The fixed idea of sex

Intersex conditions and non-heterosexuality are two well-established sites for encountering early medical circumscriptions of one’s identification as male or female. The European late nineteenth century is often nominated as a period of ‘emergence’ or ‘invention’ in these two respects. According to Geertje Mak and Rainer Herrn, among others, it is only after the turn of the nineteenth century that ‘hermaphroditism’ (intersex) cases came to illustrate a ‘transformation from sex as inscribed in a person to sex as ingrained in the self’.Footnote ³ Scholarship on this frame shift, from sex attached to the legal entity of a person to an experienced, expressed sex of self (Herrn speaks of subjektive Geschlechtszugehörigkeit), elaborated on earlier scholarship on the sexual self of sodomites and tribades in the eighteenth and early nineteenth centuries, categories cross-fading with collectivizing lesbian and gay identities – ‘a dramatic narration with the true, inner sexual self as outcome.’Footnote ⁴ This would have paved the way to a ‘new autobiographical script available for the life history of a person with a so-called “error of sex”’, a script echoing the older metropolitan ones of the gay male: the molly, urning, warme Bruder. Footnote ⁵ The new script and attention turned sex inward, noted Mak: ‘what had previously been indicators for a person’s sexed position in society, now pointed to lifelong inclinations, preferences and aversions which characterized the sex of a person’s inner, genuine being.’Footnote ⁶ Mak more recently maintained that it was ‘only through medical cases of (pseudo-)hermaphroditism and psychiatric cases of ‘sexual inversion’ that the idea of an inner, inalienable psychological ‘sex of self’ started to take shape’.Footnote ⁷ The mid-twentieth-century nominal introduction of ‘gender identity’ in American medical psychology has been understood as the outcome of clinical engagements with similar problems concerning sexual differentiation, including adrenal hyperplasia. Gender identity, Jules Gill-Peterson proposed, was ‘the endpoint of a teleology of growth out of plasticity […] a psychosocial dimension of sex, rather than a separable ontological entity’.Footnote ⁸

What has remained undiscussed in this scholarship are considerably older frames for ‘misidentification of sex’ as a space of alienation, namely those of melancholic delusion and monomania. Proto-psychiatric nosological slots for ‘melancholic’ misidentification of one’s sex were advanced as early as the early 1730s. The Scythian, ‘feminine malady’ (θήλεα νοῦσος) of both Herodotean and Hippocratic fame, was one of multiple sites where this interpretative innovation took place.Footnote ⁹ By the 1730s, legal and nosological considerations in France independently spawned explicitly psychiatricising frames for Scythian but also modern gender-crossing, rendering it a distinct form of melancholia or vapours.

Several vignettes and causes célèbres animated this modern aetiological turn. Ubiquitous eighteenth-century characterisations of male cross-dressing in popular terms of manie or démence followed the 1737 gossipy and perhaps fabricated Mémoires of cross-dressing abbot François Timoléon, abbé de Choisy (1644–1724), for instance. De Choisy made for one of the various cases of cross-dressing ‘mania.’ As in Jörger’s case chronicled above, scrutiny extended to Choisy’s mother, who reportedly cross-dressed them as a child, indeed on the basis of what would be a singular mania. Build-up to these qualifications is captured by an opinion provided by polymath Jean le Rond d’Alembert (1717–1783): ‘The kind of taste that he [Choisy] retained too long for such a strange and blameworthy travesty [travestissement], is sad proof of the unfortunate empire that the first nonsense, with which a bad education has infected them, retains over certain minds.’Footnote ¹⁰ More specifically: ‘This species of dementia [démence] (for why not call it by its name?) would […] have been only madness without consequence, if the Abbé de Choisy had not abused it in a very serious circumstance’.Footnote ¹¹ Childhood habituation was indeed an aetiological reading widely ventilated as soon as De Choisy’s biography came out.Footnote ¹² Widespread nineteenth-century attention to similar instances routinely referenced eighteenth-century exemplars such as this one, references animated by various quasi-medical verdicts – manie efféminée, manie de se déguiser en femme, manie de s’habiller comme une femme, manie de l’habiller en fille.

