rvie w was about 3 ye ars. A set of physical measure s and an 18-m l blood sample were also obtaine d se miannually by proje ct nurse s. All questionnaire s and most physical asse ssments we re comple te d in participan ts’ hom e s. In addition to these se miannual appointme nts, adole scents were visite d once a week by the same proje ct inte rvie wer for the first 2 ye ars of the study. (Each participant had an assigne d inte rvie wer and/or nurse who conducte d all visits exce pt in case s of illne ss or staff change .) At this weekly visit, the boy comple ted a se lf-administe re d, confide ntial Be havior Checklist and produce d a 5-ml saliva sample . The inte rvie wer also picke d up a saliva sample which the boy was to have produce d the morning of the visit day. Proje ct fie ld staff did not have acce ss to que stionnaire re sponse s or hormone data. Participants were paid a mone tary incentive upon comple tion of weekly and semiannual measure s.

Measures Sexual Variables Behavior che cklists include d items tapping incide nts of physical aggre ssion, ve rbal aggre ssion, proble m be haviors (e .g., smoking, drinking) , social activity (e .g., dating, calling a girl on the phone ), physical activity (e.g., sports participation) , stre ssful life e ve nts, and multiple aspe cts of sexual behavior. Sexual items were esse ntially ide ntical to those appe aring on the semiannual que stionnaire , e xce pt for the time frame spe cified in the questions. Se xual que stions have bee n used in a serie s of studie s beginning in 1978 (e.g., Udry et al., 1985; Smith and Udry, 1985; Halpe rn et al., 1993) . Q ue stions about partne re d activity were base d on the Hete rosexual Behavior Inventory deve lope d by Be ntle r (1968a, 1968b) ; ite ms were modifie d to be appropriate for an adole scent sample , and were extensive ly pretested. All ite ms re fe rring to partne re d activity are e xplicitly he terosexual. Because adole scents and pare nts were aske d to re view all questionnaire s as part of the informe d conse nt process, the heterose xual focus was cle ar to participants when the y conse nted to study participation. Four ve rsions (A, B, C, D) of the che cklist were deve lope d, and weekly checklist administratio n rotate d through the ve rsions. Not all ite ms appeared on e ach checklist version. For example , give n the age of the sample , coital activity was unlike ly to occur e ach wee k, so this item was include d on only one checklist version. Checklist versions A, B, and C aske d whether expe rie nces occurre d “ yeste rday” (yes/no) and in the “ past week” (ye s/no) . Checklist ve rsion D was longe r than A, B, or C, because it include d all

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items in the pool. Che cklist ve rsion D aske d whethe r expe rience s occurred in the “ past week” and in the “ past month.” For the pre sent analyse s, the “ past week” ratings from all four checklist ve rsions are used. Two sexual variable s were constructe d from Behavior Che cklist items. All compone nt items were scored 1/0 (ye s/no) to indicate whe ther the experience did or did not occur in the past week. The se xual variable s derive d from the che cklist and the wording of compone nt items are: Partnered-Activity compose d of kissing ( “you kissed a girl”), petting ( “you felt a girl’s breasts with your hands e ither under or over he r clothes,” “a girl felt your penis with her hand either under or over your clothes,” “ you felt the sex organs of a girl with your hands e ither under or over her clothes ”), and coital experience s. Coitus is the single item “ had se xual intercourse.”

The first time participants comple ted the se xual inte rcourse item, it was define d for them as “ To have sex (se xual inte rcourse) is to put the male penis into the female vagina. This is some times calle d screwing, ge tting laid, or going all the way.” Se xual variable s constructe d from the Behavior Checklists represent the pe rcentage of “ yes” re sponse s in each 6-month period betwee n semiannual blood draws, give n the numbe r of opportunitie s an adole scent had to re port the behavior (i.e., the numbe r of times those 3 items were presente d to the adole scent within that time period). O ne sexual variable , coital initiation , was sele cted from the semiannual que stionnaire . This variable refle cts the timing of coital initiation, as indicate d by the numbe r of months betwee n study entry and the first re port of coital activity on the semiannual que stionnaire . ( “ Last week” ratings on checklist reports may miss the first coital e xpe rie nce, especially if the re were no additional coital activity for se veral months after the first experience . We there fore use the “ have you ever had se x” question in the semiannual que stionnaire .)

3

This method of variable construction potentially allows responde nts with different levels of expe rience to re ceive the same score. For e xample, the boy who is asked about coitus once in a 6-month period (due to missing data, e tc.) and reports “ yes ” re ceives a score of 100% , as does the boy who is aske d about coitus five times and reports “yes ” e ach time . We examine d the possibility that this construction distorted results by conducting log linear analyses of counts of reports (controlling for opportunities to re port) using a Poisson distribution and log link function (SAS Institute, Inc., 1993). These analyses did not incorporate the dimension of re peated me asure ments on the same subjects over time, but may be better suited to nonnormal distributions of response variables. Analyses base d on 6-month pe riods betwee n plasma T me asure s, and on pooled distributions of all responses for the 2-year period yielded results that are e ntirely consistent with the repeate d-measures re gre ssion models reported he re . We report the re pe ated-me asures analyses be cause they allow e xamination of within-individual change over time.

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Physical Variables Average Saliva T. At e ach weekly visit, participants were aske d to expectorate 5 ml of saliva into a polypropyline tube . Participants were provide d with fruit punch flavore d “ Gatorgum ” as a stimulant. All afte rnoon sample s were colle cted be twe e n 3 PM and 9 PM, whe n T levels are ne arly flat (Butle r et al., 1989) ; the se hours refle ct the same colle ction window use d for blood sample s. Participants were also instructe d to produce a morning saliva sample within 2 hr of waking on the same day as the ir weekly visit. Saliva sample s were le ft at room tempe rature until the evening of the same colle ction day, when they were frozen at ¯20 C. A “ se miannual ” saliva sample was also colle cted concurre ntly with blood sample colle ction as part of the se t of se miannual physical measure s. For comparability with blood measure s, only value s from afte rnoon saliva sample s were use d in the present analyse s. Be ginning with the first physical exam, saliva sample s were selected for T assay which would represent a measure approximate ly eve ry 4th wee k of the 2-ye ar pe riod. T assays were pe rformed using the Diagnostic Products Corporation I125 Coat-a-Count kit, with the addition of an e xtraction step. All sample s were assaye d in duplicate , and all spe cimens for a give n boy were assaye d toge ther. The intraassay variation figure s for low and high controls were 11.2 and 5.7% , respectively. The interassay variation figure s for low and high controls were 14.4 and 6.7% , re spe ctive ly. For each boy, the re sulting monthly T value s were ave rage d within each of the 6-month pe riods, corre sponding to the 6-month pe riods used for weekly che cklists and blood draws. Thus, each adole scent who comple ted the first 2 years of the study has four ave rage salivary T value s, reflecting T measure ments from the semiannual measure ments at the beginning of period, up to, but not including, the ne xt set of semiannual measure s. Pubertal Developm ent. Pube rtal de ve lopme nt is inde xed by a factor score base d on ite ms from the semiannual physical exam. Compone nt items of the factor are Tanne r stage s of pubic hair and genital growth, testicular volume , prese nce/patte rn of facial hair, de nsity of facial hair, density/te xture of axillary hair, and density/te xture of leg hair. See Halpe rn et al. (1993) for a more comple te de scription.

Statistical Meth ods The timing of coital initiation was e xam ine d with a hazard mode l analysis. We have repeate d measure ments of T and pube rtal developme nt; the y are there fore include d as time-de pende nt covariate s. Behavior Checklist reports were analyze d using re peate d measure s re gression mode ls with

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time-depe nde nt covariate s (Stevens, 1986) . Because be havioral measure s that are closer toge ther in time were be tter correlated than more distantly spaced measure s, a covariance structure of autore gressive of orde r 1 was spe cifie d for all re pe ate d measure s mode ls. We have spe cific directional hypothe ses for all behavioral mode ls. Highe r levels of T, or incre ase s in T, should be associate d with a gre ater like lihood of activity or increases in activity. We the re fore use one -taile d significance tests for all be havioral mode ls. In all analyse s, ave rage salivary T value s, which span a 6-month period, are concurre nt with behavioral reports covering the same time periods. Se miannual measure s (such as pube rtal de ve lopm ent) refle ct asse ssment at the start of the 6-month periods. Mode ls examining the relationship between within-individual change s in behavior over time , and change s in T and pube rtal deve lopme nt include the first saliva T value and pube rtal deve lopme nt score as a base line .

Treatm en t of Tim e 1 Non virgin s in Horm on e/Behavior Mod els At study entry, 21 responde nts reporte d that the y had had sexual inte rcourse at least once . This numbe r represents almost 40% of the 55 males who ever have se x by the e nd of the ir study participation. O ne of the project’s goals was to improve on earlie r cross-se ctional analyse s by prospe ctively examining the relationship be twe e n pube rtal change s in hormone s and change s in sexual activity. Howe ve r, to exclude all participants who have se xual e xpe rie nce at study e ntry from behavioral analyse s would introduce additional sample bias by sele cting out adole scents who have sex earlie st; as note d above , it would also e liminate 40% of responde nts who eve r expe rience this eve nt. For be havioral analyse s we the refore report the results of models base d on responde nts who start the study with a salivary T value of less than 155 pmol/L. This T level refle cts a pre pube rtal value , and its use as an exclusion criterion is consiste nt with the study’s original rationale of tracking the sexual activity and hormonal change s of adole scent males as they moved from pre pube rtal to adult leve ls of T.4 This crite rion results in a loss of 22 responde nts from behavioral analyse s, 14 of whom were nonvirgins at study e ntry. We also re port, in abbre viate d form, the 4

Based on corre lational analyses of concurrently collecte d salivary and plasma samples collected from this sample of adolescents and assayed in the same lab, a salivary T level of 155 pmol/L corre sponds to a plasma T level of approximately 250 ng/dl. In a se parate study of 150 18- to 25-year-old males, the lowest salivary T value me asured (from afternoon/e arly evening samples) was 192 pmol/L, based on assays conducted in the same lab and using the same assay kit. Our crite rion salivary T level thus falls well be low the lowest postpubertal values typically measured in male s.

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results of alte rnative analyse s excluding all Time 1 nonvirgins. (Eve n with gre ate r re sponde nt loss, results of hormone /behavior analyse s using a more extre me salivary T crite rion level of 99 pmol/L were consiste nt with those reporte d he re for the 155 pmol/L e xclusion rule.) By using an indicator of pube rtal, rathe r than coital, status as the exclusion crite rion we avoid furthe r sample bias base d on the behavior we ’re trying to pre dict, and re ly on more conservative te sts of our primary hypothe sis. It is unlike ly that coital activity would cause a long-te rm increase in T levels that is sufficie ntly stable to be de te cted in a 6-month average of monthly T measure s. If all re sponde nts are include d in be havioral analyses, the re are four possibilitie s in te rms of whether Time 1 hormone value s colle cted from Time 1 nonvirgins will appropriate ly support or fail to support the hypothe sis that coital transition and othe r activity are partially the result of pube rtal increases in hormone s: If T prior to first sex is:

A B C D

high low high high

and T at Time 1 measure ment is: high low high low

the implication for hypothe sis: evaluation is:

appropriate support appropriate contradiction inappropriate support inappropriate contradiction

By excluding re sponde nts whose initial T le ve l e xce eds our criterion value , possibilitie s A and C are exclude d. Only C would libe ralize tests by supporting the hypothe sis whe n better time d hormone data would not have . Howe ver, because we do not have precoital T measure s for Time 1 nonvirgins, C cannot be distinguishe d from A. By e xcluding all boys who start the study with pube rtal T levels, regardle ss of coital status, we are eliminating cases that would legitimate ly support the hypothe sis, as well as those that would imprope rly inflate a hormone /behavior re lationship.

RESULTS Relation ship s Amon g Testosteron e Measures an d Pu bertal Developm en t Previous re ports have de monstrate d the variability that can occur in salivary T value s base d on assays of the same spe cime ns using diffe rent assay systems or laboratorie s (Halpe rn and Udry, 1992; Dabbs et al., 1995) .

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Table I. Corre lations Among Salivary Te stosterone (T), the Plasma Fre e T Index (FTI) , and Pubertal Developmen t Concurrent (n = 103) Plasma FTI Semiannual saliva T Semiannual plasma FTI Ave rage saliva T

.56 b

¯

Lagge da (n = 92)

Pube rtal deve lopme nt

Pubertal developme nt

.57 b .60 b

.49b .55b .52b

¯

a

Se miannual hormone measure s are pai re d with pube rtal de velopme nt measure d at the subseque nt round, 6 months later. Ave rage salivary T me asure s are paired with pube rtal deve lopment at the end of the 6-month saliva averaging period. b p £ 0.0001.

Accurate , reliable re sults can be achie ved with salivary assays, but it is useful to che ck their validity by comparing salivary results with those from plasma or se rum whe n possible , and with re levant physical measure s, such as pube rtal de velopme nt, for appropriate populations. To asse ss the se issues in the current data, we e xamine d the re lationships among concurre ntly colle cted se miannual measure s of salivary T, pube rtal deve lopme nt, and a plasma Free T Inde x (FTI— a unit-fre e ratio of T and se x hormone binding globulin) . The mean ratio of salivary T to total plasma T was .03. Table I pre se nts the corre lations among the se measure s, base d on the earlie st round for which all measure s are nonmissing for a give n responde nt. The se figure s are comparable to those re porte d in the lite rature (Wang et al., 1981; Sannikka et al., 1983; Halpe rn and Udry, 1992; Rilling et al., 1996) , and indicate an acce ptable re lationship be twe e n salivary and plasma measure s. T value s from the two spe cime n type s are similarly associate d with pube rtal de velopme nt; salivary T value s base d on semiannual and monthly measure ment are also similarly associate d with pube rtal status.

Tim e Trends Figure 1 plots mean value s of pube rtal factor score s, ave rage salivary T, and se xual re ports for e ach of the four 6-month pe riods (pube rtal de ve lopme nt re fle cts status at the start of the 6-month periods) . Saliva T value s are lowe r than those re porte d for adult male s (Dabbs et al., 1995), re fle cting the varying pe rcentage s of prepube rtal and pube rtal male s at each round. Average salivary T and pube rtal de velopme nt factor score s incre ase d significantly ove r time (p = 0.0000). Reports of coital and othe r partne re d-activity showe d a positive , though nonsignific ant, tre nd ove r time .

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Fig. 1. Mean sailvary T, pubertal deve lopme nt and sexual reports across 6-month pe riods.

Average Salivar y Testosteron e Levels an d Sexu al Activity Results of coital initiation analyse s are summarize d in Table II. Highe r le ve ls of salivary T were significantly associate d with an increasing hazard of coital initiation. Whe n pube rtal deve lopme nt is also include d in the mode l, T, but not pube rtal de ve lopm ent, is significantly associate d with coital initiation. 5 Figure 2 plots the predicte d risk ratio base d on salivary T 5

Hazard models e xcluding all Time 1 nonvirgins yie ld a marginal relationship (p = 0.08, one-tailed) betwe en T and coital initiation.

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Table III. Standardized Coefficients from Re peated Me asures Regression Models of Weekly Sexual Re ports Using Concurrent Me asures of Salivary Te stosterone and Pubertal Developmen t (n = 101) a De pe ndent variables Coitus Model 1: T only Ave rage salivary T Time Model 2: T and pubertal de velopmene t Ave rage salivary T Pubertal developme nt Time

Partne red activity

2.43 ¯ .65

c

2.56 ¯ .72

c

2.10 0.94 ¯1.06

b

2.44 0.92 ¯1.13

c

a

Re spondents with initial salivary T levels > 155 pmol/L excluded. p < 0.05, one-tailed. c p < 0.01, one -tailed. b

and salivary T were not significant). 6 The se cond se t of mode ls in Table III adds pube rtal de ve lopme nt. As would be expe cted give n the relationship between T and pube rtal de ve lopme nt, the regre ssion coefficients for T are some what reduced, but re sults are othe rwise unchange d. Pube rtal deve lopment is unre late d to activity whe n T measure s are include d in the mode l.

With in -Individ ual Chan ge Table IV summarize s the results of analyse s examining the relationship between within-individual change s in ave rage salivary T across consecutive 6-month pe riods and concurre nt change in che cklist be havior re ports. Change in salivary T was significantly associate d with change in partne red activity; the re lationship be twee n change in T and change in coital activity was positive but not significant. The association between change s in partnered activity and T did not vary by time .7 Whe n change in pube rtal de6

Using the full sample of respondents, we also tested whether the relationship betwe en salivary T and checklist reports of partnered activity varied by coital status at study e ntry (i.e., the interaction of salivary T and initial coital status). This interaction was not significant, sugge sting that responde nt attrition associated with initial coital status was not me aningfully affecting the de monstrated relationship between salivary T and weekly reports of partnered activity. Models of coital and other partne re d activity that e xcluded all Time 1 nonvirgins produced significant relationships between T and partnere d activity (p < 0.05) and a marginal re lationship with coital reports (p < 0.06) . 7 The relationship betwee n change in salivary T and change s in reports of partne re d activity also did not vary by the coital status of re spondents at study entry. A model of partnered activity that excluded all Time 1 nonvirgins indicated significant relationships between change in T and change in activity (p < 0.05) .

458

Halp ern , Udry, an d Su ch in d ran Table IV. Standardize d Coefficients from Repeated Me asure s Re gression Models of Change in We e kly Se xu al Re ports Using Concu rre nt Chan ge in Salivary T and Pubertal Developme nt (n = 94) Change in dependent variables

Model 1: T only Baseline salivary T Salivary T-change Time Model 2: T and pubertal developme nt Baseline salivary T Baseline pubertal score Salivary T-change Pubertal deve lopment change Time a b

Coitus

Partnered activity

¯ 1.11 1.05 0.75

¯ 1.09 b 1.64 0.81 ¯ 1.39 1.06 a 1.37 ¯ 0.01 0.68

p < 0.10, one -tailed. p < 0.05, one -tailed.

velopme nt was adde d to the mode l of partne red behavior, the coefficient for salivary T is re duce d and is of marginal significance . Approximate ly 25% of all T-change scores were ne gative (i.e ., the average T le ve l droppe d from one 6-month period to the ne xt); we the refore te ste d whether the re lationship be twee n T and behavior varie d according to the dire ction of T change . This inte raction was not significant (p = 0.21) , indicating that incre ase s in T are associate d with incre ased behavioral reports and decrease s in T are associate d with de creased behavioral re ports. Figure 3 illustrate s the mode l of within-individual change over time , by plotting pre dicte d chan ges in partne re d e xpe rie nce base d on mean change s in salivary T, and T-change value s that are 1 standard de viation above and below the mean change scores. (T le ve l at study entry is held constant at its mean.) The re gression parame te rs indicate that across 6month periods, incre ases in T le ve ls that are 1 standard de viation above the mean level of T change would be associate d with incre ase s in sexual activity that are approximate ly four times as large as those associate d with le ve ls of T change that are 1 standard deviation below the mean.

Com parison s Across An alys es of the Pan el Data Results for the pre se nt sample indicate that adole scent males with highe r salivary T leve ls are more sexually active and are more like ly to initiate coitus than are males with lower le vels. Further, within-individual analyse s ove r time sugge st that incre ase s in T are associate d with mean-

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Table V. Summary of Main E ffects Models Testing Re lationships Be tween Time-De pende nt Measures of Te stosterone and Sexual Be havior Across Specimen Type, Collection Schedule s, and Sexual Measures for Adolescent Male Panel Sample a Te stosterone measures b Sexual me asures c Semiannual Initiation of coitus Partne red behavior (cumulative) Weekly Coitus Partne red behavior

Semiannual plasma FTI

Semiannual saliva T

Ave rage of monthly saliva T

ns ns

p < 0.05 ns

p < 0.01 ns

ns ns

ns ns

p < 0.01 p < 0.01

a

Analyses are base d on responde nts with initial salivary T levels of < 155 pmol/L. All hormone measures are time-depe ndent; significance tests of hormones are one-tailed. For semiannual sexual measures: Semiannual T measures at the start of the behavior report period are use d; ave rage salivary T measure s for the 6-month period leading up to the se m iannual re port about that 6-m onth pe riod are u se d. For we ekly sexual me asu re s: Semiannual T me asure s at the start of the 6-month reporting period are use d; average salivary T measures are concurrent with the 6-month reporting period. c Coital initiation results are based on hazard model analyse s; repe ated-measures regression analyses were used for all other variables. b

ove rall expe rience (which could reach a ceiling afte r 10 occurre nce s). Other analyse s (Jaccard and Wan, 1995) indicate that the aggre gation of weekly reports of sexual activity, e spe cially for salie nt behaviors such as coitus, can be used as a crite rion for the accuracy of se xual re ports re quiring re call ove r longe r pe riods. Thus the more fre que nt colle ction sche dule and the gre ate r specificity of the checklist variable s used he re should alle viate proble ms of recall, and provide a more discre te link be tween hormonal and behavioral change . To e xamine whe the r these measure ment diffe rence s contribute d to difference s across pane l re sults, we re pe ated analyse s on the weekly checklist variable s use d in the pre sent pape r and on the paralle l semiannual questionnaire variable s pre viously analyze d. We teste d the re lationship be tween each type of sexual measure and plasma FTI and salivary T. In saliva models we looke d at both the ave rage saliva T le vels ove r 6-month periods, and the semiannual saliva T value s that corre spond to se miannual plasma FTI. This latte r distinction addre sses the issue of whethe r the numbe r of measure s (i.e ., colle ction sche dule ) for a give n specimen type is important. An ave rage of multiple T measure ments may be a more re pre sentative inde x of an individual ’s T le vel ove r a give n time pe riod than is a single random assessment. Table V summarize s the re sults of the se mode ls. The se miannual plasma Free T Inde x is unre late d to all sexual measure s. The semiannual

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measure of salivary T is significantly associate d with coital initiation, but not with cumulative or weekly behavioral re ports. Ave rage salivary T, like the othe r two T measure s, doe s not predict cumulative noncoital experie nce as measure d in the se miannual que stionnaire . Howe ve r, it is associate d with weekly reports of the se be haviors, and is a bette r predictor of coital initiation than semiannual saliva T. This patte rn of relationships sugge sts that all factors (specimen type , T measure ment schedule , and the way in which sexual be havior is measure d) are contributing to diffe rence s across pane l findings, and that developing T/be havior re lationships may be more evide nt when hormone le ve ls are measure d more freque ntly, and when be havior reports are specific, time-limite d, and re quire recall ove r a shorte r period. Figure 4 illustrates the basic similarity in T re lationships that exist across analyse s, and the variations in relationship strength stemming from measurement difference s. Predicted value s of weekly coital activity are plotte d, based on the three T indice s. Testosterone value s used in the regression equations reflect mean T, and T value s that are 1 standard deviation above and below the mean, as calculate d within each 6-month period. The plots illustrate that there is a positive relationship between each T measure and coital activity, but the magnitude of the relationship is greater when more frequently colle cted salivary T measure s are use d. In plot A, predicted coital activity base d on ave rage salivary T value s that are 1 standard de viation above the mean is 2 1/2 to almost 4 time s highe r than predicte d be havior based on salivary T le vels that are 1 standard de viation be low the mean T le vel for this sample of adole scents. Plots B and C, based on se miannual saliva T and plasma FTI measure s, predict slightly smalle r be havioral differences base d on diffe rence s in T. In each case, howe ver, the models predict meaningful e le vations of coital activity across the 2-year pe riod.

DISCUSSION In biosocial mode ls of adole scent sexual behavior, pube rtal change s in te stoste rone are hypothe sized to have both dire ct and indire ct effe cts on adole scent sexual timing and activity. Indire ct e ffects re fle ct te stoste rone ’s causal role in various facets of pube rtal de ve lopm ent. Multiple aspe cts of pube rtal deve lopme nt are visible to the adole sce nt, pe ers, pare nts, and othe r adults. The se cues signal impe nding sexual maturity, and deve lopmental change s in attitude s, capabilitie s, and behavior. The adole scent who is more physically mature is perceived, by the self and othe rs, as an attractive and appropriate se xual partne r. Te stosterone ’s relationship with sexual activity is thus partly a re sult of social proce sse s that are se t into motion by te stoste rone ’s contribution to physical maturation.

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Fig. 4. Predicted coital activity.

