body image and personality traits of male-to- female

SOCIAL BEHAVIOR AND PERSONALITY, 2006, 34(8), 927-938 © Society for Personality Research (Inc.)

Body Image and Personality Traits of Male-toFemale Transsexuals and Homosexuals Ali Bozkurt Gülhane Military School of Medicine, Ankara, Turkey Hasmet Isikli and Fusun Demir Kasimpasa Naval Hospital, Istanbul, Turkey K. Nahit Ozmenler, Zeynep Gulcat, Tunay Karlidere and Hamdullah Aydin Gülhane Military School of Medicine, Ankara, Turkey The aim of this study is to identify the body image and personality traits of male-to-female transsexual and homosexual persons in Turkey: 36 homosexuals and 52 male-to-female transsexuals were evaluated. According to the Body Cathexis Scale (Secord & Jourard, 1953) transsexuals compared with controls are statistically more satisfied with their waist, height, eyes, hips, legs, body posture and weight; dissatisfied with their body hair distribution, shoulder width and genitals. Homosexuals compared with controls are statistically more satisfied in height, sharpness of senses, hips, legs, sexual activity and body posture; dissatisfied in body hair distribution and genitals. It may be interpreted that transsexuals are identified with female body. The Eysenck Personality Questionnaire (Eysenck & Eysenck, 1978) revealed that transsexual participants have statistically higher mean neuroticism (N) scores than do controls. Keywords: transsexuals, homosexuals, personality, body image, transgender Ali Bozkurt, MD, Assistant Professor of Psychiatry, Department of Psychiatry, Gülhane Military School of Medicine, Ankara, Turkey; Hasmet Isikli, MD, Psychiatrist, Department of Psychiatry, Kasimpasa Naval Hospital, Istanbul, Turkey; Fusun Demir, MS, Psychologists, Department of Psychiatry, Kasimpasa Naval Hospital, Istanbul, Turkey; K. Nahit Ozmenler, Associate Professor of Psychiatry, Department of Psychiatry, Gülhane Military School of Medicine, Ankara, Turkey; Zeynep Gulcat, PhD, Psychologist, Department of Psychiatry, Gülhane Military School of Medicine, Ankara, Turkey; Tunay Karlidere, Assistant Professor of Psychiatry, Department of Psychiatry, Gülhane Military School of Medicine, Ankara, Turkey; Hamdullah Aydin, Professor of Psychiatry, Department of Psychiatry, Gülhane Military School of Medicine, Ankara, Turkey. Appreciation is due to reviewers including: Ozlem Hekim, Department of Child and Adolesce936

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According to the DSM-IV-TR (American Psychiatric Association, 2000) gender identity disorders are mental disorders characterized by strong and persistent cross-gender identification, persistent discomfort with one’s sex or a sense of inappropriateness in the gender role of that sex. The term homosexuality usually describes a person’s overt behavior, sexual orientation and sense of personal or social identity. In 1973 homosexuality was eliminated as a diagnostic category by the American Psychiatric Association and in 1980 it was removed from the DSM (Sadock & Sadock, 2003). The term homosexuality describes individuals whose sexual interests are directed primarily towards people of the same sex. The mainstream of psychoanalysis continues to see homosexuality as a pathological state or perversion (Bancroft, 1989). There are several studies on the body image of gender identity disorders and gay men. According to Herzog et al. homosexual men are likely to desire an underweight ideal (Herzog, Newman, & Warshaw, 1991). Assessing bodyself concept, body weight problems, sports activities, parental relationship, interpersonal self-concept and general self-concept of homosexual males it was found that they were significantly less adjusted during adolescence than were heterosexual controls (Prytula, Wellford, & DeMonbreun, 1979). Fagan, Wise, Derogatis, and Schmidt (1988), comparing a transvestite group with married heterosexual men, found that the transvestite group displayed a more negative body image, a more feminine gender role perception, and less experience than the comparison group according to the Derogatis Sexual Functioning Inventory (DSFI). They also concluded that transvestites who had no homosexual experience were less frequently gender dysphoric but more frequently had a concurrent Axis I disorder. According to Beren et al. gay men were much more dissatisfied with their bodies than were heterosexuals (Beren, Hayden, Wilfley, & Grilo, 1996). Research on psychopathology is controversial. A wide range of psychopathology from depression to psychosis has been reported in the studies. Hoening et al. reported that 70% of transsexuals have a comorbid psychiatric disorder (Hoening, Kenna, & Youd, 1970). Using the Minnesota Multiphasic Personality Inventory (MMPI) Battal et al. and Gulcat et al. reported that homosexual subjects had elevations on depression (D), psychopathic deviation (Pd) and Schizophrenia (Sc) subscales and male-tofemale transsexual subjects had elevated paranoia (Pa) subscales (Battal, Aydin, & Gulcat, 1989; Gulcat, Aydin, Battal, & Aydinalp, 1988). Bodlund and Armelius (1994) found that the transsexual group compared with the nontranssexual gender dysphoric group had only moderate degrees of nt Psychiatry, Ege University, Bornova/Izmir, 35100, Turkey, Email: [email protected]; Melanie A. Morrison, PhD, Department of Psychology, University of Saskatchewan, 9 Campus Drive, Saskatoon, SK, S7N 5A5, Canada, Email: [email protected]; Cagatay Oktenli, MI, Department of Internal Medicine, GMMA, Ankara, Turkey, Email: [email protected]