It is during the first half of the eighteenth century, then, that an ideational, namely delusional, frame for ‘one’s sex’ came into focus, inviting early speculations concerning aetiology, eventually also early anti-psychiatric arguments. Illustrative is a nineteen-page apologia written in 1831 by French Navy commander Christophe-Paulin de La Poix de Fréminville (1787–1848) concerning his interest in cross-dressing: ‘the inclination that some men have to dress as women […] the passion that leads them to assimilate, as much as possible, with a sex of which they are idolaters’.Footnote ¹³ This inclination, as so many, would be caused less by education than by an inborn and lifelong ‘physical constitution, by a certain disposition of the organs of the individual’.Footnote ¹⁴ Moreover, were an individual so disposed, cross-dressing ‘operates delightfully on his nervous system and on his delicate being’. This fairly unique work challenged not criminalisation (local ordinances targeting crossdressing were in place in France) but popular psychiatrisation, of a ‘mania to assimilate to women […] that some austere censors call real madness’ but that ‘does not change in the slightest [the cross-dresser’s] intellectual faculties’.Footnote ¹⁵

Ample evidence shows that nineteenth-century ‘sodomites’ before Karl Heinrich Ulrichs, Ulrichs himself, and the urnings he wrote about, often fell subject to this prevailing nosology of monomaniac, ‘fixed ideas’ concerning sex. Ulrichs was mock-diagnosed with ‘gynandromania’, for instance. Itself a conceptual idée fixe under heavy fire by the early 1850s, the sponsoring notion of monomania had seeped deep into European popular-scientific concepts of mental health, and it is thus that male cross-dressing tended to be classified throughout the latter half of the century: as a man’s étrange monomanie de se déguiser en femme, in the late-1880s words of a retired Parisian chef de la Sûreté. Footnote ¹⁶ Americans had been comparably calling it gynomania since 1877.

Crucially, the nosological nestling of cross-‘sex’ identity among other melancholic ‘fixed ideas of transformation’, including lycanthropy, ubiquitous already by the end of the eighteenth century, remained largely bereft of substantive aetiological attention deep into the nineteenth. This was so despite ubiquitous nosological interest and despite multiple pertinent cases known to Pinel, Esquirol, and their students, including François Leuret. The 1880s, however, saw a wealth of theoretical approaches. The best-known example of this aetiological turn of the fixation of sex qua idea – qua concept of self – was Richard von Krafft-Ebing’s reception of Carl Westphal’s convoluted, 1869 concept of ‘contrary sexual feeling’ (conträre Sexualempfindung). The notion conflated what to many had hitherto seemed distinct phenomena: (homo)sexual orientation and (cross)sexed behaviour. Engagements remained brief during the 1870s but became more ambitious during the next decade. Krafft-Ebing’s concept of eviration referred to a putative ‘second stage’ of ‘acquired contrary sexual instinct’ entailing ‘deep and lasting transformations of the psychical personality’. Ultimate – third and fourth – stages of ‘psychosexual degeneration’ in both supposedly acquired and inborn Konträrsexualismus entailed delusional – ‘paranoid’ – investments in a ‘sexual’ (geschlechtliche) transmutation. This schema connected Westphal’s essentially descriptive approach to gender variance with Bénédict Morel’s degeneration theory. Like multiple contemporaries, Krafft-Ebing sought to reconcile established nosological notions of ‘delusion of sex’ with Westphal’s new formulation of ‘sexual inversion’: a confrontation of early medical notions of Geschlecht/sexe as idea that could be either correct or singularly mistaken (a particular monomania), with new ones of ‘sex’ as a specific and symptomatic awareness or sense of self (Geschlechtsempfindung). Krafft-Ebing spelt out in 1892 that this new sense of Sexualempfindung/Geschlechtsempfindung admitted no overlap with earlier notions of ‘dynamic hermaphroditism’, which hitherto had explained behavioural-psychological variance as the lowest, non-genital and indeed largely behavioural, grade of intersexuality.Footnote ¹⁷ Atypical sex identity, in other words, had become a discrete ‘psychosexual’ symptom, with the question of its somato-psychic aetiology an open-ended one.

Contextualised below, Krafft-Ebing’s quadripartite stage model of sexual inversion was the fruit of protracted nosological deliberation. Culminating in 1891, initially as a three-stage model for ‘delusion of sexual transformation’, it entered his Psychopathia sexualis only in the subsequent, seventh (1892) edition and, hence, its first English translation. This typology has been considered a baffling moment in pre-Hirschfeldian trans/gender medicine. The here projected continuum between still reversible bi-/homosexual orientation and irreversible sex/gender ‘delusion’ indeed deserves more historical interpretation than has been offered.Footnote ¹⁸ Cross-dressing urges here remained what they had been to Westphal, a functional signum degenerationis within the purview of conträre Sexualempfindung. But questions of how the self was felt or thought to be, specifically how sensations of the sexed/sexual body were being perceived, interpreted, and assimilated to a sense of self, now became much more explicitly problematic, even to some extent oriented around clinical observation. Moreover, differential diagnosis became a more circumspect process. For instance, cross-dressing possibly signified ‘clothing fetishism’, a category specified by Krafft-Ebing in 1889.