The prese nt pane l re sults, base d on monthly measure s of salivary T, are consiste nt with the biosocial model. Boys with highe r leve ls of T re port more sexual e xpe rie nces re quiring a partne r and are more like ly to initiate coitus. Within-individual change s in T ove r time are associate d with change s in sexual activity. Increase s in T are associate d with incre ase d activity and T de creases are associate d with de creased activity. The relationship between T and sexual activity holds whe n le vel of pube rtal developme nt is controlle d, although in change models that include both factors neither is

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statistically significant. O ve rall, these findings support the hypothe sis that the re are both direct and indire ct T effe cts on sexual be havior. Further, the behavioral diffe rences associate d with variation in T le ve ls are of a meaningful magnitude , and are evide nt for the se xual behaviors that have the gre ate st implications for the he alth and well-be ing of the adole scent. A male adole scent with T levels in the low adult range is at least twice as like ly to initiate coital be havior as an adole scent with prepube rtal T le ve ls. Incre ase s in othe r partne red se xual activity are about four times as large . Results for male s confirm, in prospe ctive longitudinal data, the re lationships betwee n pube rtal te stosterone le vels and adole scent se xual activity that were de monstrate d in earlie r cross-sectional work (Udry et al., 1985) . Findings for male s are also consiste nt with those of a paralle l pane l study of adole scent females in which T le vels, and increases in T leve ls, were associate d with a highe r like lihood of coital initiation (Halpe rn et al., 1997) . Taken toge the r, the findings indicate that pube rtal incre ase s in T contribute to diffe rence s in sexual activity betwee n individuals and within individuals ove r time for both male and fe male adole scents. O ur conclusions about the relationship between T and se xual activity should be evaluate d in the context of the limitations of the current study. Ide ally, all participants would have entered the study with pre pube rtal T le ve ls and no sexual e xpe rience , and would have been followe d throughout the ir pube rtal pe riod. Howe ve r, such a de sign would have ne cessitate d recruiting re sponde nts at a much earlie r age (when que stions about sexual activity would be inappropriate ), and tracking participants with an intensive weekly inte rvie w sche dule for a period longe r than 3 years. Given the ethical and practical difficultie s of the ideal, we are limite d to a sample in which some responde nts had alre ady had sex at study entry and some were already expe riencing pube rtal change s in T. Responde nts with the se characte ristics were more like ly to le ave the study e arly, and biase s ste mming from selectivity and attrition may affe ct the validity or ge neralizability of our conclusions. Howeve r, the effect of the se sele ction patte rns is like ly to be a lessened ability to de te ct hormone /behavior relationships. We have tried to addre ss these limitations to the extent possible . Because we have Time 1 measure s for virtually all participants (and have measure s at multiple time points for many of the study dropouts), we can include data from dropouts in be havioral analyse s. We have also examine d the issue of whethe r re lationships be twe en T and sexual measure s varie d according to responde nts’ coital status at study entry, and found that they did not. Furthe r, analyse s base d on those adole scents whose T levels at study entry were pre pube rtal, and analyse s in which all Time 1 nonvirgins were exclude d, yield similar patte rns of results.

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Although prese nt analyse s have focused on T, we do not mean to imply that social conte xt or othe r attribute s of the individual play a lesser role in adole scent se xuality. O bviously there are multiple important de te rminants, and as we have de monstrate d in othe r analyse s of male and female pane l data, social and dispositional factors can mode rate relationships between hormonal change and be havior in important ways (Halpe rn et al. 1994b, 1997) .

ACKNOWLEDGMENT Portions of this manuscript were pre sente d at the Socie ty for Research on Adole scence Mee ting, March 7-10, 1996, Boston, Massachuse tts.

REFERENCES Bentler, P. M. (1968a) . Heterose xual behavior asse ssment-I. Males. Behav. Res. Ther. 6: 21-25. Bentler, P. M. (1968b) . He terosexual behavior asse ssment-I. Females. Behav. Res. Ther. 6: 27-30. Brown, W. A., Monti, P. M., and Corriveau, D. P. (1978) . Serum te stosterone and sexual activity and interest in me n. Arch. Sex. Behav. 7: 97-103. Butler, G. E., Walker, R. F., Walker, R. V., Teague, P., Riad-Fahmy, D., and Ratcliffe, S. G. (1989). Salivary testosterone levels and the progre ss of puberty in the normal boy. Clin. Endocrinol. 30: 587-596. Cox, D. R. (1972) . Regression models and life tables (with discussion). J. Roy. Statist. Soc, Series B 34: 187-220. Dabbs, J. M., Jr., Campbell, B. C., Gladue , B. A., Midgley, A. R., Navarro, M. A., Read, G. F., Susman, E . J., Swinkels, L. M. J. W., and Worthman, C. M. (1995) . Re liability of salivary testosterone me asurements: A multicente r evaluation. Clin. Chem . 41: 1581-1584. Davidson, J. M., Camargo, C. A., and Smith, E. R. (1979) . E ffects of androge ns on sexual behavior of hypogonadal men. J. Clin. Endocrinol . Metab. 48: 955-958. Halpe rn, C. T., an d Udry, J. R. (1992) . Variation in adole sce nt horm one me asure s and implications for behavioral research. J. Res. Adolescence. 2: 103-122. Halpe rn, C. T., Udry, J. R., Campbell, B., and Suchindran, C. (1993) . Testosterone and pube rtal de ve lopme nt as predictors of se xual activity: A pane l analysis of adole sce nt male s. Psychosom . Med. 55: 436-447. Halpe rn, C. T., Udry, J. R., and Suchindran, C. (1994a). Effects of repeate d questionnaire administration in longitudinal studies of adole sce nt males ’ sexual behavior. Arch. Sex. Behav. 23: 41-57. Halpe rn, C. T., Udry, J. R., Campbe ll, B ., Suchindran, C., and Mason, G. A. (1994b) . Te stosterone and re ligiosity as predictors of sexual attitudes and activity among adolescent males: A biosocial model. J. Biosoc. Sci. 26: 217-234. Halpe rn, C. T., Udry, J. R., and Suchindran, C. (1997) . Te stosterone predicts initiation of coitus in adole sce nt female s. Psychosom . Med. 59: 161-171 Jaccard, J., and Wan, C. K. (1995) . A paradigm for studying the accuracy of self-reports of risk be havior rel evant to AIDS: Empirical pe rspe ctive s on stability, re call bias and transitory influences. J. Appl. Soc. Psycol. 25: 1831-1858. Kraeme r, H. C., Be cke r, H. B.; Brodie, H. K. H., Doering, C. H., Moos, R. H., and Hamburg, D. A. (1976) . Orgasmic freque ncy and plasma testosterone in normal human males. Arch. Sex. Behav. 5: 125-132.

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Luisi, M., and Franchi, F. (1980) . Double-blind group comparative study of te stosterone undecanoate and mesterolone in hypogonadal male patients. J. Endocrin ol. In vest. 3: 305-308. O ’Carroll, R., Shapiro, D., and Bancroft, J. (1985) . Androge ns, be havior and nocturnal e re ctions in hyp ogonadal me n: The e ffect of varying the re place me nt dose . Clin. Endocrinol. 23: 527-538. Raboch, J., and Starka, L. ( 1973) . Reporte d coital activity of men and le vels of plasma testosterone . Arch. Sex. Behav. 2: 310-315. Rilling, J. K., Worthman, C. M., Campbell, B. C., Stallings, J. F., and Mbizvo, M. (1996) . Rat ios of plas ma an d sal ivary te stoste rone throu gh out pube rty: Pr oduction vs. bioavailability. Steroids 61: 374-378. Salmimie s, P., Kockott, G., and Pirke, K. M., Vogt, H. J., and Schill, W. B. (1982) . E ffects of testosterone re placement on sexual behavior in hypogonadal me n. Arch. Sex. Behav. 11: 345-353. Sannikka, E., Te rho, P., Suominen, J., and Santti, R. (1983) . Testoste rone concentrations in human se minal plasma and saliva and its correlation with non-protein bound and total testosterone levels in serum. Int. J. Androl. 6: 319-330. SAS Institute, Inc. (1993) . SAS Techn ical Report P-243, SAS/5TAT Software, The G ENMOD Procedure, Release 6.09, Cary, NC. Skakke bae k, N. E ., B ancroft, J., Davi dson, D. W., an d Warn e r, P. ( 1981) . A ndroge n replaceme nt with oral testosterone undecanoate in hypogonadal men: A double blind controlled study. Clin. Endocrino l. 14: 49-61. Smith, E ., and Udry, J. R. (1985) . Coital and noncoital sexual behaviors of white and black adole sce nts. Am . J. Pu blic Health 75: 1200-1203. Steve ns, J. (1986) . Applied Multivariate Statistics for the Social Sciences, Erlbaum, Hillsdale, NJ. Udry, J. R., Billy, J. O . G., Morris, N. M., Groff, T. R., and Raj, M. H. (1985) . Serum androgenic hormones motivate sexual be havior in adole sce nt boys. Fertil. Steril. 43: 90-94. Wang, C., Plymate, S., Nie schlag, E ., and Paulsen, A. (1981) . Salivary testosterone in men: further e vidence of a direct corre lation with se rum testosterone. J. Clin. En docrinol. Metab. 53: 1021-1024.

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

Birth Order an d Siblin g Sex Ratio in Hom osexual an d Heterosexual Non -White Men Anth on y F. Bogaert, Ph.D.1

Researc h ers in terested in th e d evelo pm en t of sexu al orien tatio n h ave in vestigated predom in an tly or exclu sively White sam ples. To ad dress this im balance, the relations between sexual orientation an d two biodem ographic variables, birth ord er an d siblin g sex ratio, were exam in ed in a sam ple of non-White m en. The m en (N = 823) were in terviewed by in vestigators at the Kinsey Institu te for Sex an d Reproduction from 1938 to 1963. A significan tly later birth order was observed for non -Wh ite hom osexual m en relative to non-White heterosexual m en. Non -White hom osexual m en also had an elevated sibling sex ratio. Results add to the generalizability of the birth order an d siblin g sex ratio effects previou sly observed to occur in (White) hom osexual m en. KEY WORDS: se xual orientation; non-Whites; birth orde r; se x ratio.

INTRODUCTION Nume rous studie s, with sample s from diffe rent countrie s, diffe rent time periods, and diffe re nt groups (i.e ., clinical and nonclinical) , have establishe d that homose xual men have , on ave rage , a late r birth order than population norms or comparable groups of heterose xual men (Blanchard and Bogae rt, 1996a, 1996b, 1997; Blanchard and She ridan, 1992; Blanchard and Z ucke r, 1994; Blanchard et al., 1995, 1996, 1997; Hare and Moran, 1979; Slate r, 1962; Zucker and Blanchard, 1994) . Recently, this birth order diffe rence has be en demonstrate d to be primarily the re sult of homose xual men be ing born late r among their brothe rs, relative to he te rosexual men (Blanchard and Bogae rt, 1996a, 1996b, 1997; Bogae rt et al., 1997) . 1

Department of Psychology, Brock Unive rsity, St. Catharines, Canada, L2S 3A1. Ele ctronic mail may be sent via Internet to tbogaert@ spartan.ac.brocku.ca. 467 0004-0002/98/1000-0467$ 15.00/0

Ó

1998 Plenum Publishing Corporation

468

Bogaert

Sibling sex ratio, the ratio of brothe rs to sisters colle ctively reporte d by a group of probands, has bee n almost as studie d as birth orde r, although the effe cts are not as consiste nt. O f the 13 large st methodologically adequate studie s, 7 have demonstrate d an elevate d sibling sex ratio in homosexual men relative to the known human sex ratio, 106 male live births to 100 fe male live births (Blanchard and She ridan, 1992; Blanchard et al., 1995, 1996; Jensch, 1941; Kallmann, 1952; Lang, 1960; Z ucke r et al., 1997) . The significant sex ratios have range d from 114 to 141 male live births to 100 female live births. Significantly e le vate d sex ratios were not found in the othe r six publishe d studie s (Blanchard and Bogae rt, 1996a, 1996b; Blanchard and Zucker, 1994; Bogae rt et al., 1997; Slate r, 1958; Z ucke r and Blanchard, 1994), but none of these studie s had significant findings in the opposite direction, i.e ., significantly sm aller se x ratios for homose xual men. O n ave rage , then, the weight of the e vide nce sugge sts that a sibling sex ratio effect is re liable . Howeve r, after revie wing trends in existing studie s, Blanchard e t al. (1995; see also Blanchard et al., 1996) argue d that elevate d sibling se x ratios occur only in extre mely fe minine homose xual groups (e.g., homose xual transse xuals) . More data is nee ded to establish the re liability of this trend. Both the birth orde r and sibling se x ratio e ffe cts, particularly the former, have be en de monstrate d across dive rse sample s, but the re search participants have be e n limite d to all White (e .g., Blanchard and Bogae rt, 1996a, 1996b) or pre dominantly White (e .g., Bogae rt et al., 1997; Slate r, 1962) sample s. Non-White groups (e.g., Blacks, Asians) may, on ave rage , diffe r from White groups in re le vant biological factors, such as hormone s (e.g., Ellis and Nyborg, 1992; Soma et al., 1975) or sociocultural factors, such as cultural norm s (e .g., Ng and Lau, 1990) , that may affe ct psychose xual deve lopme nt, including the de velopme nt of sexual orientation. Thus, confirmation of these e ffe cts in a non-White sample would de monstrate that the corre lation be twe en birth orde r and sibling se x ratio and sexual orientation in men is not the re sult of a biological or sociocultural factor idiosyncratic to White men. The present study used information from the Kinse y Institute for Research in Sex and Reproduction, one of the world ’s large st database s on human se xuality, to inve stigate the re lationship be tween sexual orientation, birth orde r, and sibling se x ratio in non-White men.

METHOD From 1938 to 1963, the Kinsey Institute for Se x Rese arch re corded 18,216 case historie s, using the inte rvie w sche dule de vise d by Kinse y

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(Gebhard and Johnson, 1979) . The compute r data file s containing adult, non-White men comprise 1188 case s. To minimize unreliable data, 205 cases having incomple te sibship information or who at some point resided in a foste r home /institution before age 18 were eliminate d. The remaining 983 case s se rve d as the database for the present inve stigation. O f the se men, 833 were Black, 122 were Hispanic or of a brown-skinne d race/ethnicity that include d East Indian, 23 were Asian/O rie ntal, and 11 were classifie d as “ othe r.” Men were classifie d as homose xual if the y reporte d “ extensive ” homosexual e xpe rience, define d by Gebhard and Johnson (1979) as more than 20 male sexual partne rs or more than 50 homose xual e xpe rience s (with one or more partne rs). Me n were classifie d as heterosexual if they reporte d either “ no ” or “ rare ” homose xual e xpe rie nce, the latte r de fined by Gebhard and Johnson (1979) as 1 male sexual partne r or 1 ¯5 homose xual experience s, an d they did not re spond that the y e xpe rience d “ much” or “ some ” arousal to que stions about se xual arousal from se eing and thinking of males. Using these crite ria, 160 case s could not be classifie d as eithe r he terosexual or homose xual. O f the re maining 823 case s, 229 were classifie d as homose xual and 594 were classifie d as he te rosexual. Birth orde r was derive d from the proband ’s numbe r of olde r brothe rs, olde r sisters, younge r brothe rs, and younge r sisters. Unfortunate ly, as part of the original inte rvie w/coding protocol, sibling numbe rs over 8 were collapse d into one category, 8+ . In addition, there was no way to distinguish full, half, and ste p siblings in the compute rized data. Decease d siblings were recorded, howeve r, and twins were not counte d in the four sibling totals. Also asse ssed were age , year of birth, biological pare nts’ age at proband ’s birth, numbe r of brothe rs and sisters, and pare ntal socioe conomic status (SES). Education was not used as a social class measure because many probands were still in school when inte rvie wed and the ir current education would not re fle ct the ir ultimate e ducation.

RESULTS The two groups diffe red on age and ye ar of birth (Table I). Because a proband ’s expe cted birth orde r de pends upon demographic tre nds operative around the time of his or he r birth, any be tween-group diffe rences in ye ar of birth re pre sents a pote ntial artifact in birth orde r comparisons (Hare and Moran, 1979) . Thus, prior to asse ssing birth orde r diffe rences in these data, ye ar of birth tre nds were partiale d from the crite rion. Birth orde r was quantifie d using Be rglin ’s (1982) inde x: (olde r siblings + .5)/( total siblings + 1), a metric that controls for family size. This inde x

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Table I. De mographic Comparisons of Homosexual and Heterosexual Non-White Men Homosexuals (n = 229) a x Age Ye ar of birth Fathe r ’s age at proband ’s birth Mother’s age at proband ’s birth No. of sisters No. of brothers b Parental SES a b

SD

Heterosexuals (n = 594) a x

SD

t

p (twotailed)

28.83 1916.80 31.89

8.81 10.10 10.18

34.28 1911.52 32.05

13.69 15.16 9.66

6.73 5.79 0.16

< 0.001 < 0.001 0.871

24.93

8.02

25.69

7.88

1.11

0.265

1.55 1.98 3.14

1.60 1.98 1.23

1.86 2.13 3.29

1.72 2.11 1.38

2.36 0.89 1.48

0.019 0.374 0.140

Sample size varies for some variables because of missing cases. Parental SES varies from 1 = extreme poverty to 8 = e xtreme we alth.

expre sse s birth orde r as a quantity betwee n 0 and 1, with highe r value s indicating a late r birth orde r. Berglin ’s inde x for homose xual men was .522 (SD = .252) ; for heterose xual men, it was .491 (SD = .393) . To evaluate a possible diffe rence betwee n the se means, I e ntered Berglin ’s inde x, along with line ar, quadratic, and cubic te rms for year of birth into a logistic regre ssion analysis to predict sexual orientation. Berglin ’s inde x significantly predicted se xual orientation (p < 0.05, one -taile d). To evaluate possible birth orde r e ffects among brothe rs or siste rs, two othe r indice s, a frate rnal inde x and a sororal inde x, were calculate d (see Bogae rt et al., 1997) . The frate rnal inde x quantifie s a proband ’s birth order relative to his brothe rs as (olde r brothe rs + .5) /(total brothe rs + 1) and, like Berglin ’s inde x, range s betwee n 0 and 1, whe re a highe r value indicate s a late r birth orde r among brothe rs. The sororal inde x similarly quantifie s a proband ’s birth orde r relative to his sisters as (olde r siste rs + .5) /(total siste rs + 1). The fraternal inde x for the homose xual men was .522 (SD = .240) ; for the he te rosexual men, it was .499 (SD = .246) . The sororal inde x for the homose xual men was .511 (SD = .216); for the he terosexual men, it was .482 (SD = .242) . To e valuate possible diffe rence s between the se means, I e ntere d the fraternal inde x or sororal inde x, along with the line ar, quadratic, and cubic terms for year of birth into logistic re gressions analyse s to predict sexual orientation. The sororal inde x was marginally significant (p < 0.07, two-taile d), but the fraternal inde x did not reach a conve ntional le ve l of significance . Finally, the two groups were assessed for their sibling sex ratios, i.e., the proportion of brothe rs to sisters colle ctively reporte d by a give n group of probands, and the se value s were compare d with the known human sex ratio, .5146, using the z approximation to the binomial te st. Unlike birth orde r, the human se x ratio is resistant to pe rturbation by demographic vari-

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able s (James, 1987). The hete rosexual men had a total of 1263 brothe rs and 1107 sisters, for a se x ratio of .5329, a value that did not diffe r significantly from the e xpe cted value (p = .08, two-taile d); however, the homose xual men had 454 brothe rs and 356 sisters, for a se x ratio of .5605, a value that differed significantly from the expected value (p = 0.01, two-taile d). Note that the se re sults probably reflect a conse rvative estimate of the re lative e xce ss of brothe rs to sisters in non-White homose xual men be cause of this sample ’s numbe r of Black participants (approx. 84% ), who have be en found to have a lower sibling sex ratio than the White population value (James, 1987).

DISCUSSION The re sults provide evide nce for a significant relationship be tween birth orde r and sexual orie ntation in non-White men. In addition, evide nce for an ele vate d sibling se x ratio in non-White homose xual men was found. These results de monstrate that the obse rve d correlation be tween birth order and sibling se x ratio and sexual orientation in men is not the result of a biological or sociocultural factor idiosyncratic to White men. The birth orde r/se xual orie ntation effect in men has shown an impre ssive degree of generalization, with sample s from differe nt countrie s, diffe rent time periods, and diffe rent groups (i.e., clinical vs. nonclinical) . With the prese nt study, e vide nce now exists that the birth order effect is generalizable across race/e thnicity. It is also of note that, although the birth order effect in the present study was re lative ly modest (e.g., p < 0.05, one -taile d), the diffe rence be twee n non-White homose xual men and non-White heterosexual men is similar in magnitude to the diffe re nce between White homose xual and White he te rose xual me n in the original Kinse y sample (Blanchard and Bogae rt, 1996a) when the data are conve rted to the same metric. Seve ral the orie s (including biological and psychosocial) have be en advance d to account for a late r birth orde r in homose xual men (se e, e.g., Blanchard and Bogae rt, 1996a) . The pre sent results indicate that the putative mechanism( s) advance d in the se the orie s to affe ct se xual orie ntation probably ope rate (s) across e thnicity/race . A que stion that remains, howeve r, is why the present data do not confirm that the late birth orde r of non-White homose xual men primarily refle cts a late birth orde r relative to brothe rs, as re cent studie s have shown in pre dominantly or e xclusive ly White sample s (Blanchard and Bogae rt, 1996a, 1996b; Bogae rt et al., 1997). Possible reasons are that previous studie s showing the e ffect had either very large power (Blanchard and Bogae rt, 1996a), a sample that allowe d for close matching on key de mographic variable s (Blanchard and Bogae rt, 1996b), or a birth order effect that was rela-

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tively large despite modest power (e.g., Bogae rt et al., 1997). In addition, the high male (vs. female) perinatal and infant mortality rate (e.g., Chahnazarian, 1988) may play a role. If the proband did or could not report olde r siblings who died in e arly childhood, at birth, or as a miscarriage, then the unreporte d olde r siblings are more like ly to be olde r brothe rs than olde r siste rs. These “ unaccounte d-for” boys, along with those actually accounte d for in the olde r brothe r tallie s, could be responsible for driving the high sororal inde x for the homose xual men be cause of the natural correlation between numbe r of olde r brothe rs and numbe r of olde r sisters, but the se lost or unaccounte d-for boys would also re duce the fraternal inde x for the se men. It is of note in this re gard that pe rinatal and infant mortality was high in Black and Hispanic familie s during the beginning of the century when most of these probands were born (e.g., Gutmann and Fliess, 1996). Pe rhaps the most inte resting finding of the prese nt study is that the non-White homose xual men had e levate d sibling se x ratios, de spite the fact that these men were not selected for ge nde r ide ntity or gender role behavior and were probably not unusually fe minine . The homose xual men in this sample had 128 brothe rs for every 100 siste rs, well within the range of sex ratio value s for homose xual men in studie s showing significant effe cts (i.e., 114 to 141) . Both biological and psychosocial theorie s have been formulate d to account for an elevate d sibling sex ratio in homose xual men (for a discussion, see Blanchard et al., 1996) . Such the orie s may now ne ed to be compatible with an e le vate d sibling se x ratio in nonfe minine , nonWhite homose xual men. O ne alte rnative is that the non-White homose xual men were , on ave rage , more fe minine than the White homose xual men, either be cause of the recruitment strate gy e mploye d by Kinse y and his colle ague s inadve rte ntly sele cted more fe minine non-White men, or, perhaps, because non-White homose xual men are, on ave rage , more feminine than White homose xual men.

ACKNOWLEDGMENTS The author thanks Thomas G. Albright for running the statistical analyses, Ray Blanchard and Carolyn L. Hafe r for comme nts on an earlie r draft of this manuscript, and the Kinse y Institute for allowing access to the se data.

REFERENCES Berglin, C. G. (1982) . Birth order as a quantitative e xpression of date of birth. J. Epidim iol. Com mun. Health . 36: 298-302.