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additional Axis I and Axis II disorders according to the DSM-III-R, whereas the nontranssexual gender dysphoric group showed a prevalence of additional disorders. Comparing transsexual patients, patients with personality disorders and healthy adult controls Haraldsen and Dahl (2000) found that transsexual patients scored lower than personality disordered patients on the Global Symptom Index and all SCL-90 subscales (Derogatis, 1977). Although the transsexual patients generally scored slightly higher than the healthy control group they found all scores to be within the normal range. Miach et al. found that according to the MMPI-2 and DSM-III-R clinical evaluation there is no severe personality disorder in the transsexual group compared with gender identity disorders of the nontranssexual type (Miach, Berah, Butcher, & Rouse, 2000). In a previous study by our group it was found that, according to the Eysenck Personality Inventory (Eysenck & Eysenck, 1978) the transsexual group had higher scores in the extroversion, and neuroticism subscales. They also had higher scores for the Maudsley Obsession Scale (Hodgson & Rahman, 1977; Isikli, Ozmenler, Bozkurt, & Demir, 1999). Gulcat et al. (1988) compared male-to-female transsexuals and homosexuals using the MMPI and found that if female norms are used instead of male norms male-to-female transsexual subjects appear to have no pathological personality characteristics. Michel et al. (2002) compared 29 men asking for a sex-change according to MMPI. Sixteen were transsexuals and 13 were not meeting the criteria for transsexuality. They found that the transsexual systematically complied with cultural stereotypes of feminity without uneasiness, whereas the nontranssexuals could be subdivided into two groups; those with a vague sense of ill-being linked to a pronounced feminine identity and those with only slight feminine identity who showed no particular difficulties. Using a physical aggressiveness scale, Blanchard, McConkey, Roper, and Steiner (1983) compared heterosexual and homosexual men’s boyhood aggressiveness and found that it was lower in homosexuals than in heterosexuals and even lower in male-to-female transsexuals. They concluded that whatever underlying factor relates homosexuality to feminine gender identity in childhood it relates this erotic preference to anomalously low levels of physical aggressiveness in childhood as well. Isikli et al. (1999) found that according to the Ilter-Kiper Aggression Inventory (Kiper, 1984) the male-to-female transsexual group had higher scores in passive, destructive and total aggression. Lothstein (1984) analyzed the published transsexual research over 30 years (1954-84). There were 41 studies at that time but only 17 (42%) had control