Differential-diagnostic problems such as these significantly outlived Krafft-Ebing. At the same time, his stage-concept of sexual inversion proved one of the most durable clinical responses to non-cisgender identification. As late as 1965, we encounter the assertion in a leading American psychiatry journal that psychosexual inversion entailed ‘a spectrum of disorders, from mild effeminacy to homosexuality, transvestism, and finally transsexualism, each representing a more extreme form, and often including the previous manifestation’.Footnote ¹⁹ This sustained traction, despite Hirschfeld’s intervening ‘sexual intermediacy’ model, is remarkable, knowing that Krafft-Ebing’s empirical basis remained small, and was more than anything the result of a protracted process of bricolage and literature review, during seven years during which Psychopathia saw a new expanded edition every year. Furthermore, ‘sexual pathology’ was long only prefacing anything we could call a developmental psychology of gender identity (as might be ascribed, at the earliest, to Alfred Adler). Krafft-Ebing’s explicit qualification of one’s ‘sex-feeling (awareness of a particular gender identity as a man or woman)’ as an ‘important mental characteristic’ only appeared in 1901, and in subsequent editions of Psychopathia. Footnote ²⁰ Only a few authors had hitherto reflected on the development of this sense of sex-consciousness.Footnote ²¹ Yet Krafft-Ebing was hardly the first nosologist grappling with the psychological problem of sex-of-self after Westphal, and his late-1880s interventions at this point need to be seen in light of a variety of contemporaneous sources both cited and uncited by Krafft-Ebing, specifically in light of the nosological status quo as sketched above. Two authors illustrate a wider emergence of what may be called theoretical gender medicine in its own right: Théodule-Armand Ribot and Rudolph Arndt. In the section below, I briefly sketch the historical context for this emergence and discuss both authors in subsequent sections, before asking how Krafft-Ebing fits into this wider context.

‘Delusional sex’: from nosology to aetiology

Writing in 1884, Eugène Gley complained about the absence of psychology as a guiding frame for, and, in turn, an unacknowledged key beneficiary of, sexual psychopathological studies, whose ‘sole purpose thus often seems to be to fill nosological frameworks’.Footnote ²² Specifically, if the (instinctive) monomanias are interconnected, somehow, as degrees or differential outcomes of degeneration and idiosyncratic weaknesses or susceptibilities, each degenerate allowed a unique glimpse of part of the mental mechanism. The sexual instinct being an ostensibly simple faculty, the pervert thus seemed an excellent inroad to psychology. Clinical sex researchers held an important key to nosological reform, well surpassing the new scope of sexualité. Gley hinted at fetishism as a developmental obsession, for instance, and like others including Ludwig Kirn, alluded to a stage-model of hermaphroditisme moral – quite likely an inspiration for Krafft-Ebing’s later stage-thinking in such terms as psychosexuale Hermaphrodisie (‘intersexed’ bisexual orientation). Descriptive sexual psychopathology had come to a dead end, failing at a clinically satisfactory and evidence-based aetiology, and failing to summon or moderate a general psychophysiology of ‘sexuality’ (Geschlechtlichkeit; sexualité). Franz Joseph Gall’s cerebellar theory of ‘amativeness’ (stipulating an ‘Organ der Geschlechtsempfindung’ or ‘organ of gender’ as some phrenologists had it), Paul Moreau’s recent notion of sens génital, and Westphal’s unpacked concept of Geschlechtsempfindung had all lacked a credible anatomical basis and, more importantly, psychological acumen.

The same can be said about centuries of proto-endocrinological deliberation about the masculinising effects on the brain by reabsorbed semen, a theory that by the 1880s had been sidelined by equally unempirical nervous reflex theories of sexual physiology. Rare attempts at a discriminating neuroanatomy of sexual psychopathology, such as by Valentin Magnan in 1885, did not extend to gender self-identification. During the 1880s, unsurprisingly, Westphal’s concept of ‘sexual inversion’ was increasingly understood to introduce more questions regarding sexual psychology than answers. As a reviewer of Julien Chevalier’s monograph on the subject opined, the second edition of which declared sexual inversion a ‘disorder of identity/personhood’ (une maladie de la personnalité), inferences on inversion psychique and sexualité psychique risked being ‘superimposed on clinical observation and [thus] to bring the facts into line with the doctrine’ rather than vice versa.Footnote ²³ The ‘absurdity in the fundamental idea of selfhood’ observed in some ‘inverts’ now posed substantive questions concerning classification, specifically of psychopathy.Footnote ²⁴