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Blanchard, R., and Bogaert, A. F. (1996a) . Biodemographic comparisons of homosexual and he terosexual men in the Kinsey interview data. Arch. Sex. Behav. 25: 551-579. Blanchar d, R., and B ogae rt, A. F. (1996b) . Homosexuality in men and numbe r of older brothers. Am. J. Psychiat. 153: 27-31. Blanchard, R., and Bogaert, A. F. (1997) . Additive effects of older brothers and homosexual brothers in the pre diction of marriage and cohabitation. Behav. G enet. 27: 45-54 Blanchard, R., and Sheridan, P. M. (1992) . Sibship size , sibling sex ratio, birth order, and parental age in homosexual and nonhomosexual ge nde r dysphorics. J. Nerv. Ment. Dis. 180: 40-47. Blanchard, R., and Zucke r, K. J. (1994) . Reanalysis of Be ll, Weinberg, and Hamme rsmith’s data on birth order, sibling sex ratio, and parental age in homosexual men. Am . J. Psychiat. 151: 1375-1376. Blanchard, R., Z ucke r, K. J., Bradley, S. J., and Hume, C. S. (1995) . Birth order and sibling sex ratio in homosexual male adolesce nts and probably pre homosexual fe minine boys. Dev. Psychol. 31: 22-30. Blanchard, R., Z ucke r, K. J., Cohen-Kette nis, P. T., Gooren, L. J. G., and Bailey, J. M. (1996) . Birth order and sibling sex ratio in two samples of Dutch gender-dysph oric homosexual males. Arch. Sex. Behav. 25: 489-508. B ogae rt, A. F., B e ze au , S., Kuban, M., and B lanchard, R. (1997) . Birth orde r, se xual orientation, and pedophilia. J. Abn. Psychol. 106: 331-335. Chahnazarian, A. (1988). Dete rminants of the sex ratio at birth: Review of recent literature. Soc Biol 35: 214-235. E llis, L., and Nyborg, H. (1992) . Racial/ethnic variations in male te stosterone le vels: A probable contributor to group difference s in health. Steroids 57: 72-75. Gebhard, P. H., and Johnson, A. B. (1979) . The Kinsey Data: Marginal Tabulations of the 1938 ¯ 1963 In terviews Con d ucted by the Institute for Sex Research, W. B . Sau nde rs, Philade lphia. Gutmann, M. P., and Fliess, K. H. (1996) . The social context of child mortality in the Ame rican Southwest. J. Interdisciplin. History 26: 589-618. Hare , E. H., and Moran, P.A.P. (1979). Parental age and birth order in homosexual patients: A re plication of Slater ’s study. Br. J. Psychiat. 134: 178-182. James, W. H. (1987) . The human sex ratio. Part 1: A review of the literature. Hum . Biol. 59: 721-752. Je nsch , K. ( 1941) . We ite re r B e itrag z ur G e ne alogie de r H om ose xu alitat [ A furthe r contribution to the gene alogical study of homosexuality]. Arch. Psychiat. Nervenkr. 112: 679-696. Kallmann, F. J. (1952) . Twin and sibship study of overt male homosexuality. Am. J. Hum . G enet. 4: 136-146. Lang, T. (1960) . Die Homosexualitat als ge netische s Problem [Homose xuality as a ge netic problem] Acta G enet. Med. G em ellol. 9: 370-381. Ng, M. L., and Lau, M. D. (1990) . Sexual attitudes in the Chinese. Arch. Sex. Behav. 19: 373-383. Slater, E. (1958) . The sibs and children of homosexuals. In Smith, D. R., and Davidson, W. M. (eds.), Symposium on Nuclear Sex, Heineman n, London, pp. 79-83. Slater, E. (1962) . Birth orde r and maternal age among homosexuals. Lancet 1: 69-71. Som a, H ., Takayam a, M., Kiyo kawa, T., Adae da, T., an d Tokoro, K. ( 1975) . Se rum gonadotropin leve ls in Japanese women. Obstet. G ynecol. 46: 311-312. Z ucke r, K. J., and Blanchard, R. (1994) . Re analysis of Biebe r et al.’s 1962 data on sibling sex ratio and birth order in male homose xuals. J. Nerv. Ment. Dis. 182: 528-530. Z ucke r, K. J., Green, R., Coates, S., Z uger, B., Cohen-Kette nis, P. T., Z ecca, G. M., Mone y, J., Hahn-Burke, S., Bradley, S. J., and Blanchard, R. (1997) . Sibling sex ratio of boys with gende r identity disorder. J. Child Psychol. Psychiat. 38: 543-551.

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

A Follow-Up Study for Estimatin g the Effectiveness of a Cross-Gender Horm on e Substitution Th erapy on Tran ssexual Patien ts Kath rin Sch latter er, M.D., Ph .D.,1 Alexan der Yassou rid is, Ph .D.,2 K lau s von Werder, M.D.,3 Dorette Polan d, M.D.,4 Joh an n es Kemper, M.D.,5 an d Gün ter K . Stalla, M.D.1,6

Th is fo llo w-u p stu d y w as c arried o u t to v alid ate th e effectiven ess o f cross-gen der horm on e therapy embedded in a m ultistep treatm ent concept for tran ssexual patients. This therapy described in detail by the au thors elsewhere an d presen ted briefly below provides cross-gen der horm one substitution to obtain an assim ilation of secon dary sex characteristics to the desired sex as quickly as possible. Person al an d social background data of 46 m ale-to-fem ale (M-to-F) an d 42 female-to-m ale (F-to-M) patients passin g throu gh different stages of the treatm ent con cept were in clu ded. In th e E n docrin olo gical Outpatien t Clin ic of the Max-Plan ck-Institute/Mun ich the effectiven ess of cro ss-gen d er h o rm o n e rep la cem e n t th erapy as well a s frequ en cy an d d istribu tio n of sid e effects were exam in ed by follo w-u p exam in atio n of endocrin ological param eters. Cross-gen der horm ones were adm inistered either paren terally or orally. Blood sam ples were collec ted rou tinely after 2 to 6 m onth s dependin g on the du ration of horm one substitu tion an d com plication rate. Th e in c id en c e o f h yp erp ro la c tin em ia in estro gen -treated M-to -F tran ssexuals lies in the range of studies publish ed before, whereas the num ber of patien ts developing galactorrhea is significan tly lower in our patients. The incidenc e of throm boem bolic events durin g the time of cross-gen der horm on e 1

Max-Planck-Institute of Psychiatry, Departmen t of Endocrinology, Kraepelinstrasse 10, D-80804 Munich, Ge rmany. 2 Max-Planck-Institute of Psychiatry, De partme nt Biostatistics, Kraepelinstrasse 10, D-80804 Munich, Germany. 3 Schloß park Clinic, Humboldt University Be rlin, He ubnerweg 2, D-14059 Be rlin, Germany. 4 Richildenstrasse 52, D-80639 Munich, Ge rmany. 5 Bauerstrasse 15, D-80796 Munich, Germany. 6 To whom correspondence should be addresse d. 475 0004-0002/98/1000-0475$ 15.00/0

Ó

1998 Plenum Publishing Corporation

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treatm ent in ou r patien ts is negligible. Chan ges in hematological param eters are observed un der cross-gen der horm on e therapy. With the cross-gen der horm on e regim en perform ed by us it is possible to generate less side effects in the treatm ent of tran ssexual patien ts than described before. KEY WORDS: transse xuality; sex reassignmen t; cross-ge nder hormone therapy; side e ffects; endocrinology.

INTRODUCTION Gende r dysphoric disorde rs have bee n known from antiquity onward across national and cultural boundarie s. They have be en de scribed in classic lite rature from Heroditus to Shake spe are (Pauly, 1965; Green, 1966) . Historically, no diffe re nce was made be twe en transse xualism and transve stism due to the lack of technical opportunitie s for sexual conve rsion like hormone application and sex re assignme nt surge ry. Beside the extre me solution of castration, clothing and cosmetics were the only tools available for both groups of individuals. A hormonal sex change became fe asible after the discove ry of the sex hormone s e arly in the 20th century, and their successful synthe sis and commercial manufacture in the 1930s. During the last decades in Weste rn Europe and the United State s multiste p concepts for the treatme nt of transse xual patie nts, in which cross-ge nder hormone application plays the central role , have be en deve lope d and continously improve d. O ur strate gy for cross-ge nde r horm one tre atme nt was re fine d during the follow-up of 129 transse xual patie nts tre ated in our ne uroendocrinological outpatie nt clinic ove r the last 5 ye ars (Schlatte rer et al., 1996) . O f those patie nts, 88 have be en include d in the prese nt study. Tre atme nt concepts, psychosocial characte ristics, and endocrinological follow-up data are pre sente d. The data show a small incide nce of side effe cts due to our the rape utic strategy.

MATERIALS AND METHODS Sam ple Pop u lation Transse xual patie nts were see n by the authors in the Endocrinological O utpatie nt Clinic of the Max-Planck-Institute be tween 1991 and 1995 inclusive ly. During that time 129 patie nts were re fe rred to us. For the purpose of the present study we revie wed the files of the se patie nts and develope d a questionnaire for pe rsonal data. The patie nts were also intervie wed. Of the 129 patie nts treate d, 88 (46 M-to-F and 42 F-to-M) provide d us with

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personal information and were the re fore include d in the present study, 41 patie nts e ithe r re fused to take part in the inve stigation or the ir addre sses could not be asce rtaine d. A comple te history for controlle d variable s and tre atment schedule s was obtaine d besides the personal data. Physical examinations were pe rformed re gularly.

Cross-Gen der Horm on e Th erap y The aim of cross-ge nde r hormone the rapy in transse xual patie nts is an assimilation of secondary sex characte ristics to the de sired se x as quickly as possible by administration of decreased dose s of specific hormone recombinants in conse cutive time inte rvals (steps) afte r be ginning therapy. For this purpose F-to-M transse xuals were treate d with a 250-mg depot of te stoste rone applie d intramuscularly. Injection inte rvals varie d be tween 2 weeks in the be ginning to 3 to 4 weeks late r on. Optimal lifelong the rapy was designe d individually by re gular scree ning of serum testosterone , while serum estroge n le vels were decreasing. Cross-ge nder hormone therapy for M-to-F transse xuals is more comple x. Testoste rone synthe sis was decreased effectively by application of the antiandroge n cyprote rone acetate. In the beginning of therapy we administe red a daily dose of 100 mg orally, slowly adapting it to falling serum te stosterone leve ls. Estroge ns usually were administe red in a two-phase re gime n. High-dose pharmacological estroge n was give n in the beginning of therapy as an intramuscular depot, ge ne rally eve ry 2 wee ks. O ptimal individual inje ction inte rvals were de fine d according to patie nt’s risk factors, side effects of the rapy, and serum hormone le vels in inte rvals of be twe en 1 and 3 months. As soon as secondary se x characte ristics had fully de ve lope d, the rapy was change d from the high-dose application to a lifelong low-dose estroge n substitution therapy. This also has to be carefully monitore d and modifie d if ne cessary. Antiandroge n the rapy at this point is no longe r ne cessary. For more information concerning crossge nde r hormone the rapy forms, its risks and side effe cts, see Schlatte rer et al., 1996.

Statistical Analys is Since the majority of the variable s conside red in the study are of nominal or cate gorial data structure , analysis of continge ncy table s was basically used for evaluating the data at hand. Be side s the freque ncy distributions of transse xuals within the levels (cate gorie s) of the various variable s, tests of significance of the depe nde nce of transse xuality and certain variable s

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base d on the chi-square statistic were pe rformed. (Note : dependent upon the value s of the cell freque ncies the p value s of the chi-square statistic were calculate d e ithe r e xactly or approximate ly with Monte Carlo simulations.) A nominal level of significance a = 0.05 was acce pte d. Various tests of inde pe nde nce (or te sts of homoge neity) were pe rforme d at a reduced le ve l of significance (Bonfe rroni correction) , in orde r to keep the Type I error le ss or e qual to 0.05.

RESULTS Before de aling with the effects of cross-ge nder re place ment the rapy on endocrinological findings the psychosocial background, the medical and drug background as well as the age distribution within each transse xuality group was inve stigate d. We propose d to compare our re sults with those obtaine d by othe r studie s. Information obtaine d by the afore mentione d investigation is prese nted in Table s I-III.

Endocrin ological an d Side Effects Durin g Cross-Gender Horm on e Th erap y The clinical data of our transse xual patie nts are prese nted in Table IV. For 12.5% of our transse xual patie nts, cross-ge nde r hormone the rapy at the time of comple tion of this study was no longe r pe rformed. The numbe r of F-to-M transse xuals with no continue d therapy was more than the Mto-F one s (M-to-F: 6.5% , F-to-M: 19.04% ). The rest (approximate ly 80% ) of our F-to-M transse xual patie nts receive d an intramuscular testoste rone application the rapy (250 mg eve ry 2 ¯3 wee ks). Among the 46 M-to-F patients 32% (i.e ., 15 patie nts) were still in the high-dose pharmacological phase of treatme nt and received a combination therapy of high dose estroge ns toge ther with antiandroge ns (estradiol 40 ¯100 mg im every 2 weeks toge ther with cyprote rone acetate 10 ¯100 mg daily) whereas 4% (i.e., 2 patie nts) re ceived high-dose e stroge n therapy with estradiol 80 ¯100 mg eve ry 2 weeks alone . Of the M-to-F patie nts 22% still needed antiandroge n the rapy whe n re ducing the e stroge n dose s to 2¯8 mg estradiol daily. In 30% of the se patie nts te stoste rone se rum levels had droppe d so far that a combination therapy was pointle ss. The y were administe red estradiol 2 ¯8 mg daily alone . For diffe rent reasons a minority of 2% of our M-to-F transsexual patie nts received the rapy with natural, unconjugate d estroge ns. The same numbe r of patie nts was administe re d a combination of 2 mg cyprote rone acetate and 35 µg ethinyle stradiol.

Horm on e Substitu tion Th erap y on Tran ssexual Patients

479

Unde r the hormone therapy 26% of the M-to-F transse xuals showe d no side effects, whe reas the numbe r of F-to-M transse xuals without side effects was significantly highe r (42% ). Although some of our patie nts showe d more than one side e ffe ct, we pre sent in Table IV the absolute freque ncy for the incide nce of single side effects only. The most common side effect obse rve d by the M-to-F patie nts was the de velopme nt of hype rprolactinemia: 24 M-to-F transse xuals showe d this symptom and in 4 we also found transie nt e levate d leve ls of prolactin. The se 4 patients perfome d mechanical compression of their breasts. The nonpe rsisting elevation of prolactin le vels could be traced to this manipulation procedure of the breast. The incide nce for transie nt hype rprolactine mia with normalizing leve ls of prolactin afte r dose adjustme nt was in the range of those found in studie s already performed for estroge n-tre ate d M-to-F transse xuals. O n the other hand we dete cted no prolactinoma as de scibe d by othe r authors (Assche man et al., 1988, 1989; Kovacs et al., 1994; Goore n et al., 1980) . The portion of patie nts developing galactorrhe a (5/40 @ 13% ) was lower in our study than the corresponding one found by Futterweit (1980) . None of our patie nts develope d deep vein thrombosis or e mbolism during cross-ge nder hormone the rapy performe d in our clinic. These side e fe cts are the most severe one s during estroge n therapy and have bee n seen in many patients (Fortin et al., 1984; Lehrman, 1976). O ne of our M-to-F patie nts suffered from iliac ve in thrombosis following surge ry, anothe r from de ep ve in thrombosis before starting therapy. Here it was not clear if the patie nt self-administe red high dose s of estroge ns without medical control. O ne patie nt suffered from lung embolism before starting the rapy. Here self-administration of estroge ns was also difficult to e valuate . O ne patie nt suffered from seve re varicosis. Therefore in his case we administe red very low dose s of estroge ns unde r pe rmane nt control of blood-clotting parame te rs. This therape utic compromise was performed as an e xception, because the patie nt, who prove d to be a serious and reliable partne r for hormone the rapy, insiste d on estrogen administration. A closer examination of blood-clotting parame te rs as a risk assessment for thromboe mbolic complications (data not shown) revealed for 11 patie nts 1 single case of pathologically alte red parame ters unde r high-dose estrogen therapy. For this purpose we analyze d the prothrombin time , partial thromboplastin time (PTT), antithrombin III, prote in C antige n, functional protein C, prote in S antige n and APC-resistance. Inte re stingly cross-ge nde r hor mone the rapy had an influe nce on erythropoe sis. In 15 e xam ine d e stroge n-tre ate d M-to-F transse xuals we found a de crease of hemoglobin compare d to levels of wome n. In 5, F-to-M transe xual patie nts testosterone treatme nt induce d an incre ase of he moglobin to levels normally se en in biological men (Fig. 1). These change s corre spond to the effe cts of androge ns on e rythropoe sis as de scribe d by

Marital status Single Married Divorced Total No. of children 0 1 2 3 >4 Total O ccupation Employed/civil servant Self-employe d Une mployed School apprenticeship/university Retired Data not available Total Siblings Ye s No Data not available Total

¯ 46

¯ 100.00

58.70 41.30

27 19

60.87 10.87 8.70 10.87 8.70

28 5 4 5 4

¯ 100.00

76.09 13.04 4.35 4.35 2.17 100.00

35 6 2 2 1 46

¯ 46

63.04 26.09 10.87 100.00

29 12 5 46

Abs. freq.

Rel. Freq. to n1

M-to-F (n1 = 46)

18 23 1 41

¯ 1 41

23 1 8 9

¯ ¯ 42

39 2 1

36 5 1 42

Abs. freq.

¯ 100.00

43.90 56.10

¯ ¯ 100.00

56.10 2.44 19.51 21.95

¯ ¯ 100.00

92.86 4.76 2.38

85.71 11.90 2.38 100.00

Rel. Freq. to n2

F-to-M (n2 = 42)

Transsexuality

45 42 1 87

51 6 12 14 4 1 87

74 8 3 2 1 88

65 17 6 88

Abs. freq.

c

2

—a

¯ 100.00

51.72 48.28

¯ 100.00

58.62 6.90 13.79 16.09 4.60

84.09 9.09 3.41 2.27 1.14 100.00

73.86 19.32 6.82 100.00

ns

ns

ns

test of Rel. Freq. indepe ndence to n

Total (n = n1 + n2)

Table I. Absolute and Relative Frequencies of Transsexuals with Various Le vels of Social Background

480 Sch latterer et al.

a

¯ 3 2 2 1

80.43 19.57 100.00

37 9 46 2

¯ 100.00

80.77 19.23

21 5 1 26 1 1 1 2

Re je ction of the inde pendence hypothe sis or significant associations.

Disorders in siblings No Yes Data not available Total Endocrinological disorders Heart/blood circulation system Psychiatric disorders Ne urological disorders Disorders in parents No Yes Total Hirsutism O ther endocrinological disorders Heart/blood circulation system Ne oplasia Psychiatric disorders Ne urological disorders 32 10 42 3 1 1 4 1 2

¯

¯ 3

¯ 18 1

14 4

76.19 23.81 100.00

¯ 100.00

77.78 22.22

69 19 88 5 1 4 6 3 3

35 9 1 44 2 1 4 2 78.41 21.59 100.00

¯ 100.00

79.55 20.45

ns

ns

Horm on e Substitu tion Th erap y on Tran ssexual Patients 481

Further patient disorders No Ye s Data not available Total Endocrinological disorders He art/blood circulation system Immunological disorders Neoplasia Infe ctious diseases Dermatological disorde rs Gastroenterological disorders Urological disorde rs He matological disorde rs O phthalmological disorders Neurological disorders Psychiatric disorders Further drugs No Ye s Data not available Total

¯ 46

39 7

¯ 1 1 4

¯ 46 6 4 1 2 4 3 1 2

24 22

Abs. freq.

¯ 100.00

84.78 15.22

¯ 100.00

52.17 47.83

Rel. Freq. to n1

M-to-F (n1 = 46)

33 8 1 41

¯ 1 5

¯ ¯ 1

¯ ¯ 2

29 12 1 41 3 3 1

Abs. freq.

¯ 100.00

80.49 19.51

¯ 100.00

70.73 29.27

Rel. Freq. to n2

F-to-M (n2 = 42)

Transsexuality

72 15 1 87

53 34 1 87 9 7 2 2 4 5 1 2 1 1 2 9

Abs. freq.

c

2

—a

¯ 100.00

82.76 17.24

¯ 100.00

60.92 39.08

ns

test of Rel. Freq. indepe ndence to n

Total (n = n1 + n2)

Table II. Medical Disorde rs (O ther Than Transse xuality) and Drug Background of Transse xuals Included in the Analysis

482 Sch latterer et al.

b

a

23.91 76.09 100.00 43.48 56.52 100.00

11 35 46 20 26 46

¯

¯ 1

¯ 2

1 3 1

Trend. Re je ction of the inde pendence hypothe sis or significant associations.

Further drugs Psychopharmace utics Heart/blood circulation system Agents Endocrinological agents Dermatics Analgetics Antialle rgics Antiinfectious agents Alcohol Yes No Total Nicotine Yes No Total 22 20 42

23 19 42

¯ ¯

2 1 2 1 2 2

52.38 47.62 100.00

54.76 45.24 100.00 42 46 88

34 54 88

¯

3 4 3 1 4 2 1

47.73 52.27 100.00

38.64 61.36 100.00

ns

b

¯

ns

Horm on e Substitu tion Th erap y on Tran ssexual Patients 483

a

6.98 37.21 37.21 13.95

3 16 16 6

¯ 100.00

¯ 2.33 2.33

¯ 100.00

¯ 1 1 3 43

11.36 40.91 31.82 11.36 2.27 2.27

5 18 14 5 1 1 2 44

Abs. freq.

Rejection of the independence hypothesis or significant associations.

Age at diagnosis < 20 21¯ 30 31¯ 40 41¯ 50 51¯ 60 > 60 Missing Total Age at be ginning of cross-gender hormone therapy < 20 21¯ 30 31¯ 40 41¯ 50 51¯ 60 > 60 No therapy pe rformed Data not available Total

Rel. Freq. to n1

M-to-F (n1 = 46)

¯ ¯ ¯ 2 3 39

3 26 8

¯ ¯ ¯ 3 39

10 23 6

Abs. freq.

¯ 100.00

¯ ¯ ¯ 5.13

7.69 66.67 20.51

¯ ¯ ¯ ¯ 100.00

25.64 58.97 15.38

Rel. Freq. to n2

F-to-M (n2 = 42)

Transsexuality

¯ 1 3 6 82

6 42 24 6

15 41 20 5 1 1 5 83

Abs. freq.

¯ 100.00

¯ 1.22 3.66

7.32 51.22 29.27 7.32

¯ 100.00

18.07 49.40 24.10 6.02 1.20 1.20

c

2

—a

—a

test of Rel. Freq. indepe ndence to n

Total (n = n1 + n2)

Table III. Age Distribution Within Transse xuality Modus at Diagnosis and at Beginning of Cross-Gender Hormone Therapy

484 Sch latterer et al.

Cross-gende r hormone the rapy No longer performe d Will not be performe d Testoste rone 250 mg im/eve ry 2 ¯3 weeks Estradiol 2¯ 8 mg daily Estradiol 80 ¯100 mg im/every 2 wee ks Natural, conjugated estrogens Cyproterone acetate 10 ¯100 mg daily + estradiol 40 ¯100 mg/every 2 weeks Cyproterone acetate 10 ¯100 mg daily + estradiol 2¯ 8 mg daily Ethinylestradiol 35 m g + cyproterone ace tate 2 mg Total Side effects of hormone therapy No Ye s Data not available Total Hype rprolactinaemia Galactorrhe a Thrombosis/e mbolism Increase of the transaminases Acne Pe rsistant ble edings He adaches Concentration problems/sleep proble ms 2.17 100.00 26.32 73.38

1 46 10 28 8 38 24 5

¯

¯ ¯ 2

¯ 6

21.74

10

¯ 100.00

¯ 30.43 4.35 2.17 32.61

4.35 2.17

¯ 14 2 1 15

2 1

Abs. freq.

Re l. Freq. to n1

M-to-F (n1 = 46)

¯ 3

¯ ¯ 4 4 3

13 18 11 31 4

¯ 100.00

41.94 58.06

100.00

¯ 10 4 3 2 3

23 46 19 69 28 5

88

1

¯

¯ 42

10

¯

¯

5 6 34 14 2 1 15

¯ ¯ ¯ ¯

7.14 11.90 80.95

Abs. fre q.

¯ 100.00

33.33 66.67

100.00

1.14

11.36

5.68 6.82 38.64 15.91 2.27 1.14 17.05

Rel. Fre q. to n

Total (n = n1 + n2)

¯ ¯ ¯ ¯

3 5 34

Rel. Freq. to n2

F-to-M (n2 = 42) Abs. freq.

Transsexuality

Table IV. Hormone Therapy and Side Effect O ccurrences Within the Two Transsexual Groups

Horm on e Substitu tion Th erap y on Tran ssexual Patients 485

Sex reassignment surgery already performe d No Yes Will not be pe rformed Data not available Total Complications due to surgery No Yes Total Wound healing proble ms Infections Thrombosis Urological proble ms Capsule fibrosis of silicone implants 83.33 16.67 100.00

20 4 24 2 1

¯ 1 1

39.53 55.81 4.65

¯ 100.00

Rel. Freq. to n1

¯

¯ 1 1

15 5 20 3

16 20 1 5 37 75.00 25.00 100.00

¯ 100.00

43.24 54.05 2.70

Rel. Fre q. to n2

F-to-M (n2 = 42) Abs. freq.