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groups. According to those studies, male transsexuals appeared to be less stable and more psychologically disturbed than were their female counterparts, had lower sex drive and were poorly informed about sexuality, became psychologically stabilized once they lived out and enacted a cross-gender role and identity and became more stable after hormone and surgical interventions. On cognitive tests their pattern of scoring suggested a higher than average intelligence and feminine way of responding. The most frequently employed tests were the MMPI, the Draw-A-Person Test and WAIS (Machover, 1949). Lothstein concluded that although 17 of the studies had control groups 6 of these were not age matched. Most of the samples did not represent the whole population. Some of the studies had very small sample sizes. The purpose of the present study was to identify the body image and personality traits of male-to-female transsexual and homosexual persons in Turkey. The majority of the previous research was carried out in North America, Western Europe and the Far East. This study may be helpful in identifying the similarities and differences in a different cultural group. METHOD Participants Thirty-six homosexual and 52 male-to-female transsexual participants referred to the Psychiatry Department of Gülhane Military Medical Academy in Ankara and Kasimpasa Naval Hospital in Istanbul were compared with 72 age matched healthy controls. The male-to-female transsexuals and homosexuals had been referred for military evaluation. Since there is still a draftee system in the Turkish military all males have to attend a military evaluation process. The participants were consecutive referrals. The controls were selected among the people who applied for the same military evaluation. All subjects participated voluntarily. The diagnosis of male-to-female transsexualism was made according to DSM-IV criteria. Homosexuality was the description given by the participants themselves. Controls were healthy subjects who were eligible for military duty. The mean age and standard deviations of homosexual, male-to-female transsexual and control groups were 25.25 ± 5.14, 23.50 ± 4.04, 24.33 ±2.19 respectively. The mean years of education were 10.38 ± 3.55, 9.86 ± 3.52, 11.33 ± 2.73 in the same order. There was no statistical difference between groups. Measures The participants received a semistructured questionnaire, the Eysenck Personality Questionnaire, and the Body Cathexis Scale. The Eysenck Personality Questionnaire (EPQ; Eysenck & Eysenck, 1978) is a three-dimensional personality questionnaire with (N) neuroticism, (P)

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psychoticism, and (E & I) extroversion-introversion subscales. There is also a (L) lie scale. The questionnaire has a total of 101 questions. 25 are related to psychoticism, 21 to extroversion-introversion, 23 to neuroticism and 21 to lie. Participants are asked to read each question and answer it as “yes” or “no”. The test-retest reliabilities are in the 0.80-0.90 range. The consistency reliabilities are mostly above 0.80. The Body Cathexis Scale (BCS; Secord & Jourard, 1953) The Body Cathexis Scale measures the degree of satisfaction with various parts and functions of the body. Participants are asked to rate 46 body parts or functions using a 5-point scale. Split-half reliability coefficient is satisfactory at 0.83. The validity and reliability of the BCS in the Turkish population is satisfactory (Hovardaoglu, 1989). Statistics One-Way ANOVA was used and Tukey HSD as a post hoc test with p< .05 as the significant level. Only the items which differed significantly between groups are shown in tables. RESULTS Body Cathexis Scale (BCS) Using the BCS (Secord & Jourard, 1953), differences were found in satisfaction with hair distribution, waist, and height, sharpness of senses, shoulder width, arms, eyes, hips, legs, sexual activity, body posture, weight and genitals (Table 1). Other parameters which included items on satisfaction with hair, color of face, appetite, hands, nose, physical strength, urinating and defecation habit, muscle strength, energy, back, ears, age, chin, body shape, endurance of pain, breasts, digestive system, resistance to diseases, teeth, sexual performance, feet, sleep habit, voice, health, knee, shape of face were not statistically different. The total score of the BCS was also not statistically different between groups. Table 1 Body Cathexis Scale (BCS) Scores† of Participants M ± SD