From the mid-eighteenth century, considerable attention had been given to aetiology specific to various ‘fixed ideas’ within the sexual sphere: ‘imaginary spermatorrhea’, ‘syphilophobia’, and impotence attributed to magic spells. As discussed, ‘transformation of sex’ was among these various nosological innovations. All of these ‘monomanias’ pertained to radical fears or doubts concerning sex role performance; indeed, all were widely associated with suicidality. Sexual physiology and behavioural neuropsychiatry presented competing explanatory frames for these problems. In 1832, Basel physician-theologian Ernst Joseph Gustav de Valenti (1794–1871) illustratively proposed that even pederasty, perhaps inborn but certainly among the nervous disorders (Nervenübeln), betrayed a complex affliction: ‘a monomania of the sexual instinct combined with simultaneous monomania of the psychic sexual love, which transfers sexual lust and sexual love from woman to man […] a true illness, a partial mania.’Footnote ²⁵ Follow-up was minimal. In 1845, Wilhelm Griesinger would extensively mock as unscientific a treatise by De Valenti exploring the relation between madness and sin. But remarkably, de Valenti also anticipated Ulrichs’ notion of mental hermaphroditism. Tribadismus was the affliction of the Mannjungfern, ‘living withdrawn and solitary, and in remarkably close intimacy with a female person. There are indeed certain hermaphrodite natures [Zwitternaturen] which, both through the structure of the genital parts and through the special psychological and moral physiognomy, have made it very difficult for some to develop a certain position in relation to one sex or the other.’Footnote ²⁶

Phrenology presented the most likely arena for arbitration on this point of position-taking, and it was still to phrenology that mid-century alienists deliberating on ‘sex transformation delusion’ turned, however fruitlessly, when asking, ‘To the lesion of what fundamental faculty can we relate such a [‘transformation’] delirium?’Footnote ²⁷ Brierre de Boismont here seems to echo Achille-Louis Foville, who wondered about this precise question already in 1829: ‘To the lesion of what fundamental faculty corresponds the delirium of a man who thinks he has changed into a woman, and vice versa […]?’Footnote ²⁸ Franz Joseph Gall (1758–1828) had been interested in ‘partial manias’ from circa 1801 but failed to tackle the problems of sexual and gender diversity head-on. Gall seemingly only once mentioned the scenario ‘when a man believes himself transformed into a woman, a wolf, etc.’, in a passage meant to affirm ‘the correspondence of partial alienations or monomanias with the plurality of cerebral organs, and their partial suffering’.Footnote ²⁹ Research into purported defective femininity/masculinity, however, remained focused on the ‘organ of parental affection’ in women incarcerated for infanticide and those affected with pseudocyesis.

In 1828, Broussais connected monomanias rather to ‘certain changes that have taken place in the [bodily] functions’: ‘This is how a madman rendered impotent by masturbation imagines himself transformed into a woman and wants to take on the [corresponding] tone [of voice] and costume.’Footnote ³⁰ Compromised sexual functions supposedly tricked the mind into the idea of a ‘sex’ switch. In his much translated textbook first published in 1845, Griesinger comparably posited with reference to Claude-François Lallemand that ‘sex change delusion’ was ‘by no means confined specifically to melancholics but may be developed during the course of this disease, and in many cases appears connected with a disease of the genital organs in which the sexual sensations disappear’.Footnote ³¹ Lallemand’s case, borrowed from André-Pamphyle-Hippolyre Rech (1793–1853), was a ‘man who believed himself to be a girl’ and on autopsy was found to have their testicular functions ‘abolished since the ejaculatory ducts were atrophied and obliterated.’ Lallemand inferred that ‘If this singular alteration of the genital organs were not the cause of the patient’s derangement, it must at least have influenced its peculiar character’. The undisclosed experience of other authors appeared similar, suggesting a somatosensory genesis of partial delirium specific to its sexual content. A student of Esquirol known for his progressive work on humane treatment of the insane, alienist and former asylum physician Maximien Parchappe de Vinay (1800–1866), seemed to fully confirm Lallemand’s inference:

This line of reasoning provides an important backdrop to 1880s interests in sexualité, which evidence an increasingly wider variety of speculations, still mostly theoretical. In mid-1870s lectures, prominent French psychiatrist Benjamin Ball (1833–1893) provisionally tied the Hippocratic ‘Scythian malady’ to the supposed mental corollaries of genital hyperesthesia, for instance.Footnote ³³ German psychiatrist Heinrich Neumann had tied it rather to male genital anaesthesia.Footnote ³⁴ Parisian alienist Evariste Marandon de Montyel (1851–1908) proceeded beyond late eighteenth-century associations with masturbation, by affirming a role for spermatorrhea. Semen loss would produce a variété vésanique, however one whose specific symptoms were culturally tinged: a folie séminale à couleur locale – ‘seminal mania’ in William Alexander Hammond’s 1882 translation.Footnote ³⁵ Hammond himself reaffirmed a hitherto well-established testicular atrophy theory, emboldened by his analogy of such an ailment he reported having observed, in the early 1850s, among Puebloan mujerados. Furthermore, various delusional states and irrational fears with some gender or genital theme were recorded by the earliest commentators on conträre Sexualempfindung during the last decades of the century: syphilophobia, gynophobia, male pseudocyesis. An 1882 Italian report often cited in the 1880s literature on ‘sexual perversion’ was that of an apparent cross-sex delusion in a gynecomastic man, a report that took aboard the possible relevance of the famed Scythian disease as well as the recent concept of sexual inversion.Footnote ³⁶

The foregoing significantly qualified blanket verdicts of intellectual (rather than instinctive) monomania: atypical adoption of sex roles was now a culture-relative and clinically heterogenous affair. Medical perspectives on male gender-crossing had in fact long been relativized by ethnological perspectives on this ‘Scythian-like’ phenomenon. A word had even been coined for it: ‘Enareanism (if I may so term it)’.Footnote ³⁷ Though he himself never discussed the ‘feminine malady’, in a footnote Westphal acknowledged an association of his own December 1868 oral paper with various phenomena widely correlated in earlier literature: the Scythian anarieîs (the ‘unmanned’), native American cross-dressing, and the Chevalier d’Éon. This unpacked reference is to pioneering physician-ethnologist Adolf Bastian, the founding editor of the Zeitschrift für Ethnologie ^, writing in its maiden volume.Footnote ³⁸ Bastian delivered some of this material apropos Westphal’s oral presentation at the December 15, 1868 meeting of the Berliner medicinisch-psychologische Gesellschaft, which he attended. Earlier in 1868 Bastian had advanced a tentative, if woefully unprocessed, ‘comparative psychological’ frame for gender-crossings, under the heading of ‘the pathology of possession’.Footnote ³⁹ Bastian had still earlier categorized species- and ‘sex’-switching as insania metamorphosis, quoting a psychiatry textbook.Footnote ⁴⁰ However, these occasional ethnopsychiatric allusions had remained woefully unelaborated.

Where Pinel’s manie/Esquirol’s monomanie frame for ‘sex change delusions’ had pinpointed a singular blind spot in rationality, Westphal stressed an observed awareness on the part of the patient of ‘the morbidity of the phenomenon’ of inborn sexual inversion. This nosologically required awareness was problematic given that, in the perception of many, it was only in Westphal’s text that such a verdict began to be insisted upon by alienists themselves. Most indicative of a move here from psychiatric conditions defined by discrete symptoms toward a more compounded, aetiological concept of sex-gender intermediacy, Westphal problematized the verdict of ‘periodic mania’ with regard to his single cross-dresser case, which had appeared in a report written by a penitentiary inspector.Footnote ⁴¹ The patient’s own terminology evidently only included Drang (urge) and Trieb (drive), Westphal observed, though without problematizing these terms. Westphal himself spoke interchangeably about Drang, Tendenz, Verlangen, Trieb, Hang. He was at this point clearly resisting Pinellian/Esquirollian readings of non-cis gender identification: here was not a ‘partial alienation’ but a strong desire urging the patient to relate to themselves and to the world in ways they realized were contrary to gross-anatomical expectation. A reviewer for the Annales médico-psychologiques (Auguste Chatelain, 1838–1923) did not pause at what he glossed ‘manie de porter des habits de femme…singulière manie’ – but clearly these dated designations now required more caution.Footnote ⁴²