Transsexuality

17 24 2 3 43

Abs. fre q.

M-to-F (n1 = 46)

Table IV. Continued

35 9 44 5 1 1 2 1

33 44 3 8 80

Abs. freq.

79.55 20.45 100.00

¯ 100.00

41.25 55.00 3.75

Re l. Freq. to n

Total (n = n1 + n2)

486 Sch latterer et al.

488

Sch latterer et al.

and Save r, 1995; Goh et al., 1995; Damewood et al., 1989; de Marinis and Arne tt, 1978) .

DISCUSSION In the last 5 years we have establishe d a cross-ge nde r hormone substitution model for our e ndocrinological outpatie nt clinic, embe dde d in a multiste p tre atment conce pt for the transse xual patie nt (Schlatte rer et al., 1996) . Here we pre sent data, summarizing our expe rience s with this the rapy. We are by no means certain that our sample of transse xual patie nts is comple te and represe ntative enough to carry out reliable epide miological calculations. Our findings the refore should be regarde d as estimate s for an ove rview of the patie nt’s pe rsonal background, e ndocrinological findings, and the outcome of sex reassignme nt. Comparing our findings with othe rs publishe d so far, we first evaluate d the psychosocial background (age distribution, marital status, numbe r of childre n, occupation al status, nicotine and alcohol consum ption, family background) of our patie nts as well as the patie nt’s anamne sis. For the most part psychosocial variable s of the two groups of our transse xual patients did not diffe r significantly (se e Table I-III), but these results compare d to those obtaine d by othe r studie s re ve al some discre pance s. With regard to marital status (Table I) the two groups did not show homoge ne ity in the fre que ncy distribution ( c 2 -te st, p < 0.05). Conside rably more M-to-F than F-to-M transse xuals live in marriage , but here also the rate of divorce is highe r. Data to date pre se nt controve rsal findings for this fe ature . O ur findings confirm the re ports of Hoenig and Kenna (1973) and Kockott and Fahrne r (1988) . Conce rning occupational status, the F-to-M patie nts show employme nt patte rns similar to M-to-F transse xuals. The re are some difference s in the freque ncies of the single occupational status levels, but the ir value s did not reach statistical significance : 8.7% of our M-to-F patie nts have alre ady re tire d. The une mployme nt rate for F-to-M transse xual patients in our study is highe r than that for M-to-F transse xuals. This is in contrast to the findings of Tsoi (1992) . In the group of F-to-M transse xuals more patie nts were still in school, appe nticeship, or visite d unive rsity than in the group of M-to-F transse xuals. Tsoi (1990) has describe d for Singapore a lower incide nce for M-to-F transse xuals to be in highe r occupational classe s than F-to-M, due to the fact that many M-to-F transse xuals take up service and e ntertainme nt jobs which can be grade d as skille d or semiskille d. O ne parame te r that diffe rs significantly from the studie s publishe d is the numbe r of siblings. In our sample as many transse xuals have siblings

Horm on e Substitu tion Th erap y on Tran ssexual Patients

489

as those having none , in contrast to Dixe n et al. (1984) , who publishe d an incide nce of being the only child of approximate ly 12% . In the transse xual patie nts ’ pare nts a high history of psychiatric disorde rs has been de scribed by Dixen et al., which could not be confirme d by us. We found a weak occurre nce of endocrinopathie s, cardiovascular proble ms, ne oplastic, and psychiatric-ne urological disorde rs in the pare nts. Approximate ly 50% of the M-to-F transse xuals and 30 % of the F-to-M transse xuals show furthe r disorde rs (se e Table II). Endocrinopathie s and psychiatric proble ms are the most freque nt disorde rs, followe d by dise ases affe cting the cardiovascular system, dermatological disorde rs, and chronic infe ctious disease s. The re latively high incide nce of psychiatric history is consiste nt with the lite rature and can be inte rpreted as e vide nce of an extreme dissatisfaction that the patie nts e xpe rie nce in their curre nt, unacce pte d gende r (Fle ming et al., 1981; Pauly 1974) . Previous studie s showe d a significant numbe r (50% ) of associate d endocrinopathie s in F-to-M transse xuals (Futterweit, 1980) . The incide nce of chronic infe ctious diseases like he patitis B and C as well as HIV infection might possibly be re late d to the se xual behavior these patie nts show be fore the ir disorde r is acce pted and tre ated (same-sex partne rs, sometimes in a homose xual e nvironme nt with an increase d incide nce of se xually transmittable infe ctious disease s). To a minor extent othe r disorde rs have been obse rve d. A ppr oxim ate ly 18% of our patie nts, inde pe nde nt of ge nde r, regularly took othe r drugs be side cross-ge nde r hormone s, Analge sics, psychophar mace utics, and e ndocrinological age nts are the most fre que nt. Slightly fewer F-to-M than M-to-F transe xuals smoke, whe reas the alcohol consumption in F-to-M transse xuals is significantly highe r. The two transse xual groups showe d significant discre pance s both in the age of diagnosis and in the age at be ginning cross-ge nder hormone the rapy ( c 2-te st, p < 0.05) . Most of the patie nts are diagnose d as transsexual betwee n the age of 21 and 30 ye ars, inde pe ndently of the biological ge nde r. About 16% of M-to-F transse xuals are diagnose d olde r than 41 ye ars (Table III). Many of the patie nts were re fe rred to our clinic by the psychiatrist, followe d by the neurologist, the gene ral practicione r, and the internist. As many patie nts are membe r of patie nts ’ organizations as not. Hormone replace ment the rapy was starte d in our clinic with the same age distribution. The kind of cross-ge nde r hormone therapy was adjuste d according to the side effects obse rve d. The incide nce of hype rprolactine mia we found in e stroge n-treated F-to-M transse xuals (Table IV ) lie s in the range of studie s publishe d before (Asscheman et al., 1988, 1989) , where as the numbe r of patie nts deve loping galactorrhe a was significantly lower in our patie nts. None of our patie nts suffered from a prolactin-produc ing pituitary ade noma. The incide nce of thromboe mbolic eve nts during cross-

490

Sch latterer et al.

ge nde r hormone tre atment in our patie nts was zero. Change s in he matological parame ters we re obse rve d unde r cross-ge nde r hormone the rapy. Transie nt rises in transaminase s occurre d at a similar fre quency as de scribed by othe r authors (Asscheman et al., 1989; Me ye r et al., 1986) . The follow-up of the se patie nts for comple te d sex re assignme nt surge ry reve ale d an incide nce of proble ms due to surge ry of approximate ly 20% . Wound healing and urological proble ms prove d to be the most fre quent. M-to-F transse xuals were affe cted slightly more than F-to-M patie nts, despite bette r surgical chance s for this group. Less than 5% of our transse xual patie nts re fuse d any surgica l inte rve ntion. The se numbe rs were inde pendent of biological sex. With this follow-up study we have be en able to demonstrate a low incide nce of se ve re complications occurring due to a spe cific cross-gender hormone replace ment the rapy in 88 transse xual patie nts. Long-te rm follow-up studie s have to be carried out to e valuate furthe r risks of crossge nde r horm one re place ment therapy like the possible deve lopm ent of neoplasia or long-te rm e ffects le ading to cardiovascular dise ases. Cases of ische mic ce re brovascular dise ase s accompagn ying infe rtility the rapy or cross-ge nde r hormone re place ment therapy, as pe rformed in transse xual patie nts, have be en reporte d (Bille r and Save r, 1995) . Influe nce s of estroge n and te stosterone therapy on lipid/lipoprote in profile s are also de scribed (Goh et al., 1995; Dame wood et al., 1989) . The de sign and realization of such stud ie s c ould he lp t o furthe r im prove the rapy strate gi e s for transse xuals.

REFERENCES Alexanian, R. (1969) . Erythropoietin and erythropoie sis in anemic man following androgens. Blood 33: 564-572 Asscheman, H., Goore n, L. J. G., Assies, J., Smits, J. P. H., and de Slegte, R. (1988) . Prolactin levels and pituitary e nlargement in hormone tre ate d male-to-fe male transsexuals. Clin Endocrinol 28: 583-588. Asscheman, H., Gooren, L. J. G., and E klund, P. L. E. (1989). Mortality and morbidity in transse xual patients with cross-gende r hormone treatment. Metabolism 38: 869-873. Biller, J., and Saver, J. (1995) . Ischemic cerebrovascul ar disease and hormone therapy for infertility and transse xualism. Neurology 45: 1611-1613. Damewood, M. D., Bellantoni, J. J., Bachorik, P. S., Kinball, A. W. Jr., and Rock, J. A. (1989) . E xoge nous e stroge n e ffect on lipid/lipoprotein chole ste rol in transsexual male s. J. Endocrinol Invest. 12: 449-454. de Gowin, R., Richard, L., Lave nde r, A. R., Forland, M., and Charle ston, D. (1970) . Erythropoietin and e rythropoie sis in patients with chronic renal failure tre ated with he modialysis and testosterone . Ann. Intern. Med. 72: 913-918. de Marinis, M., and Arnett, E . N. (1978) . Ce re brovascular occlusion in a transsexual man taking me stranol. Arch. Intern. Med. 138: 1732-1733.

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Dixe n, J. M., Madde ver, H., van Maasdam, J., and E dwards, P. W. (1984) . Psychosocial characte ristics of applicants evaluated for surgical cross-gende r re assignment. Arch. Sex. Behav. 13: 269-276. Fleming, M., Cohe n, D., Salt, P., Jone s, D., and Jenkins, S. (1981). A study of pre- and postsurgical transsexuals: MMPI characteristics. Arch. Sex. Behav. 10: 161-170. Fortin, C. L., Kle in, T., Me ssmore, H. L., and O ’Connell, J. B. (1984) . Myocardial infarction and severe thromboembolic complications as se en in an e strogen-de pende nt transsexual. Arch. Intern. Med. 144: 1082-1083. Fried, W., Jonasson, O., and Lang, G. (1973) . The hematological effect of androgen in uremic patients. Ann. Intern. Med. 79: 823-827. Futterweit, W. (1980) . Endocrine manageme nt of the transse xual. N.Y. State J. Med. 80: 1260-1264. Glashan, R. W., and Robinson, M. R. G. (1981) . Cardiovascular complications in the tre atme nt of prostatic carcinoma. Br. J. Urol. 53: 624-627. Goh, H. H., Loke , D. F. M., and Ratnam, S. S. (1995). The impact of long-term te stosterone replaceme nt therapy on lipid and lipoprotein profiles in women. Maturitas 21: 65-70. Goodwin, W. E., and Cummings, R. H. (1984) . Squamous me taplasia of the verumontanum with obstruction due to hypertrophy: long-term e ffects of e strogen on the prostate in an aging male-to-female transsexual. J. Urol. 131: 553-554. G oore n, L. ( 19 90) . T he e ndocri nology of tran sse xu alism : Re vie w an d com m e ntar y. Psychoneuroend ocrinology 15: 3-14. Gooren, L. J. G., van der Ve en, E . A., and van Kessel, H. (1980) . Modulation of prolactin secretion by gonadal ste roids in men. In: MacLe od, R. M., and Scapagnini, U. (eds.), Cen tral and Peripheral Regulation of Prolactin Fun ction, Rave n Press, New York, pp. 373-375. Gre en, R. (1966). Mythological, historical, and cross-cultural aspects of transsexualism. In Benjamin H. The Transsexual Phenom enon. The Julian Press, Ne w York. Hannaford, P. C., Croft, P. R., and Kay, C. R. (1994). Oral contraception and stroke. Stroke 25: 935-942. Hoe nig, J., and Ke nna, J. (1973) . Epide miological aspe cts of transsexualism. Psychiat. Clin. 6: 65-80. Kenne dy, B. J., and Gilbe rtsen, S. (1957). Incre ase d erythropoe sis induce d by androge nic hormone therapy. New. Engl. J. Med. 256: 719-726. Kockott, G., and Fahrne r, E . M. (1988) . Male-to-female and female -to-male transsexuals: A comparison. Arch. Sex. Behav. 17: 539-546. Kovacs, K., Stefaneanu, L., E zzat, S., and Smyth, H. S. (1994) . Prolactin-producing pituitary ade noma in a male-to-female transsexual patient with protracted estroge n administration. Arch. Pathol. Lab. Med. 118: 562-565. Le hrman, K. L. (1976) . Pulmonary embolism in a transsexual man taking diethlstilbestrol. J. Am. Med. Assoc. 235: 532-533. Meyer, W. J., Webb, A., and Stuart, C. A. (1986) . Physical and hormonal evaluation of the transse xual patient. A longitudinal study. Arch. Sex. Behav. 15: 121-138. Pauly, I. (1965) . Male psychosexual inve rsion: Transsexualism. Arch. G en. Psychiat. 13: 172-181. Pauly, I. B. (1968) . The curre nt status of the se x change ope ration. J. Nerv. Ment. Dis. 147: 460-471. Pauly, I. B. (1974) . Female transsexualism I and II. Arch. Sex. Behav. 3: 487-526. Pritchard, T. J., Pankowsky, D. A., Crowe, J. P., and Abdul-Karim, F. W. (1988) . Bre ast cance r in a male-to-female transsexual. A case re port. J. Am. Med. Assoc. 259: 2278-2280. Schlatterer, K., von Werder, K., and Stalla, G. K. (1996) . Multistep treatment concept of transse xual patients. Exp. Clin. Endocrino l. (in press) . Stade l, B. V. (1981) . Oral contraceptive s and cardiovascular disease. New Engl. J. Med. 305: 612-618, 672-677. Symme rs, W. C. (1968) . Carcinoma of the breast in trans-sexual individuals after surgical and hormonal interference with the primary and secondary sex characteristics. Br. Med. J. 2: 83-85.

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Tsoi, W. F. ( 1990) . De ve lopme ntal profile of 200 male and 100 fe male tran sse xu als in Singapore. Arch. Sex. Behav. 19: 595-605. Tsoi, W. F. (1992) . Male and female transsexuals: A comparison. Singapore Med. J. 33: 182-185.

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

Meanin gs Assign ed by Undergraduates to Frequency Statements of Con dom Use Heath er Cecil, Ph.D.1,3 an d Gregor y D. Zim et, Ph .D.2

Stud ies of con dom use m ust rely upon self-report data which m ay not be reliable an d valid. This in vestigation exam ined how 192 undergraduates (17 ¯48 years) in terpret response categories (never, rarely, som etim es, m ost of the tim e, always) used in some su rveys to assess frequency of condom use. Subjects com pleted a qu estion naire that described a scenario of a couple who had engaged in sexual in tercourse 20 tim es during the past 3 m on ths. As part of the survey, there were 21 statem ents in which the stated num ber of tim es condom s were used varied from 0 to 20 (e.g., condom s were used 18 out of the 20 episod es of sexual in tercourse). For each statem en t, subjec ts were instructed to circle the category they believed best m atched the frequency with which con dom s had been used: 31% indicated that using condom s 1 out of 20 tim es was an exam ple of ne ve r usin g condom s; sim ilarly, 23% indicated that usin g con dom s 2 tim es out of the 20 encou nters was an exam ple of never using condom s, 40% indicated that con dom use for 19 out of 20 encoun ters was always using con dom s, whereas 23% applied the always label to con dom use for 18 ou t of 20 encounters. These results generally support the validity of this type of condom use m easurem ent, but suggest that cau tion is needed in interpretation . Im plication s of these find ings are discussed with respect to health m essages an d research m ethodology. KEY WORDS: se lf-report; verbal me aning; condoms; measureme nt. Data collection and analysis supported in part by Grant MCJ-189596 from the Bureau of Maternal and Child Health. Preparation of this manuscript supported in part by National Institute of Me ntal Health center Grant P30-MH52776 to the Cente r for AIDS Intervention Re search. 1 Ce nter for AIDS Interve ntion Re search, 1201 N. Prospe ct Ave nue, Milwaukee , Wisconsin 53202. (e-mail: hce cil@ post.its.mcw.edu) 2 Indiana Unive rsity Medical School, Indianapolis, Indiana. 3 To whom correspondence should be addresse d. 493 0004-0002/98/1000-0493$ 15.00/0

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1998 Plenum Publishing Corporation

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INTRODUCTION The focus of many HIV and pregnancy preve ntion, interve ntions, and educational programs is to increase the rate of condom use . To de te rmine whethe r this goal has been achie ved, scientists and health care profe ssionals colle ct sexual be havior data, most often in the form of self-report (Konings et al., 1995) . Rese arche rs speculate that various biase s are like ly to be prevale nt in self-re port measure s of sexual behavior due to the private nature of se xual be havior (Bradburn et al., 1978; Catania et al., 1990a, 1990b; Clement, 1990) and the inability to verify re ports (Catania et al., 1990a; Konings et al., 1995; Saltzman et al., 1987) . For e xample , it is hypothe sized that the te rminology used in surve y instrume nts may influe nce the degre e to which re sponde nts ove r- or unde rreport the frequency of a particular sexual activity (Catania et al., 1990b; Coyle et al., 1991) . This may be because surve y items or terms are not unde rstood or have diffe rent meanings for each individual re sponde nt (Turne r et al., 1989; Wyatt, 1990) . When measuring sexual be havior, in particular, condom use behavior, there are thre e freque ntly use d formats (She eran and Abraham, 1994) ; (i) ope n-e nde d format in which the responde nt write s in a specific nume rical value , (ii) numerical close-e nde d cate gorie s (e.g., 25% of the time I use d condoms), and (iii) fre que ncy labe led cate gorie s (e .g., never use d condoms) . Reviews indicate that the frequency labe led cate gorical format is the more commonly employe d method for asse ssing condom use behavior (Kauth et al., 1991; Schae ffer and Charing, 1991; She eran and Abraham, 1994). The issue of te rminology is most pronounce d in those studie s requesting re sponde nts to indicate how ofte n condoms were employe d ove r a spe cifie d time period, with typical response choice s of always, most of the time, some times, rare ly, and never. Labe le d categorical frequency measure s of condom use are proble matic for three re asons (She eran and Abraham, 1994) . First, ambiguity is inhe re nt because the re is no consensus concerning what constitute s e ach cate gory of re sponse s. Se cond, inte rpre tations of te rms such as rarely, some time s, and so forth are subje ctive . Third, freque ncy of inte rcourse and numbe r of partne rs may influe nce how re sponde nts re spond to this type of me asure . In summary, the n, re searche rs cannot be certain that a re sponse of never means that a condom was employe d with a freque ncy of zero; nor can one assume that a response of always indicate s that a condom was use d e very time the pe rson had sexual intercourse. Give n the ubiquity of categorical fre quency measure s of condom use and the importance of measuring this sexual be havior, it is impe rative to e valuate how accurate ly re sponde nts re port the ir use of condoms (Abramson and Herdt, 1990) . This study e xamine s how young adults define cate gorical re sponse choice s (i.e., neve r, rare ly, some times,

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most of the time , and always) in a surve y conce rning frequency of past condom use.

METHOD Particip an ts Participants were 192 unde rgraduate s attending a large , urban unive rsity in Indianapolis, IN. Age s range d from 17 to 48 ye ars (X = 22.8, SD = 6.3) and 73.4% were women. Ethnicity was as follows: 11.8% African American, 75.9% White , and 12.3% othe r. Participants were recruited from psychology classes. Participation was voluntary and participants re ceive d extra credit. Participants comple ted a self-report que stionnaire eithe r at the beginning or the e nd of a re gularly schedule d class pe riod. Permission to re cruit stude nts was obtaine d from e ach instructor be forehand. Prior to the administration of the surve y, the class instructor introduce d the first author to the stude nts to le nd credibility to this individual and to encourage students to take this ende avor seriously. Both the course instructor and the first author, who colle cted the data, stre sse d the seriousne ss and importance of this rese arch. The first author e xplaine d to participants that the obje ctive of the study was to he lp re searche rs unde rstand how participants interpre t condom use response cate gorie s commonly used in surve ys. Participants then were read the instructions printe d at the top of the questionnaire to e nsure compre he nsion of the task. In addition, que stions concerning the task were answe red. The que stionnaire require d approximately 15 min to fill out. After comple tion of the surve y, the first author debriefed the stude nts and e ncourage d discussion of stude nts ’ perceptions and implications of the task.

Measure The se lf-re port que stionnaire me asure d the de mographi c characte ristics of age , ge nde r, and race /ethnic background. As part of the questionnaire , participants were give n a written description of a scenario of a couple who had e ngage d in se xual inte rcourse 20 time s during the past 3 months (se e Appendix) . Twenty-one statements followe d in which participants were told that the couple used condoms n time s, with n varying from 0 to 20. The items were presente d in nume rical orde r. For each statement, participants we re instruc te d to circle the cate gory the y be lie ve d be st

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matche d the fre que ncy with which condom s had be en use d. Response choice s range d from never to always. For instance , in one statement, participants were told that condoms were used for 19 out of the 20 sexual encounte rs. The participants ’ task was to decide if this statement reflected condom use of ne ve r, rarely, sometime s, most of the time, or always.

RESULTS Each surve y was reviewed to dete rmine whether the participant ’s response s progre ssed along a continuum from always to never as the numbe r of condom uses decreased. This procedure re vealed that 3% of the surve ys were inconsiste nt because the re sponse s did not conform to this patte rn. These surve ys were exclude d from the data reporte d he rein. Chi-square analyse s did not re ve al inconsiste nt re sponde rs to differ from those persons who comple ted the surve ys in a consiste nt fashion. To determine whethe r male s and females assigne d meanings differe ntially to the freque ncy state ments, chi-square analyse s with a Bonfe rroni adjustme nt were conducte d. This analysis did not re ve al variation in participants ’ assignme nts of condom use state ments to fre quency categorie s as a function of ge nde r. Similar analyse s we re pe rforme d to de te rmine whe the r linguistic interpre tations diffe red as a function of ethnic background. Three se ts of chi-square analyse s with a Bonfe rroni adjustme nt were conducte d to test this hypothe sis (i.e., White vs. African Americans vs. Hispanic vs O ther; White vs. African Americans; White vs. non-White s). These analyse s did not reveal variation in participants ’ assignme nts of condom use state me nts to fre que ncy cate gorie s as a function of ethnicity. Hence , the data were poole d across gende rs and ethnic groups and are reporte d for the whole sample . The range of state ments assigne d to e ach fre quency cate gory (i.e., never, rarely, som etim es, m ost of the tim e, and always), the modal response for each category, and the most freque ntly e ndorse d state ment for each cate gory are shown in Figs. 1 though 5. These figure s demonstrate that most participants agre e d that use of condoms 0 out of 20 time s is never; 4 out of 20 times is rarely using a condom, 10 out of 20 times is som etim es using a condom, 17 out of 20 time s is m ost of the tim e using a condom, and 20 out of 20 time s is always. O f particular inte rest is the obse rve d variation in the categorie s never and always (see Figs. 1 and 5). Although to most re searche rs never means no use at any time, 31 and 23% , re spective ly, of the responde nts assigne d the response category never to state ments indicating condom use 1 and 2 times out of 20. Similarly, in normative usage , always de note s condom use

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Fig. 1. Pe rcentage e ndorsing the response category never (items indicating number of time s out of 20 that a condom was used).

for all occasions. Howe ve r, 40% of the re sponde nts applie d this response cate gory to the statement de scribing condom use 19 out of 20 times, and 23% applie d it to the statement indicating condom use 18 out of 20 times. This sugge sts that the se response cate gorie s are subje ct to some degree of individual inte rpre tation (Table I).

DISCUSSION The obje ctive of this study was to disce rn how participants interpre t the re sponse cate gorie s of never, rarely, sometimes, m ost of the tim e, and

Fig. 2. Pe rcentage endorsing the response cate gory rarely (items indicating number of times out of 20 that a condom was used).

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Fig. 5. Pe rcentage e ndorsing the re sponse category always (items indicating number of times out of 20 that a condom was used).

represe nt each of the se response cate gorie s. This is not surprising because a strict definition or meaning doe s not e xist for the se te rms. There fore, one would e xpe ct the re to be conside rable variation in how each individual define d these middle fre que ncy categorie s. O f particular conce rn and inte rest is the patte rn of response s observed for the e xtre me categorie s, never and always. Although the meanings for the se two response cate gorie s were the least dispe rse d, it is striking that 31% and 23% of the responde nts conside red using a condom 1 to 2 times out of 20 as never and that 40% and 23% of the responde nts classifie d 18 to 19 times using a condom as always using a condom. A plausible explanation for this finding is that individuals may not vie w a term such as never or always as an absolute , but as a range of be havior with exceptions. Given that variation exists in participants ’ interpre tation of categorie s of condom use, it is also sugge sted that caution is neede d whe n inte rpreting fre quency of condom use data. In othe r words, one cannot be comple tely confide nt in a participant ’s or clie nt ’s answe r for frequency of condom use. Because condom use is socially de sirable , one can anticipate that people will ove r-estimate or re port their fre que ncy of using condoms (Bradburn et al., 1978) . This finding may e xplain the transmission of HIV de spite consiste nt condom use re porte d in studie s of se rodiscordant couple s (Fischl et al., 1987; Maye s et al., 1992; Peterman et al., 1988; Pinke rton and Abramson, 1997; Saracco et al., 1993) . That is, couple s may claim consiste nt use, when in fact, condoms were use d all but one or two times, with HIV transmission occurring the one or two times condoms were not used. Additional support for this hypothe sis is provide d by studie s that docume nt pregnancy or transmission of a se xual infe ction within couple s re porting consiste nt condom use (Farr et al., 1994; Z enilman et al., 1994) .