Male-to-female Homosexual transsexual (T) (H) n=52 n=36

Control F Significance (C) n=72

Statistical Difference Between

Body hair 2.40 ± 1.69 2.58 ± 1.38 3.43 ± 1.14 9,379 ,000 distribution

T-C **** H-C**

Waist

T-C *

3.96 ± 1.17

3.88 ± 1.16 3.44 ± 1.01

3,907

,022

Height 4.01 ± 0.85 4.33 ± 0.71 3.27 ± 1.21 15,790 ,000

H-C **** T-C ****

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Table 1 continued M ± SD

Male-to-female Homosexual transsexual (T) (H) n=52 n=36

Control F Significance (C) n=72

Statistical Difference Between

Sense sharpness 3.80 ± 1.17 4.47 ± 0.81 3.69 ± 1.06 6,875 ,001

H-C ** H-T ****

Shoulder width

3.11 ± 1.40

3.72 ± 1.36 3.69 ± 1.05

3,886

,023

T-C *

Arms

3.44 ± 1.33

4.16 ± 1.00 3.75 ± 0.83

5,000

,008

H-T **

Eyes

4.44 ± 0.84

4.27 ± 1.08 3.97 ± 0.90

4,041

,019

T-C *

Hips 4.32 ± 098 4.02 ± 1.29 3.11 ± 1.05 20,616 ,000

H-C **** T-C ****

Legs 3.92 ± 1.31 4.16 ± 0.84 3.23 ± 1.18 9,555 ,000

H-C **** T-C ***

Sexual activity

H-C ***

4.11 ± 1.02

4.38 ± 0.83 3.76 ± 0.91

5,790

,004

Body posture 3.90 ± 1.24 4.05 ± 1.04 3.12 ± 1.07 11,280 ,000

H-C **** T-C ****

Weight

T-C *

3.46 ± 1.32

3.25 ± 1.18 2.90 ± 1.08

3,459

,034

Genitals 2.05 ± 1.37 2.75 ± 1.42 3.84 ± 0.70 38,708 ,000 TOTAL SCORE

144.00 ± 24.05

149.19 ± 142.04 ± 19.41 1,279 22.93

H-T * H-C **** T-C ****

,276

One-Way ANOVA has been used for statistics. Post hoc test is Tukey HSD. *p< .05, **p< .01, ***p< .005, ****p< .001 †Only items which differed significantly between groups were shown.

In the body hair distribution parameter, controls had higher scores which indicate they were more satisfied than homosexuals and male-to-female transsexuals. The male-to-female transsexual participants were more satisfied with their waist and hips compared with controls. Homosexuals were more satisfied with their hips although they had higher scores in waist also, but this item was not statistically significant. Both male-to-female transsexuals and homosexuals were more satisfied with their height, legs and body postures compared to controls. The most satisfied group in those three parameters was the homosexual group. The male-to-female transsexual participants were not satisfied with their shoulder width and arm length. In shoulder width, the difference was between controls and male-to-female transsexuals; in arm length between homosexuals

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and male-to-female transsexuals. The scores are lower in both of these parameters, interestingly in contrast with height and legs. Male-to-female transsexuals were satisfied also with their eye shape, and weight compared with controls. Regarding genitals both male-to-female transsexuals and homosexuals were dissatisfied compared with controls. The least satisfied on this parameter was the male-to-female transsexual subgroup. But regarding the sexual activity, the most dissatisfied group was the control group. Statistically significant difference is only between homosexuals and controls. Although male-to-female transsexuals got higher mean scores than controls the difference is not statistically important. In the sharpness of senses parameter, both homosexual and male-to-female transsexual groups are more satisfied compared with controls. In summary; male-to-female transsexuals compared with controls are statistically more satisfied in waist, height, eyes, hips, legs, body posture and weight; dissatisfied in body hair distribution, shoulder width and genitals. Homosexuals compared with controls were statistically more satisfied in height, sensation sharpness, hips, legs, sexual activity and body posture; dissatisfied in body hair distribution and genitals. There was no difference between male-tofemale transsexuals and homosexuals in favor of male-to-female transsexuals; but male-to-female transsexuals were more dissatisfied in sharpness of senses, arms and genitals compared with homosexuals. Eysenck Personality Questionnaire (EPQ) By using the EPQ (Eysenck & Eysenck, 1978) it was found that male-tofemale transsexual participants had statistically higher mean neuroticism (N) and psychoticism (P) scores whereas homosexuals had higher scores only in psychoticism compared with controls. Since the P subscale of the EPQ does not have reliability in a Turkish population it was not considered during discussion. The introversion/extroversion (E&N) scores and lie (L) scores of the three groups were not statistically different (Table 2). Table 2 Eysenck Personality Questionnaire (EPQ) Scores† of Participants M ± SD Eysenck-N Eysenck-E&I Eysenck-L

Male-to-female transsexual (T) n=52

Homosexual (H) n=36

Control (C) n=72

Statistical Difference Between

14.57 ± 5.82 14.09 ± 4.10 8.98 ± 4.72

13.50 ± 5.90 14.11 ± 4.59 8.77 ± 4.79

11.41 ± 5.17 12.94 ± 3.62 9.95 ± 3.39

T-C ****

One-Way ANOVA has been used for statistics. Post hoc test is Tukey HSD. ****p< .001 †Only items which differed significantly between groups are shown.