Antique and new ideas were seen side by side during the closing decades of the century. By 1888, the Scythian malady was still widely cited as only one of a variety of symptomatic instalments of ‘identity confusion’ (Personenverwechslung), even associated with a FtM case presented by Konrad Alt (notably in a journal co-edited by Krafft-Ebing).Footnote ⁴³ Classical scholar Wilhelm Heinrich Roscher (1845–1923) thought likewise, fully agreeing with an opinion then already over a century old, and also considered by Arndt: here was a ‘therianthropy-like pathological phenomenon’.Footnote ⁴⁴ However, even authors uninformed of the new diagnostic slot of sexual inversion leaned toward reframing: aetiology and development now became central objectives. French physician Ernest Martin (1830–1897) wrote in 1880 that here was ‘a monstrosity that would undoubtedly be difficult to find in our time but which existed in the time of Hippocrates because he gives a very precise description of it’.Footnote ⁴⁵ But in tune with many contemporaneous voices, even Martin actively pursued modern analogies (he continued with a long account of d’Éon) and even threw in a developmental-nosological speculation regarding such ‘monstrous’, but not ‘hermaphroditic’, cases: ‘During development their constitution did not follow a clearly determined sexual direction; it remained hesitant and it offers the spectacle of a singular whole for which it is difficult to give a physiological explanation unless it is considered as an atavistic manifestation which would be based on the primitive androgyny [androgynisme] of Man.’Footnote ⁴⁶ Psychological ‘sex’-switching, then, seemed in a particular class of its own meriting developmental perspectives.

‘Metamorphosis from above not from below’: Ribot

While sexual preoccupations and fears invited psychiatric verdicts already throughout the eighteenth century, concepts of sexual disorder took a progressively psychological turn during the late 1870s and 1880s, especially in France.Footnote ⁴⁷ The psychology of selfhood saw widespread attention, often with reference to clinical problems related to identity, self-perception, and self-awareness. One’s notion of one’s sex (sexe comme idée) now spoke to increasingly general questions of the fixity of self-identity (notion/sens intime de la personnalité, notion/conscience du moi). ‘Errors’ or ‘alienations’ of self-identity (erreurs/alienations de la personnalité) prominently included multiple identities (personnalités multiples et coexistantes) seen in hysterics, and fictive identities (personnalités fictives) brought about by suggestion.Footnote ⁴⁸ German philosophers and experimental psychologists before Westphal had been using terms such as Selbstempfindung/Selbstgefühl (also called Gemeingefühl, Allgemeingefühl) which in psychiatry came to mean a self-consciousness (Selbstbewusstsein) or self-concept (Vorstellungscomplexe des Ich). Such faculties were seen to be at the mercy of, and thus at risk of being deceived by, the senses: by pleasure and displeasure (Lust/Unlust) and their potential excesses. The Self, the Me, was dissected more elaborately and explicitly than before, and although bereft of a clear-cut concept of ‘gender identity’, multiple authors struggled with the now psychological-developmental questions of how sexual instinct, sexed bodies, and sexual functioning were to fit into this psychological Me. We have William James, for instance, insisting that clothes were quintessential ‘constituents of the me’, the outer part of the ‘material Self,’ a point of acute relevance to Hirschfeld’s Transvestiten. Footnote ⁴⁹

James stopped short of explicitly reifying sexed appearance and sex role, however. More remarkable at this point is mid-1880s work by Théodule-Armand Ribot (1839–1916), founder of experimental psychology in France and one of a number of contemporaneous French authors to reflect on identity-selfhood, or personnalité. Footnote ⁵⁰ Ribot has been considered one of the first French experimental psychologists with an interest in sexuality, which, as Sylvie Chaperon has argued, proceeded mostly through psychopathology. He never offered cases, but with François Leuret’s of the 1830s in mind, in 1884, Ribot provided a primarily moral-cerebral approach to specifically sex-of-self crossings.Footnote ⁵¹ This was evolving insight, judging from a very brief mention of cross-sexe identification already in 1880, building up to a hitherto rare developmental frame for Westphal’s sexualité contraire: development of the sex character (caractère sexuel) of the mental apparatus.Footnote ⁵² ‘This development of an organ and of its functions, with their train of instincts, imaginings, feelings, sentiments, and ideas, has produced in the neuter personality of the child a differentiation – has made of it a male or female Me [un moi mâle ou femelle], in the complete sense of the term’. This bare postulation of developmental psychosexuality was to guide extrapolations from physiology to ‘exceptional and morbid cases’, including the mental condition of the intersex individual and the eunuch being ‘emasculated morally as well as physically’ – or ‘mutilated in mind as in body’, in the words of Britain’s leading mental pathologist Henry Maudsley.Footnote ⁵³ But even Maudsley, in a single unpacked sentence, had also mentioned something else, as if to support his wider claim of ‘the intimate and essential sympathy between the brain as a mental organ and other organs of the body’: ‘And there is certainly a characteristic variety of insanity caused by self-abuse, which makes the patient very much like a eunuch in character’.Footnote ⁵⁴ This may or may not refer to a prevailing French interpretation of Hp. Aer. 22 seeing feminisation as a corollary of onanism/spermatorrhea, though this outcome clearly differed from the more characteristic, florid, and lethal ‘mental derangement’ by means of self-abuse.Footnote ⁵⁵ Regardless, these phenomena in clinical psychology Ribot considered suggestive of the outstanding heuristic value of sexual disturbances in conceptualizing the larger, hitherto elusive phenomenon of selfhood: ‘For if personnalité [i.e. sense of personhood, identity, sense of self] is a compound, varying according to its constituent elements, a change in the sexual instincts will change it, a perversion will pervert it, an inversion will invert it [une interversion l’intervertira]; and this is exactly what takes place.’