500

Cecil an d Zim et Table I. Responses for Each Fre quency Category of Condom Use Re sponse category in perce ntage

Condom use occasions

Neve r

Rarely

Sometimes

Most of the time

Always

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

94 31 23 11 6 4 3 3 2 1 0 0 0 0 0 0 0 0 0 0 0

4 67 73 81 82 76 58 40 27 18 12 5 5 3 0 0 0 0 0 0 0

2 2 4 8 12 19 38 55 68 76 77 72 63 56 40 22 11 3 2 1 0

0 0 0 0 0 1 1 2 3 5 11 23 32 41 60 76 80 85 76 59 4

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 9 12 23 40 96

The findings here in have implications for rese arch methodology in this domain. First, the post hoc practice of collapsing across cate gorie s of condom use or dichotomizing re sponse s (e .g., into always vs. all othe r cate gorie s), which has be en advocate d by some re searche rs (DiClemente , 1991; DiCle mente et al., 1996) , is not supporte d by our results. O ur data sugge st that a responde nt’s be havior may not be precise ly re pre sente d by a give n cate gory; that is, he or she may say always when in fact, the corre ct response is frequ ently. Collapsing the response categorie s into always versus all othe r cate gorie s, the re fore, presumes a measure ment accuracy that does not exist. In addition, collapsing across seve ral cate gorie s results in an unne cessary loss of information and a resultant incre ase in me asure ment error. The incre ased e rror may produce biase d estimates of the pre vale nce of be havior and/or may le ad to the miside ntification of at risk pe rsons; all of which, may ultimate ly impe de he alth promotion. Second, the data sugge st that surve y items may ne ed additional clarification to help reduce the degre e of individual inte rpretation. For example , for the response cate gory of always, additional information could be pro-

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vide d indicating that this means a condom was used every single time a person had inte rcourse, with no exceptions. In summary, our results provide preliminary e vide nce that categorical fre quency measure s of condom use are ge ne rally valid, but subje ct to individual inte rpretation. Thus, this asse ssment approach may not provide a comple tely accurate portrayal of actual be havior. A limitation of this study is that responde nts were colle ge stude nts, and the se results may not ge neralize to olde r adults or to adole scents. Furthe rmore, women constitute d the majority of the sample . Although chi-square analyse s did not reveal ge nde r to influe nce cate gory assignme nts, future re search should include sample s in which male s and fe male s are more equally represe nted. In addition, it also is not known whethe r responde nts would classify the ir own condom use behavior in the same manne r the y use d for the fictional couple . O ne may spe culate that the y would, according to related results on re sponse bias (Bradburn et al., 1978; Sudman and Bradburn, 1974) . Nonethe less, studie s are ne ede d to addre ss this issue . Future rese arch building on pre sent findings could examine the complementary que stion of how subje cts perceive the categorie s. For example , responde nts could be give n the response categorie s and aske d to indicate how many times out of 20 occasions that category indicate d. Future studie s also are require d in which the re sponse categorie s are operationalize d by participants, in orde r to de te rmine how response choice s could be st be phrase d so as to optimize the reliability and validity of response s. In addition, re search is warrante d that e xamine s how participants process categorical fre que ncy state ments, along with identifying which individuals may be more like ly to re port invalid information. Such an inve stigation would answer the que stion of whethe r re sponde nts recall the ir behavior (e.g., I had se x 3 times in the past week and use d a condom each time) and then classify their behavior or if the y make an infe rence base d on the options available to them in the surve y (e.g., I don ’t recall not using a condom, so I must have always use d the m). In conclusion, this inve stigation highlights the importance of studying the meanings assigne d to the re sponse cate gorie s used to asse ss how often condoms were use d. This study is the first to docume nt the existence of this form of re sponse bias.

ACKNOWLEDGMENT The authors thank Ste ve n D. Pinke rton for his he lpful comme nts on earlie r drafts of this manuscript.

Appen dix. Q uestionnaire

never never never never never never never never never never never never never never never never never never

(2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2) (2)

rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely rarely

(3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3) (3)

some some some some some some some some some some some some some some some some some some

of of of of of of of of of of of of of of of of of of

the the the the the the the the the the the the the the the the the the

time time time time time time time time time time time time time time time time time time

(4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4)

most most most most most most most most most most most most most most most most most most

of of of of of of of of of of of of of of of of of of

the the the the the the the the the the the the the the the the the the

time time time time time time time time time time time time time time time time time time

(5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5) (5)

always always always always always always always always always always always always always always always always always always

(1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

20 out of the 20 time s a condom was use d. 19 time s a condom was use d out of the 20 18 time s a condom was use d out of the 20 17 time s a condom was use d out of the 20 16 time s a condom was use d out of the 20 15 time s a condom was use d out of the 20 14 time s a condom was use d out of the 20 13 time s a condom was use d out of the 20 12 time s a condom was use d out of the 20 11 time s a condom was use d out of the 20 10 time s a condom was use d out of the 20 9 times a condom was used out of the 20 8 times a condom was used out of the 20 7 times a condom was used out of the 20 6 times a condom was used out of the 20 5 times a condom was used out of the 20 4 times a condom was used out of the 20 3 times a condom was used out of the 20

Below are stateme nts conce rning how freque ntly condoms have been used during the past three months. Circle the re sponse that you think the couple would circle conce rning how often the y use d a condom.

Below are statements indicating the numbe r of times out of 20 sexual encounters that a condom was use d

Below are statements conce rning how often a couple used a condom during the past three months. Note , the couple are having se x regularly and have had sexual intercourse 20 time s during the past three months. Each stateme nt listed in the LEFT HAND CO LUMN indicate how many times out of the 20 times a condom was used. For each state ment in the LEFT HAND CO LUMN, indicate how you think they would answer a surve y question concerning their freque ncy of condom use [frequency state ments in the right-hand colum].

502 Cecil an d Zim et

2 times a condom was used out of the 20 1 times a condom was used out of the 20 0 times a condom was used out of the 20

(1) never (1) never (1) never

(2) rarely (2) rarely (2) rarely

C. Race/Ethnity: (1) White (2) African-American (3) Hispanic (4) O ther

B. Ge nder: (1) male (2) female

A. Age:

PLE ASE ANSWER THE FOLLOWING QUE STIONS ABOUT YO URSELF:

19. 20. 21.

(3) some of the time (3) some of the time (3) some of the time

(4) most of the time (4) most of the time (4) most of the time

(5) always (5) always (5) always

Mean ings Assign ed by Un der gradu ates 503

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REFERENCES Abramson, P. R., and Herdt, G. (1990). The assessment of se xual practice s relevant to the transmission of AIDS: A global perspe ctive. J. Sex Res. 27: 215-232. Bradburn, N., Sudman, S., Blair, E ., and Stocking, C. (1978) . Q ue stion threat and re sponse bias. Public Opinion Quart. 42: 221-234. Catania, J. A., Gibson, D. R., Marin, B., Coates, T. J., and Gre enblatt, R. (1990a). Re sponse bias in assessing sexual behaviors re levant to HIV transmission. Eval. Prog. Plan n. 13: 19-29. Catania, J. A., Gibson, D. R., Chitwood, D. D., and Coate s, T. J. (1990b). Methodological proble m s in A ID S be h avi oral re se arc h: Influe nc e s on me as ure m e nt e rror an d participation bias in studies of sexual behavior. Psychol. Bull. 108: 339-362. Clement, U. (1990) . Surveys of heterosexual behaviour. Ann. Rev. Sex Res. 1: 45-74. Coyle, S. L., Boruch, R. F., and Turner, C. F. (1991) . Methodological issues in AIDS surveys. In Coyle , S. L., Boruch, R . F., and Turner, C. F. (e ds.), Evaluating AIDS Prevention Program s: Expanded Edition, National Acade my Press, Washington, DC, pp. 207-316. DiCle me nte, R. J. (1991) . Pre dictors of HIV-pre ve ntive se xual beh avior in a high-risk adole sce nt population: The influence of perce ived peer norms and sexual communication on incarcerated adolesce nts’ consistent use of condoms. J. Adolescent Health 12: 385-390. DiClemente, R. J., Lodico, M., Grinstead, O. A., Harper, G., Rickman, R. L., Evans, P. E., and Coates, T. J. (1996) . African -Ame rican adolesce nts re siding in high-risk urban e nvironme nts do use con dom s: Corre late s an d pre dictors of con dom use amo ng adole sce nts in public housing deve lopments. Pediatrics 98: 269-278. Farr, G., Gabelnick, H., Sturgen, K., and Dorflinge r, L. (1994) . Contraceptive efficacy and acce ptability of the female condom. Am . J. Pu blic Health 84: 1960-1964. Fischl, M. A., Dickinson, G. M., Scott, G. B., Klimas, N., Fletche r, M. A., and Parks, W. (1987). Evaluation of heterosexual partners, children, and house hold contacts of adults with AIDS. J. Am. Med. Assoc. 257: 640-644. Forte nbe rry, J. D., Ce cil, H., Z ime t, G., and O rr, D. P. ( 1997) . Concordance be twee n self-report que stionnaires and coital diaries for sexual behaviors of adolesce nt women with sexually transmitte d disease s. In Bancroft, J. ( e d.), Researching Sexual Behavior, Indiana Unive rsity Pre ss, IN, pp. 237-249. Kauth, M. R., St. Lawre nce , J. S., and Ke lly, J. A. ( 1991) . Reliability of re trospective assessments of sexual HIV risk be havior: A comparison of biweekly, three-month, and twelve-month self-reports. AIDS Educ. Prevent. 3: 207-214. Konings, E ., Bante bya, G., Carae l, M., Bagenda, D., and Me rte ns, T. (1995) . Validating population surveys for the measure me nt of HIV /STD preve ntion indicators. AIDS 9: 375-382. Mayes, S. D., Elsesser, V., Schaefe r, J. H., Handford, H. A., and Michael-Good, L. (1992) . Se xu al prac tice s an d AIDS knowle dge am ong wom e n par tne rs of H IV-infe cte d he mophiliacs. Pu blic Health Rep. 107: 504-514. Peterman, T. A., Stoneburner, R. L., Allen, J. R., Jaffe , H. W., and Curran, J. W. (1988). Risk of hu m an im m u node ficie n cy vi ru s tran sm ission from he te rose xu al adu lts with transfusion-associate d infections. J. Am . Med. Assoc. 259: 55-58. Pinkerton, S. D., and Abramson, P. R. (1997) . E ffectiveness of condoms in preve nting HIV transmission. Soc. Sci. Med. 44: 1303-1312. Saltzman, S. P., Stoddard, A. M., McCuske r, J., Moon, M. W., and Mayer., K. H. (1987) . Reliability of self-reported se xual behavior risk factors for HIV-1 infection in homosexual me n. Public Health Rep. 102: 692-697. Saracco, A,. Musicco, M., Nicolosi, A., Angarano, G., Arici, C., Gavazzeni, G., Costigliola, P., Gafa, S., Gervasoni, C., Luzzati, R., Piccinino, F., Puppo, F., Salassa, B., Sinicco, A., Stellini, R., Tirelli, U., Turbessi, G., Vuge vani, G. M., Visco, G., Z erboni, R., and Lazzarin, A. (1993) . Man-to-woman se xual transmission of HIV: Longitudinal study of 343 ste ady partners of infecte d men. J. AIDS Syndr. 6: 497-502.

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Sch ae ffer, N. C., and Charing, H. W. (1991) . Two e xpe rime nts in simplifying re sponse cate gories: Intensity ratings and behavioral frequencies. Sociol. Perspect. 34: 165-182. She e ran , P., an d Abrah am, C. ( 1994) . Me asu re m e nt of con dom use in 72 studie s of HIV-pre ventive behaviour: A critical re view. Patient Educ. Couns. 24: 199-216. Sudman, S., and Bradburn, N. (1974) . Response Effects in Surveys, Aldine, Chicago, IL. Turner, C. F., Miller, H. G., and Moses, L. E. (Eds.). (1989) . AIDS: Sexual Behavior and Intravenous Drug Use, National Academy Pre ss, Washington, DC. Wyatt, G. E . (1990) . Maximizing appropriate populations and response s for sex re search. In B. Voeller, J. M. Reinisch, and M. Gottlieb (eds.), AIDS and Sex: An Integrated Biom edical and Biobehavioral Approach, Oxford Unive rsity Pre ss, New York, pp. 81-96. Z enilman, J. M., Weisman, C. S., Rompalo, A. M., Ellish, N., Upchurch, D. M., Hook, E. W., III, and Celentano, D. (1994) . Condom use to pre vent incident STDs: The validity of self-reported condom use. Sex. Transm . Dis. 22( 1) : 15-21.

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

Swingin g: A Review of the Literatu re Rich ard J. Jen ks, Ph .D.1

No review of the topic of swinging has been done in the last 20 years. This review is intended to update the literature. Studies estim ating the incidence of swinging, the demograph ic and person ality characteristics of swin gers, along with h ow swingers are perceived by nonswingers are reviewed. Numerous theories explaining this behavior have been presented with a social psychological m odel being the prim ary focus here. Major reasons for getting involved in swinging, initiation into the lifestyle, effects on marriage, and dropping out of swinging are also covered. Finally, the literature dealing with some of the major problem s with swinging, focusing on AIDS, are also discussed, along with the current state of swinging and suggestions for future research. KEY WORDS: swinging; comarital sex; mate swapping.

INTRODUCTION The purpose of this pape r is to revie w the area of comarital se x, or what is commonly referred to as swinging. Although single pe ople do engage in the swinging world, the literature on this topic has limite d itse lf to marrie d couple s. There fore, the definition of swinging as married couple s exchanging partne rs solely for sexual purpose s (Buunk and van Drie l, 1989) is employe d he re and the studie s focus on married couple s. In addition to the focus on marrie d couple s in the re search, the re is often a significant proble m with sample s. Like most are as of sexuality it is difficult, if not impossible , to get random sample s. The refore, most studie s reporte d in the lite rature have be en base d on small numbe rs of people within a single city or community. Furthe rmore , studie s, with some excep1

Department of Sociology, Indiana University Southeast, Grant Line Road, New Albany, Indiana 47150. 507 0004-0002/98/1000-0507$ 15.00/0

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1998 Plenum Publishing Corporation

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Jenks Table I. Summary of Studies on Swingers

Author

Ye ar

N

Bartell Denfeld

1970 1974

280 473

Duckworth and Levitt Gilmartin Je nks

1985

30

1974 1985a

200 406

Je nks

1985b

342

Je nks

1985c

406

Je nks

1986

406

Je nks Je nks Levitt Murstein et al.

1988 1992 1988 1985

60 88 85 60

Palson and Palson Smith and Smith Varni

1972 1970 1972

136 503 32

Sample

Control group?

Mid/Southweste rn whites Counselors who had se en swingers as clients Swing club members

No No

Sexual freedom groups/re fere nce Convention attendees/national swinge rs magazine Convention attendees/national swinge rs magazine Convention attendees/national swinge rs magazine Convention attendees/national swinge rs magazine Convention attendees National swingers magazine Swingers convention Reference s/ads place d in swinge rs magazine Reference s Sexual freedom groups/swingers parties Ads

Yes Yes

No

No Yes Yes Yes No No Yes No No No

tions, have faile d to use control groups. Table I lists the various studie s conducte d in this area along with information relevant to sample size and nature of the sample . With the se proble ms in mind, what has bee n found re levant to the size of the swinging population? Bartell (1971) place d the figure at 1% of marrie d couple s, whe reas Cole and Spaniard (1974) conducte d a surve y in a Midwe stern colle ge community and found that 1.7% had participate d in swinging at least once . In a nationwide surve y Hunt (1974) found that 2% of the male s and le ss than 2% of the females admitte d to having eve r swung, with a large proportion having engage d in it only once. It appe ars, the n, that the incide nce of swinging among married couple s in the U.S. is fairly low, around 2% . It must be e mphasize d, however, that these estimates are date d; no curre nt estimates e xist.

CHARACTERISTICS OF SWINGERS Much inte re st has bee n shown in the characte ristics of swinge rs. Fortunate ly, a numbe r of studie s have be en conducte d on this topic and the results have bee n consiste nt.

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The majority of swinge rs fall into the middle and uppe r middle classe s. Studie s have found swinge rs to be above ave rage in education (Gilmartin, 1975; Jenks, 1985b; Le vitt, 1988) and income (Jenks, 1985b; Le vitt, 1988) and to be in profe ssional and manage ment positions (Jenks, 1985b; Le vitt, 1988) . Studie s (e.g., Bartell, 1970; Jenks, 1985b) also reve al that the majority (ove r 90% ) of swinge rs are White . Anothe r demographic characte ristic that has bee n studie d is age . Nearly two thirds in the Jenks (1985b) study of 342 swinge rs drawn from atte nde es at a national swinge rs conve ntion and reade rs of a national swinge rs magazine were between 28 and 45; the mean age was almost 39 ye ars. The mean age in the Le vitt study was 40.7 and, in the Bartell study the y cluste re d in the 28¯34 age group. Politically swinge rs are moderate to conservative and ide ntify with the Republican party. While 50% vote d for Ronald Reagan in 1980 only 23.7% voted for Carte r (Jenks, 1986) . Bartell (1970) also reporte d many Republicans in his sample of Midwe stern and Southwe stern swinge rs. There is strong evide nce (Flanigan and Zingale , 1991) that highe r income , highe r educate d, people vote Republican. As we have seen, swinge rs have above ave rage income s and e ducations. Thus, the swinge rs may be voting the ir class inte rests. The ir political philosophie s are also in accordance with social class. Whe n aske d to labe l the mselves the plurality of swinge rs said “ moderate ” (41% ), followe d by “ conse rvative ” (32% ), then “ libe ral ” (27% ) (Jenks, 1985a) . O ne are a, howeve r, where swinge rs do se em to be libe ral is the are a of se xuality. In a study of ove r 400 swinge rs (Jenks, 1985a) it was found that the swinge rs were significantly more libe ral than a control group of nonswinge rs on items dealing with are as such as divorce , pre marital se x, pornography, homose xuality, and abortion. Barte ll reporte d that the majority of his sample did not atte nd church regularly. Fully two thirds of the responde nts in the Jenks ’ (1985b) study had no prese nt religious ide ntification. This finding also is consiste nt with othe r studie s. Gilmartin ’s (1975) figure for the swinge rs was 63% . When asked if the y had be en raise d in a re ligious home ove r 68% said yes. Although a little over 70% said the y did not currently atte nd church se rvices in a typical month, the most fre que nt response conce rning church attendance when growing up was every wee k. Thus, swinge rs were raised in religious home but, some whe re along the path to adulthood, a majority gave up the ir re ligion. This contrasts with the American population in general. For example , 92% of Americans claim a religious prefere nce (Gallup and Castelli, 1989) and only 4% can be see n as “ totally nonre ligious ” (Bezilla, 1993) .

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A profile of the swinge r, the re fore, is of a White , middle to uppe r middle class pe rson in his or he r late 30s who is fairly conve ntional in all ways exce pt for her or his lack of religious participation/ ide ntification and participate s in swinging. This conclusion, howe ve r, is at odds with the popular perception of swinge rs.

PERCEPTIONS OF SWINGERS It is safe to say that swinge rs do not e njoy the be st of re putations in our society. Gilmartin (1975) found that almost half of a sample of nonswinge rs would mind if an “ othe rwise unobje ctionable swinging couple move d into their neighborhoods ” (p. 55) . To find out how swingers are perceive d, a surve y (Jenks, 1985b) was conducte d where over 100 nonswinge rs were asked to give their perceptions towards swingers. The se response s were then compare d with the response s of over 300 swingers. Swingers were perceived as using alcohol, marijuana, and othe r drugs far more than the swingers themselve s indicate d. In addition, nonswinge rs ove re stimated the pe rcentage of non-White s participating in swinging, the proportion having a libe ral philosophy, and having a Democratic party identification. When asked to place themselves and swingers on various attitudinal items the nonswingers place d themselves away from where they thought swingers would be on seven of the ten ite ms. Finally, almost one half of swinge rs were seen as in need of psychological counse ling; in contrast only 26% of swinge rs had undergone counse ling (Jenks, 1985b). Swinge rs, the re fore, are ofte n pe rceive d by nonswinge rs as deviant in respects remove d from their sexual behavior. The argume nt used by Jenks to explain this is base d on a labe ling approach. Spe cifically, Becker (1963) and Hughe s (1945) have maintaine d that when the person is seen, or labeled, as having an unde sirable trait, then that person is also assume d by people to have othe r unde sirable traits as well. In summary, from the little rese arch that exists it can be conclude d that (i) swinging is perceived as a de viant activity, and (ii) swinge rs are perceived not only as “ specific ” de viants but as “ ge neral” deviants, that is, deviating in not just one way (swinging) , but in areas totally unre lated to the ir swinging.

PERSONALITY CHARACTERISTICS What about the personality make up of swinge rs? Are they more (less) authoritarian or alie nate d than nonswinge rs? What are the ir value s?

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511 Table II. Terminal Values in Orde r of Preferen ce 1. 2. 3. 4. 5. 6. 7. 8. 9.

Self-respect Family security Inner harmony Happiness (Tie ) Mature love (Tie) True friendship Ple asure Freedom Sense of accomplishme nt

10. 11. 12. 13. 14. 15. 16. 17. 18.

Exciting life Comfortable life Wisdom World at peace Social recognition Equality World of beauty National se curity Salvation

O ne study include d que stions relevant to Authoritarianism, Machiavellianism, Philosophy of Human Nature, Internal-E xternal Control of Reinforce ment, and Alie nation. Basically the results reve ale d that swinge rs and nonswinge rs were not significantly diffe re nt on any of the se measure s (Jenks, 1986) . Swinge rs have also be en aske d to rank orde r a numbe r of te rminal value s (Jenks, 1988) . Te rminal value s are those that refer to a preferable end state of e xiste nce . This scale, deve lope d by Roke ach (1968) , has be en give n to diffe re nt groups of pe ople : police officers, Calvinist stude nts, unemploye d White s and Blacks, and stude nts at a unive rsity. It has been found, for example , that Calvinist stude nts ranke d salvation first. Jewish stude nts, and those e xpre ssing no re ligion, place d the same value last (Roke ach, 1969) . The re sults for the swinge rs are prese nted in orde r of preference (Table II). The swinge rs emphasize d the pe rsonal value s ove r the more social one s. And, like the Jewish sample and pe ople with no religious identification, salvation was place d last. Some whe re in the middle were those value s which were pe rsonal but more achie vement-orie nted. Duckworth and Levitt (1985) gave the MMPI to a sample of 30 swingers. The MMPI is the most wide ly used measure of personality and emotional disorde rs and consists of approximate ly 600 items. They found that half their re sponde nts scored be yond the normal range on their clinical scale evaluations. The large st group (one sixth of all the subje cts) was high on Hypomania, which consists of being hype ractive , often being irritable and low on behavior re straint. O ve rall, however, the findings did not se em to indicate grave psychological proble ms. The limite d numbe r of re spondents and the fact that they were drawn from only one swinge rs’ club should le ad us to treat this finding with caution howe ve r. Finally, in a study of exswinge rs conducte d by Murstein et al. (1985) no evide nce was found that swinge rs were particularly disturbe d individuals.

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INITIATION According to a study by Henshe l (1973) , initiation into the world of swinging generally take s place through the husband. She found that the husband was the first to learn of swinging in 44% of the cases; the wife le arne d first of swinging in only 16% of the instance s. O nce the initial discove ry had bee n made the re was a time lapse until they actually conside red swinging, a second time lapse be twee n conside ring it and actually re aching the final decision, and, finally, anothe r lapse be twe en deciding and actually becoming involve d. In 68% of the cases it was the husband who made the original sugge stion to swing. O nly 3 women (12% ) in Henshe l’s sample made the sugge stion; the remaining 20% was a joint decision. Finally, 16 (64% ) of the husbands, as oppose d to only 2 (8% ) of the wives, were re sponsible for the final decision to swing. Henshe l, then, found the male to be the dominant force in the swinging situation. O n the basis of her findings she argue d that swinging is a male institution and the often used argume nt that swinging is an egalitarian situation nee ds to be re assessed. These findings, however, were based entirely on the response s of only 25 re sponde nts in the Toronto are a. In addition, she inte rvie wed only the wife and, the re fore, a possibility for bias exists. Varni (1974) , who found that the male initiate d swinging in 15 of his 16 cases, also agre e s that swinging is a male institution. It should be note d, howe ve r, that this has bee n a point of debate (Bartell, 1971; Palson and Palson, 1972, Smith and Smith, 1970).