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DISCUSSION The male-to-female transsexual, homosexual and control groups were matched according to age and education. There was a difference in their occupational status, a lower percentage of male-to-female transsexuals being employed. Similar results have been obtained from other studies in Turkey (Gulcat et al., 1988). Poor social acceptance may make it harder for male-to-female transsexuals to find a job. Body Image In studies on the body image of male-to-female transsexuals and homosexuals, the problems seen most often were related with weight. In this study the maleto-female transsexual participants were more satisfied with their body weight compared with controls. The homosexual participants also had higher scores in the BCS which indicates more satisfaction, but it was not statistically significant. There are more studies with homosexual participants in the literature (Herzog et al., 1991). In general the homosexual men were described as desiring an underweight ideal. Although some researchers had found concerns about weight even in adolescence (Prytula et al., 1979) in this study our participants were satisfied with their weight. It might be possible that our participants do not really have weight problems since they are in a young age range. Homosexuals and male-to-female transsexuals were more dissatisfied with body hair distribution compared to controls. This is understandable in terms of female identification for male-to-female transsexuals. Masculine hair distribution may be a cause of dissatisfaction. In the homosexuals it might be related either with dissatisfaction about a hairy body or a possible desire to be more hairy. Since the BCS is not questioning which type of dissatisfaction this is it is not possible to interpret this result for gay men. Male-to-female transsexuals and homosexuals were more satisfied with their height, hips, legs, and body posture when compared with controls. There are not many studies about body image satisfaction of male-to-female transsexual and homosexual participants. To be taller, to have longer legs might be an advantage related to male genetic background. But this turns into a disadvantage with shoulder width and arms. Both groups are dissatisfied with their shoulders width compared with controls and male-to-female transsexuals are dissatisfied with their arms compared to homosexuals. These findings may be interpreted in terms of identification with the female body in the male-to-female transsexuals group. But again the meaning for gay populations is not interpretable. It was an interesting finding that the male-to-female transsexuals had lower scores in the genitals item, which means they are more dissatisfied with their genitals compared with both controls nad homosexuals. Though statistically

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nonsignificant they had higher scores in sexual satisfaction. Compared with controls, homosexuals were statistically more satisfied with their sexual activity. But they also were dissatisfied with their genitalia. This might be related to either male or female identification. The total scores of the BCS were not statistically different among the groups. There are several studies that found transsexuals, transvestites and homosexuals to have low body satisfaction (Beren et al., 1996; Fagan et al., 1988). In this study, although there was difference in body satisfaction with some parts of the body the total score of body satisfaction of male-to-female transsexuals, homosexuals and controls was not statistically different. It can be interpreted that both male-to-female transsexuals and homosexuals are satisfied with their bodies except for several parameters. The male-to-female transsexuals have a possible female identification. The homosexuals also have dissatisfaction with some body parts but it is not possible to say what is the meaning of this. Psychopathology Research on psychopathology is controversial. A wide range of psychopathology from depression to psychosis has been reported. In an early study the comorbid psychiatric disorders were found to be 70% (Hoening et al., 1970). Using the MMPI, male-to-female transsexuals and homosexuals in Turkey had elevated subscales indicating psychopathology (Battal et al., 1989; Gulcat et al., 1988). On the other hand several studies did not find significant psychopathologies (Bodlund & Armelius, 1994; Haraldsen & Dahl, 2000; Miach et al., 2000). Most studies depend on information from subjects who apply to psychiatry departments. The data in our study represent the general male-tofemale transsexual and homosexual population in Turkey. According to the Eysenck Personality Questionnaire, male-to-female transsexual participants had higher scores on the neuroticism subscale. Homosexual participants did not statistically differ from healthy controls. Different from a previous finding (Isikli et al., 1999) the male-to-female transsexuals did not have higher scores in any subtest compared with homosexuals. The findings in our study indicate a slightly higher neuroticism in the Turkish male-to-female transsexual participants and no significant difference in personality traits in Turkish homosexual persons compared with controls The majority of research on male-to-female transsexual and homosexual people has been carried out in North America, Western Europe and the Far East. It might be helpful in identifying the similarities and difference in a different cultural group like Turkey. These data are valuable in respect of representing knowledge about the Turkish male-to-female transsexual and homosexual population.