Clinical experience suggested an additional, reverse causality, however. For in ‘sex change delusion’ cases such as Leuret’s, ‘the starting point of the [gender/psychosexual] metamorphosis is to be sought elsewhere: it must be found in the cerebrospinal organ.’ As would not much later Krafft-Ebing among others, Ribot ended up postulating neurological ‘centres from which psychic incitements are sent out to the sexual organs to put them in action […] the cerebral, and consequently the psychic, representatives of the sexual organs’.Footnote ⁵⁶ This cerebral seat of sexuality, then, would explain cases of ‘metamorphosis from above not from below’: that seen in known cases of a ‘cerebral disorder of unknown character (a woman supposing herself to be a man, or vice versa) whence results a fixed erroneous state of consciousness.’ This consciousness then seeks its own completion, radiating widely to ‘the feelings, the ways, the speech, the dress of the imaginary sex.’ Cross-sexe identification and desire here became one of the ‘cognitive deviations of identity’ (déviations intellectuelles de la personnalité). The ‘psychological monstrosity’ of sexual inversion, by comparison, would be an entirely different and indeed larger problem: precisely that of the lack of parity in character between body and soul, where, in other words, consciousness does not ‘tend to complete itself’ and rather produces homosexuality. Psychology, here, would for the moment have to admit its ignorance, Ribot insisted. Degenerationists, for instance, could indeed not explain ‘why degeneration takes this [sexual inversion] form and not another’; maybe ‘the mystery is to be sought in the multiple elements of heredity, in the complex play of the conflicting male and female elements’.Footnote ⁵⁷

Ribot never set out to unravel the mystery laid out here. In evaluating his 1880s contributions, it is notable that he never provided a critical review of the available literature on the psychological sequelae of castration, for instance. Castration had been a minor theme in contemporaneous psychiatry that spoke most directly to this theorising. One example is a Russian discussion of the psychological sequelae and psychiatric profile of self-castration as practised by the Russian Skoptsy, translated into German in 1876.Footnote ⁵⁸ Not unlike 1860s reactions to Ulrichs’ concept of ‘mental hermaphroditism’, the alleged ‘proselytizing’ and ‘propaganda’ of the afflicted (the sectarian self-afflicted, more precisely) proved all-too-easy fodder for psychiatrisation. Illustratively, the ostensible difference between eunuchs and the cross-dressing pseudo-eunuchs of Hippocratic fame proved assets in criticisms of Krafft-Ebing’s Anlagetheorie of sexual inversion and its appeal to notions of bisexual constitution. For while an intimate correspondence would have to be assumed between gonads and brain, castration in the usual sense did not activate any latent potentiality for a ‘new sexuality’, let alone a full sexe-identity switch, August Cramer noted in 1897: ‘The eunuch is indeed a silly and effeminate fellow and makes a womanly impression, but he does not feel like a woman; he develops no sexual inclinations at all, least of all homosexual ones.’Footnote ⁵⁹ At the same time, homosexuality would not be inversion but perhaps a mere ‘product of the imagination,’ and as such fully compatible with both physical and mental health, even beyond the developmental years. Where this intervention into nosology left cross-gender identification, Cramer did not develop, however.

Selbstempfindung and Geschlechtsempfindung: Arndt

It was under the early modern nosological heading of ‘delusion of metamorphosis’ that an early sense of gender identity acquired definitive contours in Krafft-Ebing’s nosological thinking. Three short borrowed ‘sex-change delusion’ cases came to speak to his classification. These cases frustrated Krafft-Ebing’s aetiological interests, however. Ostensibly for this reason, they were still discussed in full in Psychopathia’s ninth (1894) edition but only cited from the tenth (1898) onward. Henceforward, only Krafft-Ebing’s own cases were integrally discussed (something that perusers of the Rebman translations, based on the tenth and twelfth editions, risk overlooking). They illustrate the ongoing clinical reasoning in which Krafft-Ebing was intervening. Krafft-Ebing quoted a case by Rudolph Arndt (1835–1900) in full, as one of the very few, besides ‘two cases known to Esquirol’, to exemplify metamorphosis sexualis paranoica, complaining that little could be learned from any prior case about possible developmental factors – Krafft-Ebing’s central concern.Footnote ⁶⁰ Krafft-Ebing had read Arndt’s work when it came out and had also read the relevant passage: in a book review for the Zeitschrift für die gesamte Strafrechtswissenschaft, Krafft-Ebing specifically pointed that passage out as having forensic relevance. In this sole contemporary description of cross-sex identification (by a transmasculine person) beyond his own that Krafft-Ebing was able to cite as late as 1891, the condition had still been assimilated with the madness of lycanthropy and other forms of mania metamorphosis. Footnote ⁶¹ But Arndt’s take was more creative than Krafft-Ebing suggested.