REASONS FOR SWINGING Why do people be come involve d in swinging? What motivate s them to engage in an activity clearly seen as outside the norms of our socie ty? The reasons are many and varie d. Howeve r, there are a numbe r of major reasons that have bee n found to be important. O ne of the primary, if not the primary, reasons for ge tting involve d in swinging is the varie ty of se xual partne rs and e xpe rie nce s. When asked to indicate the major re ason for swinging, varie ty was name d by 26% in one study (Jenks, 1986) . The se cond most freque nt response (19% ) in the same study was that of ple asure or e xcite me nt. This include d the ide a that it was, in one swinge r’s words “ forbidde n fruit” providing the opportunity to participate in a “ deviant ” life -style , to defy socie tal sexual norms.

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513 Table III. A Process Model of Swinging

Step 1: Step 2: Step 3: Step 4: Step 5:

A strong interest in and/or e arly involve ment in se x Pe rsonal characte ristics conducive to swinging: liberal sexual orientation, low degre e of jealousy Passive phase characterize d by learning and talking about swinging, thinking about participating Active phase characte rized by contact with swingers, possibility for withdrawal Commitment phase characterize d by actual involvement, socialization into swinging and the developme nt of a rationale for swinging

The third most popular reason was the possibility of meeting ne w pe ople. Thirte e n pe rcent gave this response . Bartell (1970) also found the increased social life aspe ct to be important with his sample of swinge rs. Voye urism has also be e n note d as a re ason for swinging. Swinge rs in the Barte ll study indicate d that watching othe rs pe rform enable d the m to eithe r le arn ne w te chnique s which they use d whe n the y returne d to their marital re lationshi p or to ove rcome any se xual inhibition s which the y might have had with their spouse . Be yond the “ e ducational ” aspe cts obse rving swinging activitie s provide s, e spe cially for the man, se xual thrills and excite ment. O the r re asons that have been cited include providing a means by which the person can re capture one s’s youth, providing an ego lift for the person in that the pe rson le arns that she or he is attractive and de sirable to people othe r than one ’s spouse , and incre asing their inte rest in their own spouse (Stinne tt and Birdsong, 1978) .

THEORY A numbe r of the orie s have bee n deve lope d to explain swinging. The se the orie s emphasize social variable s like middle class marginality (Walshok, 1971) , autonomy from one ’s family and the othe r institutions in our socie ty (Gilmartin, 1974) , economic prope rty (Palson and Palson, 1972) , and male socialization emphasizing sex (Bartell, 1970) . The most recent theory argue s (Jenks, 1985c) that the se mode ls fail to tell us why all marginal people , autonomous people , etc., do not engage in swinging . Base d on his finding s, along with a mode l pre sente d by Ste phe nson (1973) , Jenks deve lope d a social psychological model of swinging (Table III). The first step involve s e ithe r an inte rest in, or early involve ment in, sex. Not eve ryone is inte reste d e nough to become a swinge r. As Stinne t

514

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and Birdsong (1978) have pointe d out, swinging require s a great amount of time and energy. It se ems logical, therefore , that a person have this strong inte rest in se x. O n the othe r hand, the behavior, rathe r than the attitude , may be important. The basis of many theories (e .g., self-pe rception theory) is that a person, who may not have give n much thought to some thing, or not have a well-de ve lope d attitude , may e ngage in a be havior and then his or her attitude change s or develops to match the be havior (Bem, 1972) . Gilmartin (1974) argue d that this early involve ment in sex is crucial in paving the way for an inte re st in sexual participation and the swinging life -style . Premarital involve ment, for e xample , give s the pe rson the experie nce of participating in “ de viant ” sexual activitie s. Although significant percentage s of male s and females engage in pre marital sexual re lations today (Allge ier and Allge ie r, 1995) it is still “ officially ” conde mne d. And, for people who gre w up in the 1940s or 1950s, pre marital se x was certainly interpreted as going against the pre vailing norms (Bryant, 1982) . Having participate d in a certain kind of activity more than like ly will increase the probability of engaging in future , similar, type s of activitie s (Ajzen and Madde n, 1986) . In othe r words, give n two individuals, one of whom has had extramarital involve ment and one who has not, it might be expe cted that the forme r would be more like ly to do it again. Gilmartin (1975) reporte d that, in his sample of 100 swinging couple s, they starte d to date earlie r, date d more often, and were much more like ly to have had se xual intercourse earlie r than a control group of nonswinging couple s. An active inte re st or involve ment, however, is not enough; only certain types of individuals are susce ptible to swinging. Two personality characte ristics are important here : a libe ral sexual pre disposition and a low degre e of jealousy. As indicate d above , swinge rs tende d to be politically mode rate and conse rvative but more libe ral when we conside r various issues relating to se xuality. In addition, Jenks (1985c) found that his sample of swinge rs score d significantly lowe r on jealousy than did a control group. At this point Jenks states that a mode l propose d by Stephenson (1973) become s re le vant. In this mode l the person first be come s involve d in a passive phase . Here , the individual finds out about swinging and doe s some thinking and talking about it. Next, come s the active phase . Here, contact may be made with swinge rs. Finally, the commitme nt stage encompasse s an actual involve ment in, and acce ptance of, swinging. The new swinge r also be comes socialize d into the subculture , le arning the language , a rational for swinging, etc. This pe rspective , a process model, he lps us to unde rstand why, within certain groups of people (middle class, e tc.), particular individuals may be-

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come involve d. Finally, the mode l is argue d to pe rtain to longte rm, successful swinging. If only some of these factors are prese nt, the individual may only try swinging for a while and the n drop out of the scene.

PROBLEMS WITH SWINGING Seve ral major proble ms have be en note d in the re search. Six of the more common one s are discusse d.

Fear of Sexu ally Tran sm itted Diseases Whe n aske d to indicate the bigge st disadvantage of swinging, the numbe r one re ason give n in the Jenks ’s (1992) study was the fear of contracting ve ne real disease . An e arlie r study by Murstein et al. (1985) reporte d that 33% of husbands and 10% of the wive s feare d V D. More recently AIDS has come to the fore front as a re ason for not swinging. In a 1992 study assessing the impact of AIDS on swinge rs it was found, somewhat surprisingly, that the swinge rs expressed, ove rall, only a mode rate fe ar of contracting the HIV (a mean score of 2.6 on a 5-point scale ). Around 58% e xpre sse d at le ast some fe ar of contracting AIDS (Jenks, 1992) . In contrast, a national surve y re porte d by Q uinle y (1988) found that only 13% of responde nts re porte d at le ast being “ fairly worried ” about the dise ase . Therefore , although the figure for the swinge rs is not as high as some might expe ct, it is highe r than a random sample of American adults. Almost 22% indicate d that they kne w some one who had the AIDS virus; howe ve r, swinging was not mentione d as the re ason why these people had contracte d the virus. Those who kne w someone who had died of the disease expre ssed more fe ar for the mselves (Jenks, 1992) . O ver 62% said that the y had change d their behaviors be cause of the AIDS scare . The two most freque ntly mentione d change s were being more selective with whom they swung and practicing safe r sex (e.g., using condoms). Almost 7% said the y had quit swinging because of the AIDS epidemic. Finally, one third said that they had not change d any of the ir habits, and, of the se responde nts, more than a third said nothing, not even AIDS, would ge t them to change . It see ms, the refore, that the swinge rs see med to recognize the de adliness of the disease, but many felt their sele ctivity in sexual partne rs and practicing “ safe sex” lowe red their risk of contracting AIDS. In addition, only a minority kne w some one who had die d of AIDS and, of those, the

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plurality indicate d that the pe rson was gay. It is possible that the se factors combine d to create no more than a moderate fe ar of contracting the disease.

Fin din g Peop le This involve s finding the right kind of pe ople with whom to swing. Many people indicate d that it was difficult finding anothe r attractive couple or anothe r couple with whom the y had some mutual intere sts (Jenks, 1986) .

Jealou sy Although the swinge rs in the Jenks ’ (1985c) study were significantly lowe r on je alousy than the nonswinge rs, this was not true of eve ryone . There fore, being je alous of one ’s partne r, being attractive to othe rs, and/or having sex with othe rs was name d by 13% as a proble m (Jenks, 1986) . Stinne tt and Birdsong (1978) also discusse d this factor as a proble m.

An xiety Anxie ty stemming from the belie fs concerning sexual performance can be a proble m in swinging. Bartell (1971) reported that only 25% of males are able to achie ve an erection on a re gular basis at the large swing party. And, while feeling sexually desirable is an advantage of swinging, the other side of the coin is the anxie ty or fear that no one will se e him/he r as attractive .

Fear Abou t Public Exp osu re Since swinging is a “ de viant ” activity one must always be guarding against e xposure . This conce rn may run all the way from the ir childre n to the ir ne ighbors and employe rs (Stinne tt and Birdsong, 1978) .

Tim e Factor s Swinging often comes to dominate the person’s life (Stinne tt and Birdsong, 1978) .

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EFFECTS ON THE MARRIAGE What effe ct, if any, doe s swinging have on the swinge r’s marriage ? Contrary to what many might be lie ve, positive effects have ofte n been found. Gilmartin (1974, 1975) , for e xample , found that approximate ly 85% of his sample of swinge rs felt that swinging pose d no re al threat to the ir marriage . In fact, the majority fe lt that their marriage had improve d. Varni (1974) inte rvie wed 16 couple s who were active ly involve d in swinging and found that half believed that swinging le d to an incre ased feeling of warmth, close ne ss, and love betwee n the husband and wife . This fe eling was re porte d to be stronge st afte r swinging with some one else. Le vitt (1988) found that almost thre e fourths indicate d that swinging had a positive influe nce on their marriage ; only 6.2% indicate d a ne gative impact. Similar re sults have bee n found by Barte ll (1971) , Smith and Smith (1970) , and Palson and Palson (1972) . Finally, Jenks (1986) found no re ason to believe that swinging was particularly de trime ntal to marriage . Ove r 91% of the males and 82% of the females indicate d that they were happy with swinging. Less than 1% of fe male s were disple ased with swinging; no males expre ssed any unhappine ss. And, whe n an analysis was done comparing their pe rception of the ir re lations, both se xual and nonse xual, be fore and afte r swinging, it was found that the majority e xpre ssed e ithe r no change or an improve ment. It should be pointe d out that these studie s have asked the ir perceptions of how swinging has affected the ir marriage s. Perceptions, of course , can be quite diffe re nt than reality. Howe ver, Stucke rt (1963) has argue d that perceptions, rathe r than actual behavior, are more important in determining marital happine ss and satisfaction. While the research doe s point to the conclusion that swinging does not affect the majority of marriage s in a negative way, the re are no doubt couple s whose marriage s are negative ly e ffected. Levitt’s (1988) study found that almost 17% fe lt that swinging had a ne gative impact upon the marriage . Unfortunate ly, no study e xists analyzing factors that might have a negative impact on the marriage . A study by Denfeld (1974) , howe ve r, did look at married swinge rs who had droppe d out of the life-style . From this we can get an ide a of some variable s that might play a role in decreasing the fe asibility of swinging for couple s.

Drop p in g Out of Swin gin g When the disadvantage s start to outwe igh the advantage s ge tting out of swinging becomes like ly. Denfeld se nt ove r 2000 que stionnaire s to coun-

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selors listed in a national and a California directory of marriage and family counse lors. Approximate ly 45% of the que stionnaire s were returne d and 49% of the se re porte d they had se en at le ast one dropout from swinging. The reasons give n by the swinge rs for dropping out were, in orde r of freque ncy: Jealousy: 24% ; Guilt: 15% ; Thre at to the marriage : 15% ; Deve lopm e nt of outsid e attac hme nts: 12 % ; Bore dom with swingin g: 11 % ; Disappointme nt with swinging: 7% ; Divorce or separation: 6% ; Wife ’s inability to “ take it” : 6% ; Fear of discove ry: 3% . The point should be made that these were couple s who were in the rapy and, therefore , may not be represe ntative of all swinge rs who drop out. The Murste in et al. (1985) study found the major reason for dropping out of swinging to be the “ wife ’s inability to take it.” (p. 26) . Other conce rns cited were fear of V D, guilt, fear of discove ry, boredom, and je alousy.

Current State of Swin gin g Almost no re search on this topic has be en publishe d within the last 10 years. To get a more curre nt pe rspective a tele phone intervie w with Dr. Robert McGinle y (personal communication , August 26, 1997) he ad of the large st organization re lating to swinging, North America Swing Club Association (NASCA), was conducte d. According to McGinle y, swinging, within the last 10 ye ars, has shown a significant incre ase . The mailing list for NASCA, e.g., approximate d 12,000 te n ye ars ago; today it is around 30,000. Atte ndance at Life styles, a yearly conve ntion which brings swinge rs from all over the country, had a pre registration of 900 ¯1000 couple s with almost 2000 registrations on site. He indicate s that atte ndance at this e ve nt has increased every ye ar. The late st conve ntion, held in Palm Springs, CA, is e stimated by the Chambe r of Comme rce to have pumpe d more than $1.6 million into the local economy (R. McGinle y, personal communication , August 25, 1997) . Although Lifestyle s is the large st in attendance , the re are othe r conventions that have annual meetings. Conclave , a conve ntion held in Chicago draws approximate ly 300 couple s. O riginally he ld just once a year, it now has expande d so that a second conve ntion is held in the fall of each year. McGinle y e stimates that there were approximate ly 200 swing clubs in existe nce 10 ye ars ago. Today the figure is approximate ly 400. One of the bigge st change s which has come about, he states, is the growing sophistication of swing clubs. O nce started as hobby clubs the y now are a significant source of re venue . As a conseque nce the club is now able to put money back into the club and offe r more services to the members. Also, the clubs have become more ope n in terms of adve rtising e xactly what they are.

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Swing-orie nte d magazine s continue to thrive . Some of the major ones are Conn ection , which has two national publications and approximate ly 15 regional magazine s. Othe rs are Odyssey and Su ndance. McGinle y is quick to point out that magazine s are not a major source for making contacts with othe r swinge rs; rathe r, clubs are a more like ly source for contacts for the swinging couple . Anothe r change in the swinging scene has come about with the growth of compute r technology, e specially with the Internet. Most swing clubs have their own we b site . One of the advantages of the Internet, according to McGinle y, is that it allows couple s to learn about swinging within the privacy of the ir own home s rathe r than going to an adult bookstore , for example . The International Couple s Network lists 91 diffe re nt swing clubs re presenting 27 states. The two top states are California (19) and Texas (12).

CONCLUSION Although many people in our society disapprove of this be havior and believe that swinge rs are very unhappy and have unsatisfactory marriage s the re is no evide nce for such a claim. Probably the be st way to conclude a discussion on the e ffects of swinging is to quote Thio (1988) : “ We may conclude that swinging is like a two-e dge d sword —it may swing in the direction of positive conse que nce s or in the opposite direction of negative conse que nce s. The nature of the conse que nce s de pends more on the individual who use s the sword than on the sword itse lf ” (p. 270) . Curre ntly, we have no estimate of the incide nce of swinging. On the one hand, give n the AIDS epide mic, along with the some what repressive sexual e nvironme nt of the last fe w ye ars, we would pre dict that the incidence would be lower. McGinle y state s that AIDS did, in the be ginning, have an impact on how often swinge rs would attend swinging eve nts but this fear did not le ad to a de cline in membe rship. Swinge rs, he states, came to realize that AIDS was not everyone ’s dise ase as the media and gove rnment portraye d it, but a disease of only certain se gments of the population. The Jenks ’s (1992) study showing no high leve l of fe ar conce rning AIDS seems to ve rify this. McGinle y believe s that the gre ater proble m for the swinge r was the herpes scare which laste d for a couple of years. If swinging has decreased it may be more appropriate to attribute it to the repressive environme nt rathe r than the AIDS scare. Howeve r, there are signs that the swinging life-style is alive and well. As indicate d, major conve ntions draw thousands of couple s each ye ar and a perusal of the Inte rne t reveale d diffe re nt Web sites for swinging. O ne such site , Inte rnational Swinge rs Union, include d tour package s for swing-

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ers and a discussion of swinging and the law. My impression is that, while the re search on swinging has de creased, the incide nce has not. The way to determine this would be to conduct a current study. In addition to the que stion of incide nce it would seem fruitful to conduct a longitudinal study of swinge rs to discove r the factors relate d to the ir continuing to swing ove r a period of time , what factors influe nce those who drop out, and how long a couple stays in swinging.

REFERENCES Ajzen, I., and Madden, T. (1986) . Prediction of goal-dire cted behavior: Attitudes, intentions, and perceived behavioral control. J. Exp. Soc. Psychol. 22: 453-474. Allgeier, A. R., and Allgeier, E. R. (1995) . Sexual Interactions, D. C. Heath, Lexington, MA. Bartell, G. D. (1970) . Group sex among the mid-Ame ricans. J. Sex Res. 6: 113-130. Bartell, G. D. (1971) . G roup Sex, Wyden, New York. Becker, H. (1963) . Outsiders: Studies in the Sociology of Deviance, Free Pre ss, New York. Bem, D. J. (1972) . Se lf-perception theory. Adv. Exp. Soc. Psychol. 6: 2-62. Bezilla, R. E. (1993). Religion in America, Princeton Religion Research Cente r, Princeton, NJ. Bryant, C. (1982) . Sexu al Devian cy and Social Proscription, Human Sciences, New York. Buunk, B. P., and van Driel, B. (1989) . Alternative Lifestyles and Relationships, Sage, Ne wbury Park, CA. Cole, C. L., and Spaniard, G. B. (1974) . Comarital mate-sharing and family stability. J. Sex Res. 10: 21-31. Denfeld, D. (1974) . Dropouts from swinging. Fam . Coord. 23: 45-49. Duckworth, J., and Levitt E. E. (1985) . Pe rsonality analysis of a swinge rs’ club. Lifestyles: J. Chan g. Patterns 8: 35-45. Flanigan, W. H., and Z ingale, N. H. (1991) . Political Behavior of the American Electorate (7th ed.), CQ Pre ss, Washington, DC. Gallup, G., and Caste lli, J. (1989) . The People ’s Religion: American Faith in the 90s, Macmillan, New York. Gilmartin, B. G. (1974) . Sexual deviance and social ne tworks: A study of social, family, and marital interaction patterns among co-marital sex participants. In Smith, J. R., and Smith, L. G. (eds.), Beyond Monogamy: Recent Studies of Sexual Alternatives in Marriage, Johns Hopkins Pre ss, Baltimore. Gilmartin, B. G. (1975) . That swinging couple down the block. Psychol. Today 8: 54-58. He nshel, A. M. (1973) . Swinging: A study of decision making in marriage. Am. J. Sociol. 4: 885-891. Hughe s, E . C. (1945). Dilemmas and contradictions of status. Am . J. Sociol. 50: 353-359. Hunt, M. (1974) . Sexual Behavior in the 1970s, Dell, Chicago. Jenks, R. (1985a) . A comparative study of swingers and nonswingers: Attitudes and beliefs. Lifestyles: J. Chang. Pattern s. 7: 5-20. Jenks, R. (1985b) . Swinging: A replication and test of a theory. J. Sex Res. 21: 199-205. Jenks, R. (1985c) . Swinging: A test of two theories and a proposed ne w model. Arch. Sex. Behav. 14: 517-527. Jenks, R. (1986) . A further analysis of swinging. Unpublished manuscript. Jenks, R. (1988) . Rokeach ’s terminal values survey and swinge rs. J Psychol. Hum . Sex. 1: 87-96. Jenks, R. (1992) . Fe ar of AIDS among swingers. Ann. Sex Res. 5: 227-237. Kagan, J., and Segal, J. (1995) . Psychology: An Introduction, Harcourt, Fort Worth, TX. Le vitt E . E. (1988). Alternative life style and marital satisfaction: A brief report. Ann.s Sex Res. 1: 455-461.

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Murste in, B. I., Case , D., an d Gunn, S. P. (1985) . Pe rsonality corre late s of e x-swingers. Lifestyles: J. Chang. Pattern s. 8: 21-34. Palson, C., and Palson, R. (1972) . Swinging in wedlock. Society 9: 28-37. Quinley, H. (1988) . The new facts of life: He terose xuals and AIDS. Public Opinion 11: 53-55. Roke ach, M. (1968) . Beliefs, Attitudes and Values. Jossey-Bass, San Francisco. Roke ach, M. (1969). The role of values in public opinion research. Pu blic Opinion Quart. 22: 547-559. Smith, J. R., & Smith, L. G. (1970) . Co-marital sex and the sexual fre edom movement. J. Sex Res. 6: 131-142. Stephe nson, R. M. ( 1973) . Involve me nt in de viance : An e xample and some theoretical implications. Soc. Probl. 21: 173-190. Stinnett, N., and Birdsong, C. W. (1978) . The Fam ily and Alternate Lifestyles, Nelson-Hall, Chicago. Stuckert, R. P. (1963) . Role perception and marital satisfaction — A configurational approach. Marr. Fam . Living 25: 415-419. Thio, A. (1988) . Deviant Behavior, 3rd e d., Harper-Collins, Ne w York. Varni, C. A. (1974). An e xploratory study of spouse swapping. In Smith, J. R., and Smith, L. G. ( eds.), Beyond Monogam y: Recent Studies on Sexual Alternatives in Marriage, Johns Hopkins Pre ss, Baltimore. Walshok, M. L. (1971) . The e me rgence of middle-class deviant subculture s: The case of swingers. Soc. Probl. 18: 488-495.