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Limitations and Possible Directions for Future Research The Body Cathexis Scale measures satisfaction and dissatisfaction about body parts, but it does not measure on which type of change subjects would expect. If a person is dissatisfied with his/her shoulders would he/she want broader or narrower shoulders? Or in the case of genitalia what is the main problem causing dissatisfaction? Future studies should include questions about the cause of the dissatisfaction. Psychopathology is a broad issue. Research of psychopathology could be done using specific personality and Axis-I measures. The Eysenck Personality Questionnaire is general measure about basic parameters and related more to personality traits. REFERENCES American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (text revised). Washington, DC: Author. Bancroft, J. (1989). Human sexuality and its problems (2nd ed.). New York: Churchill Livingstone. Battal, S., Aydin, H., & Gulcat, Z. (1989) Cinsel kimlik ve cinsel davranis bozukluklarinda kisilik ozellikleri [Personality characteristics in gender identity and sexual orientation disorders]. Gulhane MJ, 31, 651-660. Beren, S. E., Hayden, H. A., Wilfley, D. E., & Grilo, C. M. (1996). The influence of sexual orientation on body dissatisfaction in adult men and women. International Journal of Eating Disorders, 20, 135-141. Blanchard, R., McConkey, J. G., Roper, V., & Steiner, B. W. (1983). Measuring physical aggressiveness in heterosexual, homosexual, and transsexual males. Archives of Sexual Behavior, 12 (6), 511-24. Bodlund, O., & Armelius, K. (1994). Self image and personality traits in gender identity disorders: An empirical study. Journal of Sex and Marital Therapy, 20, 303-317. Derogatic, L. R. (1977). SCL-90; administration, scoring, and procedure manual-I (2nd ed.). Baltimore: John Hopkins University Press. Derogatic, L. R., & Melisaratos, N. (1979). A multidemensional measure of sexual functioning. Journal of Sex and Marital Therapy, 5, 244-281. Eysenck, H. J., & Eysenck, S. B. G (1978). Manual of Eysenck Personality Questionnaire. London: Hodder & Stoughton Ltd. Fagan, P. J., Wise, T. N., Derogatis, L. R., & Schmidt, C. W. (1988). Distressed transvestites. Psychometric characteristics. The Journal of Nervous and Mental Disease October, 176 (10), 626-32. Gulcat, Z., Aydin, A., Battal, S., & Aydinalp, K. (1988, September). Transseksüeller ve homoseksüeller üzerine psikososyal bir çalısma. [A psychosocial study on transsexuals and homosexuals.] Paper presented at the Turkish XXIVth National Psychiatry and Neurological Sciences Congress, Ankara, Turkey. Haraldsen, I. R., & Dahl, A. A. (2000). Symptom profiles of gender dysphoric patients of transsexual type compared to patients with personality disorders and healthy adults. Acta Psychiatrica Scandinavica, 102 (4), 276-81. Herzog, D. B., Newman, K. L., & Warshaw, M. (1991). Body image dissatisfaction in homosexual ¸ and heterosexual males. The Journal of Nervous and Mental Disease, 179 (6), 356-359. Hodgson, R. S., & Rahman, S. (1977). Obsessional-compulsive complaints. Behavioral and Research Therapy, 15, 389-395.

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Hoening, J., Kenna, J., & Youd, A. (1970). Social and economic aspects of transsexualism. British Journal of Psychiatry, 117, 163-172. Hovardaoglu, S. (1989). Vücut Algisi Ölce˘gi’nin güvenirlik ve geçerlik çalısması. [The validity and reliability study of the Body Cathexis Scale.] Unpublished manuscript, University of Hacettepe at Ankara. Isikli, H., Ozmenler, K. N., Bozkurt, A., & Demir, F. (1999, August). The personality traits and the levels of obsession and aggression of homosexual and transsexual persons. Paper presented at the 14th World Congress of Sexology, Hong Kong. Kiper, I. (1984). Saldirganlik Türlerinin Cesitli Ekonomik, Sosyal, Akademik Degis Kenlerle Iliskisi [The relationship of aggression types with economical, social and academic variables]. Unpublished doctoral dissertation, Social Sciences Institute, University of Ankara, Ankara, Turkey. Lothstein, L. M. (1984). Psychological testing with transsexuals: A 30-year review. Journal of Personality Assessment, 48, 500-507. Machover, K. (1949), Personality projection in the drawings of the human figure. Springfield, IL: Charles C. Thomas. Miach, P. P., Berah, E. F., Butcher, J. N., & Rouse, S. (2000). Utility of the MMPI-2 in assessing gender dysphoric patients. Journal of Personality Assessment, 75 (2), 268-79. Michel, A., Ansseau, M., Legros, J. J., Pitchot, W., Cornet, J. P., & Mormont, C. (2002). Comparisons of two groups of sex-change applicants based on the MMPI. Psychological Reports, 91 (1), 233240. Prytula, R. E., Wellford, C. D., & DeMonbreun, B. G. (1979). Body self-image and homosexuality. Journal of Clinical Psychology, 35 (3), 567-72. Sadock, B. J., & Sadock, V. A. (2003). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences, clinical psychiatry (9th ed.). Philadelphia: Lippincott Williams & Wilkins. Secord, P. F., & Jourard, S. M. (1953). The appraisal of body cathexis: Body cathexis and the self. Journal of Consulting Psychology, 17, 343-347.