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

BOOK REVIEWS Th e Tr an s vestite an d th e Tr an s s exu al: Pu blic Categor ies an d Private Identities. By Dave King. Ave bury, Alde rshot, England, 1993, 223 pp., £32.50. Reviewed by An ne Bolin , Ph.D.1 Dave King ’s 20 years of scholarly re search on male -to-female transse xual and transve stite ide ntitie s is the backbone of an impressive inve stigation of the cultural-hist orical construction of transve stite and transse xual social identitie s in England. This work is an invaluable contribution to be ginning the proce ss of distinguishing American medical practice s from British ones. Too often the rubric “ Western ” circumscribe s sociocultural analysis of the interaction of clinical sector ¯client populations and assume s a uniformity of practice and belief. King ’s work care fully examine s the deve lopme nt of British transse xual and transve stite identitie s by inte grating information from the history of British medical conceptions of these identitie s with that of American medical and subcultural influe nce s. For those of us studying the social construction of transse xual/transvestite and transge nde red identitie s in America, King has not only documented the e volution of British gende r variant ide ntitie s but throughout offers initial comparisons with American research findings. For example , my inve stigation of sociocultural change in American transse xual ide ntitie s ove r 16 ye ars re ve als an early dichotomization of male -to-fe male transse xual and male transve stite ide ntitie s along the dimension of the surgical conve rsion, followe d by a c ultural tre n d towards ide ntity contin uitie s reproduce d in the burge oning of ne w identity options and configurations such as transge nde rism and nonsurgical transse xualism (Bolin, 1988, 1994) . O n the basis of King ’s discussion of important sites for ide ntity genesis and trajectory, rese archers may begin to explain the diffe rences between the English categorie s and American one s. 1

Department of Sociology, Elon College, E lon College, North Carolina 27244. 523 0004-0002/98/1000-0523$ 15.00/0

Ó

1998 Plenum Publishing Corporation

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This volume is in the analytical genre of cultural constructionism and sociological labeling theory. It include s postmode rn elements that focus on the historical fluctuation in the meaning and relations of categories and identities (i.e ., the transve stite and the transse xual) ; structures/institutions (i.e., the medical sector, including psychose xual clinicians); the media; the subculture of transve stite /transse xual communitie s; and individual interpre tations. In the first chapte r ( “ The Proble m and its Context” ), the reade r is introduce d to the sociocultural framework. A medley of data are include d that fuse an original classification of theore tical pe rspe ctives on transse xual and transve stite social identitie s with four sites for inte rpreting these ide ntities: the medical in chapte r 2 ( “ The Developme nt of Medical Conceptions and Practice ” ) and chapte r 3 ( “A Study of Me dical Practice in England ” ); the media in chapte r 4 ( “ Popularizing Medical Categorie s; the Mass Media ” ); the subcultural in chapte r 5 ( “ The Transve stite/Transse xual Community” ); and the individual/pe rsonal in chapte r 6 ( “Action, Care er Strands and Ide ntitie s” ). Chapte r 7 ( “ Public Cate gorie s and Private Identitie s” ) summarize s ce ntral points and tre nds in transse xual/transve stite ide ntity cate gorie s but also provide s insights into sociostructural diffe rences; for example , “ In Britain, Gende r Ide ntity Clinics ne ver seem to have existed except in name . . . ” (p. 62) and “ In Britain the re has be en no large scale promotion and ‘hard selling ’ of transse xualism and sex change which, it is claime d, has take n place in the United State s” (p. 182) . Covering the culture -historical de velopme nt of transse xual and transvestite identitie s not only in Great Britain, but also in the Unite d State s to a le sser e xtent, is a formidable task unde rtake n by King. It was accomplishe d with e legance , clarity, and depth. Howe ve r, the analysis and comparison with the Unite d State s throughout the book and particularly in chapte r 7 ( “ Public Categorie s and Private Identitie s” ) would have benefited from a review of the more recent re se arch. Although publishe d in 1993, the re are only 11 re fe re nces from 1987 ¯1990 and one in 1992 spanning the 18 1/2 page s of bibliography. This should not be construe d as a major weakness in King ’s literature revie w, as the scope was a most ambitious one including ample historical and cross-disciplinar y coverage . This book is writte n in a lucid and readable style . It is accessible for unde rgraduate s, ye t sophisticate d in its the ore tical orientation and original in rese arch methodology. Conse que ntly, it will be of gre at inte rest to scholars and practicing profe ssionals in the fie ld of gender variance . The sociologic al ap proac h of King offe rs pa rticular insigh t for clinici ans and “ psychose xual specialists ” who may want to pursue , like the discipline of anthropology, a se lf-critique and begin a proce ss of dise ntangle ment of ourselve s, our scientific categorie s, and our mission. For example , anthropological propone nts of this approach have re flected on the history of the

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relationship of the e thnographe r to her or his “ people ” and on the writte n products of these re lations (Fox, 1991; Gee rtz, 1988; Roscoe, 1987) . Such a proce ss, in which clinicians re flect on their own disciplinary categorie s and view the mselve s conte xtually within their discipline s/profe ssions as one in which the politics of power and knowle dge are inte rtwine d with clinical cate gorie s of transse xual and transve stite, will undoubte dly enhance scientific explanation as well as clinical approache s to clie nt manage ment. King has inde ed provide d an in de pth re view of the factors influe ncing the cultural construction of the transse xual and transve stite social identitie s. As discusse d, this book include s the historical situation and the multiplicity of meanings found in medical, media, subcultural, and individual transse xual/ transve stite inte rpretations and the comple xity of inte raction be tween the se sectors. As the author states: “ . . . I have not systematically focused on the meanings assigne d within fe minist and gay communitie s . . . legal meanings have hardly be en commente d on...nor have those to be found in commercially produce d transve stite and transse xual pornography . . . [or that of] the general ‘lay’ public ” (p. 183) . In fact, one stre ngth of this work is in such heuristic comments providing glimpse s of avenues for future research and noting are as whe re data are not available . O ne such area of rese arch, produce d by North American anthropologists in particular and some sociologists that is critical for the unde rstanding of the sociohistorical construction of ge nde r variant ide ntitie s, is that of re lating social ide ntitie s to the broade r ge nde r paradigm/sc he ma about what it means to be a man and a woman in the socie ty unde r inve stigation (Herdt 1990; Jacobs and Cromwell 1992; Williams 1986) . In this way, medical, media, subcultural, and individual meanings and accounts of transve stism/transse xualism as British or American cate gorie s can be articulate d with the broade r sociohistorical construction of ge nde r from which the se social ide ntitie s are e mbedde d. Although Kessler and McKe nna (1978) , who may be re garde d as one of the e arly sociocultural pare nts of this ge nder schema/paradigm approach, are cite d seve n times in the text, the re levanc e of the ge nd e r paradi gm pe rspe ctive is not pursue d, althou gh mentione d (p. 24) . I argue that such an approach is of more than passing interest to those whose task is the de construction of gende r variance . This are a of slippage doe s not, howe ve r, detract from the overall contribution of this work. Each chapte r provide s the reade r with a conceptual or methodological treat. For e xample , chapte r 1 offers a fresh look at scientific vie ws of transve stism and transse xualism providing a fourfold grid for displaying the comple xity of essentialist/construc tionist positions. King has ide ntifie d four dominant approache s: the orientation mode l, the condition model, the role mode l, and the false consciousne ss model. The role mode l approach is advocate d by King whe rein he states: “ Sce pticism con-

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cerning medical cate gorie s see ms the only possible tactic if one is intere sted in making medical knowle dge a ‘topic ’ rathe r than a ‘re source ’ and in exploring the ways in which it functions in society” (p. 31) . These four models are wove n throughout the remainde r of the book providing an important thread of continuity. O the r cere bral desse rts include , for example , data analyzed from inte rvie ws with ten psychiatrists, two clinical psychologists, and te n surge ons (circa 1970s ¯e arly 1980s) in chapte r 3 and a content analysis of over 600 newspape r and magazine article s (1950 ¯1983) as discourse s on transse xual/transve stite ide ntitie s in chapte r 4. O verall, King has illuminate d the he te roge ne ity in transse xual/transvestite ide ntity categorie s by moving e ffortle ssly between the sociocultural and individual inte rpre tations. King ’s book will be well received by those concerned with ge ne ral principle s of stigmatize d “ career strands ” and the comple xitie s of transse xual/transve stite identity cate gorie s. REFERENCES Bolin, A. (1988) . In Search of Eve: Transsexu al Rites of Passage, Bergin and Garve y, South Hadle y, MA. Bolin, A. (1994) . Transcending and transgende ring: Male-to-female transse xuals, dichotomy and diversity. In Herdt G. (e d.), Third Sex Third G en der: Beyond Sexual Dimorphism in Culture and History, Z one Books, New York, pp. 589-596. Fox, R. G. (ed.). (1990) . Recapturing Anthropology: Working in the Present, School of Ame rican Research Press, Santa Fe , NM. Gee rtz, C. (1988) . Works and Lives: The Anthropologist as Author, Stanford University Press, Stanford, CA. He rdt, G. ( 1990) . Mistake n ge nde r: 5-alpha re ductase he rmaph roditism and biological reductionism in sexual identity reconsidere d. Am. Anthropol. 92: 433-466. Jacobs, S., an d Cromwe ll, J. (1992). Visions and revisions of reality: Re flections on se x, sexuality, gende r and gende r variance. J. Hom osex. 23: 43-69. Kessler, S. J., and McKenna, W. (1978) . G ender: An Ethnom ethodological Approach , Wiley, New York. Roscoe, W. (1987) . Bibliography of be rdache and alte rnative ge nder roles among North American Indians. J. Hom osex. 14: 81-173. Williams, W. (1986) . The Spirit and the Flesh: Sexual Diversity in American Indian Culture, Beacon Press, Boston, MA.

Gender Outlaw: On Men, Wom en an d the Rest of Us. By Kate Bornstein. Routle dge , New York, 1994, 245 pp., $30.95. Reviewed by Step h en Whittle, Ph.D.2 Kate Bornste in take s us through a life story of sex roles and ge nder confusion. It could be argue d that it is a comple te education in the curre nt 2

The School of Law, Manchester Metropolitan University, Hathersage Road, Manchester M13 0JA, England.

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position of ge nde r ble nding in the world of Q ue er the ory. But gender ble nding according to Bornste in is a misnome r to the transge nde red community: Gende r mere ly exists as itse lf, that is, an ide a, an inve ntion, a means of oppre ssion and a means of expre ssion. Gende rs are rarely in fact ble nde d e xce pt in notions of androgyny, but while pe ople perform the ir live s along a gende r continuum, their gende re d place need not be static. The transge nde rist can move from point to point along that continuum and have a gende red life that is fluid in its represe ntation and pe rsonal performativity. The transge nde red community that Bornste in is referring to is a Western conce pt develope d by the cross-dre ssing and transse xual activist movement in the United State s in the 1990s. The community has a long history of self-re ferentialism through the autobiographical history of its members, but re cently it has also sought to allude to othe r cultural times and social move ments in which gende r was not trappe d in the binary dichotomy of poste nlighte nment modernism that most of us currently live with. Accordingly, Bornste in in practicing both the art of autobiography and in referring to othe r cultural indications is at the forefront of the transge ndere d community’s the orizing. According to Bornste in, many in the transge nde red community would see themselves as existing outside of gende r, of being oppre ssed by it, while ye t using its icons and signifie rs to say who they are. This is what Bornste in has chose n to do throughout he r life —as a sailor, a pre acher, a pe rformance artist, as a man, and as a woman, but in the end are we any closer to finding out who she is? The point may be in that through he r writing we are not meant to be able to pin her down e xce pt in so far as to who she is today may not be who she is tomorrow. Bornste in use s her position as a respected pe rformance artist, both within and outside of the transge nde re d community, to argue for a fluidity of gende r politics. In most of the book, she take s us through he r gende re d live s, separating off he r sexuality not as irre levant but merely as anothe r expre ssion of what those gende red live s have be en. She answers the “ nuts and bolts ” que stions about ge nde r re assignme nt and its associate d hormone the rapy and surgical procedure s, in an almost comic book style inte rmingling he r autobiographical state ments with high and low cultural re fe rences. She use s he r personal expe rience of ge nde r boundarie s and the crossing of the m to que stion the basic assumptions made within those cultural refere nces: the assumptions that there are only two gende rs, which are invariant and bound by the genital; that eve ryone must be long to one ge nde r or anothe r and that this is “ natural ” and inde pe nde nt of scie nce or social construction; and that any transfe rs from one ge nde r to anothe r are either

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ceremonial or masque rade s and any e xce ptions to the two ge nders are not to be take n seriously. She argue s that the re are rules to gende r, but rules can be broke n, ambiguity doe s e xist, and it is how we provide for that ambiguity that matte rs even more than ambiguity itself. Bornste in argue s that the re can be , and is, fluidity within a gende re d world: Gende r fluidity is the ability to free ly and knowingly become one or many of a limitless number of ge nders, for any length of time, at any rate of change . Gende r fluidity recognises no borde rs or rules of gende r. (p. 52)

This has meaning in the real politics of se x and ge nde r. To be fluid in one ’s gende r challe nge s the oppre ssive proce ss of gender and the power proce sse s which use gende r to maintain power structures. It makes it hard for the m to know who, where, or what “ you ” are and to set up rule s and systems which control. As Bornste in points out, transge nde rists are only at the be ginnings of having any se nse of community, but gende r outlaws exist, though there are still fe w groups that “ e ncompass the full rainbow ” (p. 68) . According to her, howe ve r, any community that wishe s to acknowle dge gender fluidity must be base d on a principle of constant change to avoid the traps that the rules of gende r dictate : A fluid identity, incidentally, is one way to solve problems with boundaries. As a pe rson’s identity keeps shifting, so do individual borde rs and boundaries. It’s hard to cross a boundary that keeps moving. (p. 52)

In an extremely succinct but clear discussion of ge nde r te rrorism, she points out that it is not the transge nde re d community who are the te rrorists; rathe r, it is ge nde r defe nde rs—those who defend the belief that ge nder is “ re al” and “ natural ” and use it to “ terrorize the rest of us.” She quote s Davie s (1983) who wrote that: Anything that undermine s confidence in the sche me of classification on which pe ople base their lives sicke ns them as though the ve ry ground on which they stood precipitously dropped away . . . . Pe ople will regard any phenome non that produces this disorientation as “disgusting ” or “dirty.” To be so regarde d, however, the phenome non must threaten to destroy not only one of their fundamental cognitive categorie s but their whole cognitive system. (p. 72)

Bornste in argue s that the transge nde red person as a ge nder outlaw (as opposed to a terrorist) causes the de struction of the gendered system of reality that most pe ople base major aspe cts of their live s on. The gender terrorists react with acts of viole nce which range from the physical, as in the rape and killing of Brandon Tee na, a passing fe male -to-male transge nderist in Nebraska in e arly January 1994 (Jones, 1994) to the theoretical, as in the attacks on transse xuals by feminists such as Raymond (1979; in The Trans-

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sexual Em pire) and Millot (1990; in Horesexe), or the “ womyn born womyn ” policy of the Michigan Womyn ’s Music Festival (Walworth, 1994) . In this book, Bornste in offers a vie w of re al-life ge nder fluidity, a refusal to be categorize d by the limite d ge nde r roles that are impose d, a refusal to be some cute and humorous represe ntation of the “ third sex” as court jester. Neither is she willing to be invisible ; inste ad, she propose s a play with ge nde r partitioning to ultimate ly make the partitions meaningle ss. She is not a third sex, but she is creating a third space, a space outside of ge nde r. E ve ry transse xual I know went through a ge nde r transformation for differe nt reasons, and there are as many truthful e xperiences of gender as there are people who think they have ge nder. (pp. 7-8)

What has all this to do with Q ue er the ory? Q uee r theory arose from a mix of acade mic re spe ctability and stre et activism. Bornste in re pre sents both sides of that association but eve n then she is constantly crossing and recrossing the boundarie s. As both an activist and acade mic in the eyes of her own small community, she re prese nts the forefront of that community’s current political theorie s around gende r: what it is and what it means. Bornste in choose s not to gende r ble nd — she does not claim the position of a third sex (meaning ge nde r); rathe r, she claims to be unique in her dive rsity and, most important, he rse lf. This is the lesson that she offe rs up to que e r the ory. Q uoting “ Ian,” in Dorenkamp and Henke (1994) : The identity politics of que er theory pe rmit us, eve n re quire us, both to take seriously and expe riment with ways of thinking and being which more conventional radical theory is ready to consign to its epistemological closet. (p. 77)

Bornste in is seriously expe rime nting with ways of “ thinking identity.” She is bringing to que e r the ory the challe nge of dive rsity, not just in terms of race and sex but in terms of gende r in its most comple te and fulle st sense . She challe nge s imaginary assumptions through her own imagination. According to Hooks (1994) [By] celebrating and affirming insurgent intellectual cultural practice...[there is] an invitation to e nter a space of changing thought, the open mind that is the he artbeat of cultural revolution. (p. 7)

G ender Outlaw is an easy re ad and an ente rtaining light-we ight te xt, yet it should be compulsory re ading to all who work in the area of transse xual and cross-dre ssing phe nome na. It has multiple le ve ls of meaning, providing a late 20th-ce ntury ove rvie w of curre nt transge nde red activist thought for members of the transge nde red community, yet it also provide s an othe rwise unobtainable insight into what it means to be a person with a fluid gender identity. The last third of the book is disappointing in that Bornste in’s play “ Hidde n Agenda ” merely re cants what has alre ady be en said much more cle arly in the preceding chapte rs, and the final chapte r fails to come to

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grips with the issue s that arise from he r lesbian love r’s transition from female to male. It is a notice ably lost opportunity to addre ss gender fluidity from the opposite side of the spectrum. Nonethe less, while transge nde red people have adopte d the book as a major force in the ir own theoretical thinking, nontransge nde red profe ssionals in the fie ld will also find in it a useful ove rview of how the ir client group is incre asingly se eing themselves. Furthe rmore , it provide s a ve ry useful starting block from which to reconceptualize the force of gende r, its meanings, and its power in postmode rnist Western thought.

REFERENCES Davies, M. (1983) . Sm ut: Erotic Reality/Obscene Ideology, Chicago University Press, Chicago. Dorenkamp, M., and, Henke , R. (1994) . Negotiating Lesbian and G ay Subjects, Routledge, New York. Hooks, B. (1994) . Outlaw Culture, Resisting Representations, Routledge, Ne w York. Jones, J. (1994, Fe bruary) . FTM crossdresse r murdered. FTM Newsletter (Issue 26, p. 3) . Millot, C. (1990). Horesexe: Essays on Transsexuality, Autonomedia, Ne w York. Raymond, J. (1979) . The Transsexual Em pire, The Wome n’s Press, London. Walworth, J. (1994) . Michigan Womyn ’s Music Festival 1994: Transsexual protesters allowed to enter. Cross-Talk (Issue 61) .

Boys an d Girls: Th e Develop m en t of Gender Roles . By Carole R. Beal. McGraw-Hill, New York, 1994, 359 pp., $40.57. Reviewed by K im berly K . Powlish ta, Ph .D.3 Although conside rable change s have occurre d during the last se veral decade s in the roles that men and women occupy in our society, the re has be en surprising consiste ncy in the stereotypical be haviors and beliefs of childre n. As in most are as of psychological inquiry, research on ge nde r role de velopme nt has progre sse d from simply docume nting the phe nomenon (i.e., how are boys and girls diffe re nt? ), to te sting the ories that focus on a single cause (e.g., mode ling and re inforce ment; biological se x diffe rences), to finally re cognizing that multiple causes must be take n into account simultane ously. At the same time , the comple xity of the phenomenon itse lf has be en increasingly recognize d. Childre n are not simply more or le ss masculine or fe minine . Inste ad, gende r role s are multidime nsional; not all compone nts of gende r are strongly re late d, nor do the y always share common cause s (e .g., Serbin et al., 1993) . 3

Department of Psychology, Northe rn Illinois University, DeKalb, Illinois 60115.

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In this book, Carole Be al has done a good job of capturing much of this comple xity, but at a leve l comprehensible to an advance d unde rgraduate stude nt. In fact, the book is roote d in Be al’s experience te aching courses on ge nde r role deve lopme nt and is directed primarily toward stude nts. It would make an e xce lle nt te xt for both unde rgraduate and graduate seminars ( if supple me nte d by origina l article s) . But eve n expe rie nce d researche rs will find it a use ful re source for tracking down re fe re nce s, refreshing one ’s memory ( “ What were those se x chromosome abnormalitie s I learne d about way back when? ” ), or whe n a quick summary of a particular are a of re search is nee de d ( “ What ’s the late st word on how boys and girls are treate d by te ache rs? ” ). Despite acknowle dging that “ biological and socialization forces interact to shape childre n ’s de velopme nt as a male or fe male ,” the book focuses primarily on socialization forces. In fact, the explicit goal of the book is to describe “ how childre n learn to be boys and girls.” [italics adde d]. Thus, reade rs wanting a more thorough discussion of pote ntial biological contributions to be havioral diffe re nce s be twe en the se xes will need to consult additional sources. Howeve r, as Be al points out, “ in no area of child developme nt will we find that biology is a sufficie nt explanation for the behavioral diffe re nce s betwee n the sexe s . . . . In othe r words, biology is not destiny” (p. xvii) . Beal acknowle dge s that she would like to see a re duction in stere otyping. From this practical standpoint, the goal of unde rstanding social contributions to gende r role developme nt is unde rstandable . This is not to say that the role of biology is neglected e ntirely. Potential biological contributions to sex diffe rences in aggre ssion and cognitive abilitie s are discussed, and the que stion of whe ther there is a “ mate rnal instinct ” is addre sse d. But the primary focus of the book is cle arly on socialization influe nces. The book is organize d in a large ly chronological fashion, with early chapte rs focusing on prenatal de velopme nt (e.g., sex dete rmination, abnormalitie s of se x chromosome s, gonadal sex, ambiguous se xual diffe rentiation) and the first ye ar of life (e .g., physical de ve lopm ent, pe rceptual abilitie s, activity le vel, pare ntal inte ractions with young sons and daughte rs). Three chapte rs the n follow that de scribe and evaluate traditional theories of gende r role de ve lopme nt (the psychoanalytic perspe ctive, social le arning, and cognitive -deve lopme ntal approache s), comparing and contrasting the the orie s and placing e ach in historical conte xt. Where as the thre e theoretical chapte rs focus on the ways in which the family (in conjunction with psychose xual or cognitive maturation) either directly or indire ctly influe nces ge nde r role deve lopme nt, the ne xt three chapte rs focus on extrafamilial sources of influe nce: pe ers, school systems, and the media. It is in this section that the book makes its most unique

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contribution, covering topics that are freque ntly ne glected, at least in typical textbook chapte rs on ge nde r role developme nt. For example , the re is rathe r extensive cove rage of a curre nt “ hot topic ” : ge nde r segre gation (i.e., childre n ’s te nde ncy to prefer playmate s of the ir own se x). This phenome non is usually first see n in the third year of life and incre ases in stre ngth through middle childho od. The “ se parate worlds ” to which boys and girls are the reby e xpose d have implications for the ways in which boys and girls are socialize d and how the y learn to inte ract with each othe r. Beal provide s convincing evide nce that childre n are not showing such preference s simply in response to pressure from adults. She argue s that the re are two causes of ge nde r se gregation in childre n ’s play: a desire for playmate s who have compatible play style s and a wish to be with othe rs who are classifie d as “ like me.” The data pertaining to the se two hypothe ses te nd to be some what overinte rpreted in the book, with indire ct evide nce and sparse findings prese nted as conclusive support. In truth, the re asons why childre n show ge nde r se gre gation re main some thing of a myste ry. Howe ver, play style compatibility and cognitive categorization are the most like ly explanations, and the basis of that like lihood is pre sente d quite nicely in the book. The next two chapte rs focus on sex diffe rence s in pe rsonality characte ristics and cognitive abilitie s during middle childhood. These are followe d by a chapte r on gende r role deve lopme nt during adole scence, a time that brings “ the ne w and e xciting prospe ct of re lationships with peers of the othe r gende r who have bee n studiously avoide d throughout childhood. ” In addition to a discussion of dating and se xual re lationships, this chapte r describe s the impact of pube rty, adole scent cognitive deve lopme nt, friendships, and family, school, and cultural influe nces. The final conte nt chapte r addre sse s gende r identity disturbance in childhood, including the issues of diagnosing childre n who have develope d a gende r identity that is inconsiste nt with their biological sex, possible origins of this phe nome non, and what tre atment, if any, should be provide d for such childre n. Boys and G irls has many strengths. The use of some time s amusing and often thought-provoking ane cdote s, both from Be al’s personal experiences and from pre vious writings, illustrate s points well and makes for enjoyable reading. There are times whe n the e mpirical e vide nce to support an assertion is lacking or we ak. But most ane cdotes and assertions are strongly grounde d in psychological re se arch. O ne dange r inhe re nt in any book de aling with sex difference s is that the reade r may be left with the impression that boys and girls are more diffe rent from each other than they really are. The ve ry nature of the topic focuse s attention on difference s, making it e asy to forge t about the similaritie s be tween boys and girls and the individual variability within each sex.

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Beal doe s a nice job of using a concre te e xample (he ight) to illustrate “ the notion that group diffe re nce s do not mean that individuals are necessarily diffe rent.” And in the conte xt of de scribing the effects of television on gender role development, there is also a useful discussion of research design (e.g., corre lational vs. longitudina l vs. e xpe rimental approache s). The se adde d feature s give the book e ven more value as a student text. But, once again, the nonstude nt also will find it use ful as an information refresher or update , a re ference source, and an inspiration for le cture material.

REFERENCE Se rbin, L. A., Powlishta, K. K., and Gulko, J. (1993) . The deve lopment of se x typing in middle childhood. Monogr. Soc. Res. Child Dev. 58( 2, Serial No. 232) .

Archives of Sexual Behavior, Vol. 27, No. 5, 1998

BOOK REVIEWS Th e Tr an s vestite an d th e Tr an s s exu al: Pu blic Categor ies an d Private Identities. By Dave King. Ave bury, Alde rshot, England, 1993, 223 pp., £32.50. Reviewed by An ne Bolin , Ph.D.1 Dave King ’s 20 years of scholarly re search on male -to-female transse xual and transve stite ide ntitie s is the backbone of an impressive inve stigation of the cultural-hist orical construction of transve stite and transse xual social identitie s in England. This work is an invaluable contribution to be ginning the proce ss of distinguishing American medical practice s from British ones. Too often the rubric “ Western ” circumscribe s sociocultural analysis of the interaction of clinical sector ¯client populations and assume s a uniformity of practice and belief. King ’s work care fully examine s the deve lopme nt of British transse xual and transve stite identitie s by inte grating information from the history of British medical conceptions of these identitie s with that of American medical and subcultural influe nce s. For those of us studying the social construction of transse xual/transvestite and transge nde red identitie s in America, King has not only documented the e volution of British gende r variant ide ntitie s but throughout offers initial comparisons with American research findings. For example , my inve stigation of sociocultural change in American transse xual ide ntitie s ove r 16 ye ars re ve als an early dichotomization of male -to-fe male transse xual and male transve stite ide ntitie s along the dimension of the surgical conve rsion, followe d by a c ultural tre n d towards ide ntity contin uitie s reproduce d in the burge oning of ne w identity options and configurations such as transge nde rism and nonsurgical transse xualism (Bolin, 1988, 1994) . O n the basis of King ’s discussion of important sites for ide ntity genesis and trajectory, rese archers may begin to explain the diffe rences between the English categorie s and American one s. 1

Department of Sociology, Elon College, E lon College, North Carolina 27244. 523 0004-0002/98/1000-0523$ 15.00/0

Ó

1998 Plenum Publishing Corporation

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This volume is in the analytical genre of cultural constructionism and sociological labeling theory. It include s postmode rn elements that focus on the historical fluctuation in the meaning and relations of categories and identities (i.e ., the transve stite and the transse xual) ; structures/institutions (i.e., the medical sector, including psychose xual clinicians); the media; the subculture of transve stite /transse xual communitie s; and individual interpre tations. In the first chapte r ( “ The Proble m and its Context” ), the reade r is introduce d to the sociocultural framework. A medley of data are include d that fuse an original classification of theore tical pe rspe ctives on transse xual and transve stite social identitie s with four sites for inte rpreting these ide ntities: the medical in chapte r 2 ( “ The Developme nt of Medical Conceptions and Practice ” ) and chapte r 3 ( “A Study of Me dical Practice in England ” ); the media in chapte r 4 ( “ Popularizing Medical Categorie s; the Mass Media ” ); the subcultural in chapte r 5 ( “ The Transve stite/Transse xual Community” ); and the individual/pe rsonal in chapte r 6 ( “Action, Care er Strands and Ide ntitie s” ). Chapte r 7 ( “ Public Cate gorie s and Private Identitie s” ) summarize s ce ntral points and tre nds in transse xual/transve stite ide ntity cate gorie s but also provide s insights into sociostructural diffe rences; for example , “ In Britain, Gende r Ide ntity Clinics ne ver seem to have existed except in name . . . ” (p. 62) and “ In Britain the re has be en no large scale promotion and ‘hard selling ’ of transse xualism and sex change which, it is claime d, has take n place in the United State s” (p. 182) . Covering the culture -historical de velopme nt of transse xual and transvestite identitie s not only in Great Britain, but also in the Unite d State s to a le sser e xtent, is a formidable task unde rtake n by King. It was accomplishe d with e legance , clarity, and depth. Howe ve r, the analysis and comparison with the Unite d State s throughout the book and particularly in chapte r 7 ( “ Public Categorie s and Private Identitie s” ) would have benefited from a review of the more recent re se arch. Although publishe d in 1993, the re are only 11 re fe re nces from 1987 ¯1990 and one in 1992 spanning the 18 1/2 page s of bibliography. This should not be construe d as a major weakness in King ’s literature revie w, as the scope was a most ambitious one including ample historical and cross-disciplinar y coverage . This book is writte n in a lucid and readable style . It is accessible for unde rgraduate s, ye t sophisticate d in its the ore tical orientation and original in rese arch methodology. Conse que ntly, it will be of gre at inte rest to scholars and practicing profe ssionals in the fie ld of gender variance . The sociologic al ap proac h of King offe rs pa rticular insigh t for clinici ans and “ psychose xual specialists ” who may want to pursue , like the discipline of anthropology, a se lf-critique and begin a proce ss of dise ntangle ment of ourselve s, our scientific categorie s, and our mission. For example , anthropological propone nts of this approach have re flected on the history of the

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relationship of the e thnographe r to her or his “ people ” and on the writte n products of these re lations (Fox, 1991; Gee rtz, 1988; Roscoe, 1987) . Such a proce ss, in which clinicians re flect on their own disciplinary categorie s and view the mselve s conte xtually within their discipline s/profe ssions as one in which the politics of power and knowle dge are inte rtwine d with clinical cate gorie s of transse xual and transve stite, will undoubte dly enhance scientific explanation as well as clinical approache s to clie nt manage ment. King has inde ed provide d an in de pth re view of the factors influe ncing the cultural construction of the transse xual and transve stite social identitie s. As discusse d, this book include s the historical situation and the multiplicity of meanings found in medical, media, subcultural, and individual transse xual/ transve stite inte rpretations and the comple xity of inte raction be tween the se sectors. As the author states: “ . . . I have not systematically focused on the meanings assigne d within fe minist and gay communitie s . . . legal meanings have hardly be en commente d on...nor have those to be found in commercially produce d transve stite and transse xual pornography . . . [or that of] the general ‘lay’ public ” (p. 183) . In fact, one stre ngth of this work is in such heuristic comments providing glimpse s of avenues for future research and noting are as whe re data are not available . O ne such area of rese arch, produce d by North American anthropologists in particular and some sociologists that is critical for the unde rstanding of the sociohistorical construction of ge nde r variant ide ntitie s, is that of re lating social ide ntitie s to the broade r ge nde r paradigm/sc he ma about what it means to be a man and a woman in the socie ty unde r inve stigation (Herdt 1990; Jacobs and Cromwell 1992; Williams 1986) . In this way, medical, media, subcultural, and individual meanings and accounts of transve stism/transse xualism as British or American cate gorie s can be articulate d with the broade r sociohistorical construction of ge nde r from which the se social ide ntitie s are e mbedde d. Although Kessler and McKe nna (1978) , who may be re garde d as one of the e arly sociocultural pare nts of this ge nder schema/paradigm approach, are cite d seve n times in the text, the re levanc e of the ge nd e r paradi gm pe rspe ctive is not pursue d, althou gh mentione d (p. 24) . I argue that such an approach is of more than passing interest to those whose task is the de construction of gende r variance . This are a of slippage doe s not, howe ve r, detract from the overall contribution of this work. Each chapte r provide s the reade r with a conceptual or methodological treat. For e xample , chapte r 1 offers a fresh look at scientific vie ws of transve stism and transse xualism providing a fourfold grid for displaying the comple xity of essentialist/construc tionist positions. King has ide ntifie d four dominant approache s: the orientation mode l, the condition model, the role mode l, and the false consciousne ss model. The role mode l approach is advocate d by King whe rein he states: “ Sce pticism con-

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cerning medical cate gorie s see ms the only possible tactic if one is intere sted in making medical knowle dge a ‘topic ’ rathe r than a ‘re source ’ and in exploring the ways in which it functions in society” (p. 31) . These four models are wove n throughout the remainde r of the book providing an important thread of continuity. O the r cere bral desse rts include , for example , data analyzed from inte rvie ws with ten psychiatrists, two clinical psychologists, and te n surge ons (circa 1970s ¯e arly 1980s) in chapte r 3 and a content analysis of over 600 newspape r and magazine article s (1950 ¯1983) as discourse s on transse xual/transve stite ide ntitie s in chapte r 4. O verall, King has illuminate d the he te roge ne ity in transse xual/transvestite ide ntity categorie s by moving e ffortle ssly between the sociocultural and individual inte rpre tations. King ’s book will be well received by those concerned with ge ne ral principle s of stigmatize d “ career strands ” and the comple xitie s of transse xual/transve stite identity cate gorie s. REFERENCES Bolin, A. (1988) . In Search of Eve: Transsexu al Rites of Passage, Bergin and Garve y, South Hadle y, MA. Bolin, A. (1994) . Transcending and transgende ring: Male-to-female transse xuals, dichotomy and diversity. In Herdt G. (e d.), Third Sex Third G en der: Beyond Sexual Dimorphism in Culture and History, Z one Books, New York, pp. 589-596. Fox, R. G. (ed.). (1990) . Recapturing Anthropology: Working in the Present, School of Ame rican Research Press, Santa Fe , NM. Gee rtz, C. (1988) . Works and Lives: The Anthropologist as Author, Stanford University Press, Stanford, CA. He rdt, G. ( 1990) . Mistake n ge nde r: 5-alpha re ductase he rmaph roditism and biological reductionism in sexual identity reconsidere d. Am. Anthropol. 92: 433-466. Jacobs, S., an d Cromwe ll, J. (1992). Visions and revisions of reality: Re flections on se x, sexuality, gende r and gende r variance. J. Hom osex. 23: 43-69. Kessler, S. J., and McKenna, W. (1978) . G ender: An Ethnom ethodological Approach , Wiley, New York. Roscoe, W. (1987) . Bibliography of be rdache and alte rnative ge nder roles among North American Indians. J. Hom osex. 14: 81-173. Williams, W. (1986) . The Spirit and the Flesh: Sexual Diversity in American Indian Culture, Beacon Press, Boston, MA.

Gender Outlaw: On Men, Wom en an d the Rest of Us. By Kate Bornstein. Routle dge , New York, 1994, 245 pp., $30.95. Reviewed by Step h en Whittle, Ph.D.2 Kate Bornste in take s us through a life story of sex roles and ge nder confusion. It could be argue d that it is a comple te education in the curre nt 2

The School of Law, Manchester Metropolitan University, Hathersage Road, Manchester M13 0JA, England.

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position of ge nde r ble nding in the world of Q ue er the ory. But gender ble nding according to Bornste in is a misnome r to the transge nde red community: Gende r mere ly exists as itse lf, that is, an ide a, an inve ntion, a means of oppre ssion and a means of expre ssion. Gende rs are rarely in fact ble nde d e xce pt in notions of androgyny, but while pe ople perform the ir live s along a gende r continuum, their gende re d place need not be static. The transge nde rist can move from point to point along that continuum and have a gende red life that is fluid in its represe ntation and pe rsonal performativity. The transge nde red community that Bornste in is referring to is a Western conce pt develope d by the cross-dre ssing and transse xual activist movement in the United State s in the 1990s. The community has a long history of self-re ferentialism through the autobiographical history of its members, but re cently it has also sought to allude to othe r cultural times and social move ments in which gende r was not trappe d in the binary dichotomy of poste nlighte nment modernism that most of us currently live with. Accordingly, Bornste in in practicing both the art of autobiography and in referring to othe r cultural indications is at the forefront of the transge ndere d community’s the orizing. According to Bornste in, many in the transge nde red community would see themselves as existing outside of gende r, of being oppre ssed by it, while ye t using its icons and signifie rs to say who they are. This is what Bornste in has chose n to do throughout he r life —as a sailor, a pre acher, a pe rformance artist, as a man, and as a woman, but in the end are we any closer to finding out who she is? The point may be in that through he r writing we are not meant to be able to pin her down e xce pt in so far as to who she is today may not be who she is tomorrow. Bornste in use s her position as a respected pe rformance artist, both within and outside of the transge nde re d community, to argue for a fluidity of gende r politics. In most of the book, she take s us through he r gende re d live s, separating off he r sexuality not as irre levant but merely as anothe r expre ssion of what those gende red live s have be en. She answers the “ nuts and bolts ” que stions about ge nde r re assignme nt and its associate d hormone the rapy and surgical procedure s, in an almost comic book style inte rmingling he r autobiographical state ments with high and low cultural re fe rences. She use s he r personal expe rience of ge nde r boundarie s and the crossing of the m to que stion the basic assumptions made within those cultural refere nces: the assumptions that there are only two gende rs, which are invariant and bound by the genital; that eve ryone must be long to one ge nde r or anothe r and that this is “ natural ” and inde pe nde nt of scie nce or social construction; and that any transfe rs from one ge nde r to anothe r are either

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ceremonial or masque rade s and any e xce ptions to the two ge nders are not to be take n seriously. She argue s that the re are rules to gende r, but rules can be broke n, ambiguity doe s e xist, and it is how we provide for that ambiguity that matte rs even more than ambiguity itself. Bornste in argue s that the re can be , and is, fluidity within a gende re d world: Gende r fluidity is the ability to free ly and knowingly become one or many of a limitless number of ge nders, for any length of time, at any rate of change . Gende r fluidity recognises no borde rs or rules of gende r. (p. 52)

This has meaning in the real politics of se x and ge nde r. To be fluid in one ’s gende r challe nge s the oppre ssive proce ss of gender and the power proce sse s which use gende r to maintain power structures. It makes it hard for the m to know who, where, or what “ you ” are and to set up rule s and systems which control. As Bornste in points out, transge nde rists are only at the be ginnings of having any se nse of community, but gende r outlaws exist, though there are still fe w groups that “ e ncompass the full rainbow ” (p. 68) . According to her, howe ve r, any community that wishe s to acknowle dge gender fluidity must be base d on a principle of constant change to avoid the traps that the rules of gende r dictate : A fluid identity, incidentally, is one way to solve problems with boundaries. As a pe rson’s identity keeps shifting, so do individual borde rs and boundaries. It’s hard to cross a boundary that keeps moving. (p. 52)

In an extremely succinct but clear discussion of ge nde r te rrorism, she points out that it is not the transge nde re d community who are the te rrorists; rathe r, it is ge nde r defe nde rs—those who defend the belief that ge nder is “ re al” and “ natural ” and use it to “ terrorize the rest of us.” She quote s Davie s (1983) who wrote that: Anything that undermine s confidence in the sche me of classification on which pe ople base their lives sicke ns them as though the ve ry ground on which they stood precipitously dropped away . . . . Pe ople will regard any phenome non that produces this disorientation as “disgusting ” or “dirty.” To be so regarde d, however, the phenome non must threaten to destroy not only one of their fundamental cognitive categorie s but their whole cognitive system. (p. 72)

Bornste in argue s that the transge nde red person as a ge nder outlaw (as opposed to a terrorist) causes the de struction of the gendered system of reality that most pe ople base major aspe cts of their live s on. The gender terrorists react with acts of viole nce which range from the physical, as in the rape and killing of Brandon Tee na, a passing fe male -to-male transge nderist in Nebraska in e arly January 1994 (Jones, 1994) to the theoretical, as in the attacks on transse xuals by feminists such as Raymond (1979; in The Trans-

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sexual Em pire) and Millot (1990; in Horesexe), or the “ womyn born womyn ” policy of the Michigan Womyn ’s Music Festival (Walworth, 1994) . In this book, Bornste in offers a vie w of re al-life ge nder fluidity, a refusal to be categorize d by the limite d ge nde r roles that are impose d, a refusal to be some cute and humorous represe ntation of the “ third sex” as court jester. Neither is she willing to be invisible ; inste ad, she propose s a play with ge nde r partitioning to ultimate ly make the partitions meaningle ss. She is not a third sex, but she is creating a third space, a space outside of ge nde r. E ve ry transse xual I know went through a ge nde r transformation for differe nt reasons, and there are as many truthful e xperiences of gender as there are people who think they have ge nder. (pp. 7-8)

What has all this to do with Q ue er the ory? Q uee r theory arose from a mix of acade mic re spe ctability and stre et activism. Bornste in re pre sents both sides of that association but eve n then she is constantly crossing and recrossing the boundarie s. As both an activist and acade mic in the eyes of her own small community, she re prese nts the forefront of that community’s current political theorie s around gende r: what it is and what it means. Bornste in choose s not to gende r ble nd — she does not claim the position of a third sex (meaning ge nde r); rathe r, she claims to be unique in her dive rsity and, most important, he rse lf. This is the lesson that she offe rs up to que e r the ory. Q uoting “ Ian,” in Dorenkamp and Henke (1994) : The identity politics of que er theory pe rmit us, eve n re quire us, both to take seriously and expe riment with ways of thinking and being which more conventional radical theory is ready to consign to its epistemological closet. (p. 77)

Bornste in is seriously expe rime nting with ways of “ thinking identity.” She is bringing to que e r the ory the challe nge of dive rsity, not just in terms of race and sex but in terms of gende r in its most comple te and fulle st sense . She challe nge s imaginary assumptions through her own imagination. According to Hooks (1994) [By] celebrating and affirming insurgent intellectual cultural practice...[there is] an invitation to e nter a space of changing thought, the open mind that is the he artbeat of cultural revolution. (p. 7)

G ender Outlaw is an easy re ad and an ente rtaining light-we ight te xt, yet it should be compulsory re ading to all who work in the area of transse xual and cross-dre ssing phe nome na. It has multiple le ve ls of meaning, providing a late 20th-ce ntury ove rvie w of curre nt transge nde red activist thought for members of the transge nde red community, yet it also provide s an othe rwise unobtainable insight into what it means to be a person with a fluid gender identity. The last third of the book is disappointing in that Bornste in’s play “ Hidde n Agenda ” merely re cants what has alre ady be en said much more cle arly in the preceding chapte rs, and the final chapte r fails to come to

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grips with the issue s that arise from he r lesbian love r’s transition from female to male. It is a notice ably lost opportunity to addre ss gender fluidity from the opposite side of the spectrum. Nonethe less, while transge nde red people have adopte d the book as a major force in the ir own theoretical thinking, nontransge nde red profe ssionals in the fie ld will also find in it a useful ove rview of how the ir client group is incre asingly se eing themselves. Furthe rmore , it provide s a ve ry useful starting block from which to reconceptualize the force of gende r, its meanings, and its power in postmode rnist Western thought.

REFERENCES Davies, M. (1983) . Sm ut: Erotic Reality/Obscene Ideology, Chicago University Press, Chicago. Dorenkamp, M., and, Henke , R. (1994) . Negotiating Lesbian and G ay Subjects, Routledge, New York. Hooks, B. (1994) . Outlaw Culture, Resisting Representations, Routledge, Ne w York. Jones, J. (1994, Fe bruary) . FTM crossdresse r murdered. FTM Newsletter (Issue 26, p. 3) . Millot, C. (1990). Horesexe: Essays on Transsexuality, Autonomedia, Ne w York. Raymond, J. (1979) . The Transsexual Em pire, The Wome n’s Press, London. Walworth, J. (1994) . Michigan Womyn ’s Music Festival 1994: Transsexual protesters allowed to enter. Cross-Talk (Issue 61) .

Boys an d Girls: Th e Develop m en t of Gender Roles . By Carole R. Beal. McGraw-Hill, New York, 1994, 359 pp., $40.57. Reviewed by K im berly K . Powlish ta, Ph .D.3 Although conside rable change s have occurre d during the last se veral decade s in the roles that men and women occupy in our society, the re has be en surprising consiste ncy in the stereotypical be haviors and beliefs of childre n. As in most are as of psychological inquiry, research on ge nde r role de velopme nt has progre sse d from simply docume nting the phe nomenon (i.e., how are boys and girls diffe re nt? ), to te sting the ories that focus on a single cause (e.g., mode ling and re inforce ment; biological se x diffe rences), to finally re cognizing that multiple causes must be take n into account simultane ously. At the same time , the comple xity of the phenomenon itse lf has be en increasingly recognize d. Childre n are not simply more or le ss masculine or fe minine . Inste ad, gende r role s are multidime nsional; not all compone nts of gende r are strongly re late d, nor do the y always share common cause s (e .g., Serbin et al., 1993) . 3

Department of Psychology, Northe rn Illinois University, DeKalb, Illinois 60115.

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In this book, Carole Be al has done a good job of capturing much of this comple xity, but at a leve l comprehensible to an advance d unde rgraduate stude nt. In fact, the book is roote d in Be al’s experience te aching courses on ge nde r role deve lopme nt and is directed primarily toward stude nts. It would make an e xce lle nt te xt for both unde rgraduate and graduate seminars ( if supple me nte d by origina l article s) . But eve n expe rie nce d researche rs will find it a use ful re source for tracking down re fe re nce s, refreshing one ’s memory ( “ What were those se x chromosome abnormalitie s I learne d about way back when? ” ), or whe n a quick summary of a particular are a of re search is nee de d ( “ What ’s the late st word on how boys and girls are treate d by te ache rs? ” ). Despite acknowle dging that “ biological and socialization forces interact to shape childre n ’s de velopme nt as a male or fe male ,” the book focuses primarily on socialization forces. In fact, the explicit goal of the book is to describe “ how childre n learn to be boys and girls.” [italics adde d]. Thus, reade rs wanting a more thorough discussion of pote ntial biological contributions to be havioral diffe re nce s be twe en the se xes will need to consult additional sources. Howeve r, as Be al points out, “ in no area of child developme nt will we find that biology is a sufficie nt explanation for the behavioral diffe re nce s betwee n the sexe s . . . . In othe r words, biology is not destiny” (p. xvii) . Beal acknowle dge s that she would like to see a re duction in stere otyping. From this practical standpoint, the goal of unde rstanding social contributions to gende r role developme nt is unde rstandable . This is not to say that the role of biology is neglected e ntirely. Potential biological contributions to sex diffe rences in aggre ssion and cognitive abilitie s are discussed, and the que stion of whe ther there is a “ mate rnal instinct ” is addre sse d. But the primary focus of the book is cle arly on socialization influe nces. The book is organize d in a large ly chronological fashion, with early chapte rs focusing on prenatal de velopme nt (e.g., sex dete rmination, abnormalitie s of se x chromosome s, gonadal sex, ambiguous se xual diffe rentiation) and the first ye ar of life (e .g., physical de ve lopm ent, pe rceptual abilitie s, activity le vel, pare ntal inte ractions with young sons and daughte rs). Three chapte rs the n follow that de scribe and evaluate traditional theories of gende r role de ve lopme nt (the psychoanalytic perspe ctive, social le arning, and cognitive -deve lopme ntal approache s), comparing and contrasting the the orie s and placing e ach in historical conte xt. Where as the thre e theoretical chapte rs focus on the ways in which the family (in conjunction with psychose xual or cognitive maturation) either directly or indire ctly influe nces ge nde r role deve lopme nt, the ne xt three chapte rs focus on extrafamilial sources of influe nce: pe ers, school systems, and the media. It is in this section that the book makes its most unique

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contribution, covering topics that are freque ntly ne glected, at least in typical textbook chapte rs on ge nde r role developme nt. For example , the re is rathe r extensive cove rage of a curre nt “ hot topic ” : ge nde r segre gation (i.e., childre n ’s te nde ncy to prefer playmate s of the ir own se x). This phenome non is usually first see n in the third year of life and incre ases in stre ngth through middle childho od. The “ se parate worlds ” to which boys and girls are the reby e xpose d have implications for the ways in which boys and girls are socialize d and how the y learn to inte ract with each othe r. Beal provide s convincing evide nce that childre n are not showing such preference s simply in response to pressure from adults. She argue s that the re are two causes of ge nde r se gregation in childre n ’s play: a desire for playmate s who have compatible play style s and a wish to be with othe rs who are classifie d as “ like me.” The data pertaining to the se two hypothe ses te nd to be some what overinte rpreted in the book, with indire ct evide nce and sparse findings prese nted as conclusive support. In truth, the re asons why childre n show ge nde r se gre gation re main some thing of a myste ry. Howe ver, play style compatibility and cognitive categorization are the most like ly explanations, and the basis of that like lihood is pre sente d quite nicely in the book. The next two chapte rs focus on sex diffe rence s in pe rsonality characte ristics and cognitive abilitie s during middle childhood. These are followe d by a chapte r on gende r role deve lopme nt during adole scence, a time that brings “ the ne w and e xciting prospe ct of re lationships with peers of the othe r gende r who have bee n studiously avoide d throughout childhood. ” In addition to a discussion of dating and se xual re lationships, this chapte r describe s the impact of pube rty, adole scent cognitive deve lopme nt, friendships, and family, school, and cultural influe nces. The final conte nt chapte r addre sse s gende r identity disturbance in childhood, including the issues of diagnosing childre n who have develope d a gende r identity that is inconsiste nt with their biological sex, possible origins of this phe nome non, and what tre atment, if any, should be provide d for such childre n. Boys and G irls has many strengths. The use of some time s amusing and often thought-provoking ane cdote s, both from Be al’s personal experiences and from pre vious writings, illustrate s points well and makes for enjoyable reading. There are times whe n the e mpirical e vide nce to support an assertion is lacking or we ak. But most ane cdotes and assertions are strongly grounde d in psychological re se arch. O ne dange r inhe re nt in any book de aling with sex difference s is that the reade r may be left with the impression that boys and girls are more diffe rent from each other than they really are. The ve ry nature of the topic focuse s attention on difference s, making it e asy to forge t about the similaritie s be tween boys and girls and the individual variability within each sex.

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Beal doe s a nice job of using a concre te e xample (he ight) to illustrate “ the notion that group diffe re nce s do not mean that individuals are necessarily diffe rent.” And in the conte xt of de scribing the effects of television on gender role development, there is also a useful discussion of research design (e.g., corre lational vs. longitudina l vs. e xpe rimental approache s). The se adde d feature s give the book e ven more value as a student text. But, once again, the nonstude nt also will find it use ful as an information refresher or update , a re ference source, and an inspiration for le cture material.

REFERENCE Se rbin, L. A., Powlishta, K. K., and Gulko, J. (1993) . The deve lopment of se x typing in middle childhood. Monogr. Soc. Res. Child Dev. 58( 2, Serial No. 232) .