A bold and comprehensive intervention into nosology, Arndt’s book proposed a new system of classification for mental disorders such as would reflect a more empirical, scientific basis in nervous excitation and muscle contraction – ‘an attempt, too little noted’ as another reviewer of his work would write in the 1888 maiden volume of the American Journal of Psychology. Where it was picked up, it scored mixed reviews. Arndt had been appointed in 1873 as Extraordinarius and in 1875 as independent director of the Greifswald Communal Irren-Heil-Anstalt, a step formalising the independence from internal medicine of the speciality of psychiatry at the site. Here, Arndt had had the opportunity to observe ‘a middle-aged woman who thought she was a man and carried herself [sic] accordingly.’ Patient ‘always felt something like this; however, the clarity of this only came to me later’. Moreover, ‘The man who is supposed to be my [patient’s] husband is not a real man at all. I conceived my children myself.’Footnote ⁶² At this point, Arndt interpreted the still new-ish phrase of conträre Sexualempfindung as a being drawn ‘to the behaviour of the opposite sex’ purely out of a paresthesia ‘which in the ego [develops] into delusions or insanity’ (psychosis, we would say, or paranoia, in Krafft-Ebing’s later terminology), demanding conformity to the new self-image. In a remarkable passage, moreover, Arndt specifically asserted the privileged developmental importance to Selbstempfindung (with attendant Selbstgefühle) of the Geschlechtsempfindung, or sense of sex: ‘the main weight for the development and transformation of self-awareness and self-feeling may be ascribed primarily to the sexual sensations and the processes underlying them’. What makes a man or a woman? The answer would have to be the differentiation that comes with sexual development:

Arndt thus reasserted the central clinical pertinence of contrary sexual feeling to not only the wider problem of the paresthesias and attendant ‘identity disorders’ but also to the developmental aspects of normal ‘self-feeling’. Cited allusion to progression (‘higher degrees’), which inverted such a sense present in Westphal’s text, anticipated or perhaps directly inspired Krafft-Ebing’s initial (1891) stage-model.

Paraesthesia sexualis (Parästhesie der Geschlechtsempfindung) is jargon notably adopted by Krafft-Ebing three years later to cover all sexual perversion and inversion.Footnote ⁶⁴ Terminology at this point clearly reflects different nosological routes, announced by two new uses for the term paresthesia: Arndt’s physiological frame for ‘identity disorders’ (with a purportedly prominent sexual dimension and aetiology) and Krafft-Ebing’s psychopathia sexualis (featuring ‘paranoid’ conceptions of social-corporeal transformation, as sexual inversion in optima forma).

Krafft-Ebing: Geschlecht and paranoia

Arndt’s short case description remarkably left out the aetiological leads he himself asserted and which Krafft-Ebing considered pivotal. Krafft-Ebing can thus properly be called the first to have given what would become a third-stage ‘acquired’ transitional variety its single, elaborate autobiographical account – ‘ein Unicum’.Footnote ⁶⁵ Similar to Ribot, Krafft-Ebing’s eventual call of metamorphosis sexualis paranoica rearticulated a long-established notion of lasting delusion of ‘sex’ transformation, granting it a clinical kinship with other sex-related species of ‘paranoia’ Krafft-Ebing had distinguished since his earliest days in medicine. This entailed a new nosological embedding and a new aetiological profiling, beyond Westphal, of eighteenth-century notions of the Wahn der Geschlechtsverwandlung – or as the 1895 French translation of Psychopathia (from the English, by Émile Laurent and Sigismond Csapo) had it, la monomanie de la métamorphose sexuelle. Krafft-Ebing’s most extensive 1890 autobiographical case of metamorphosis, by a physician, has been marked as one of the first ones on record, and one much-reinterpreted, as exhaustively studied by Julien Fischer.Footnote ⁶⁶ What interests me here is that the case was understood early on as indicative of the particular aetiological problem presented by the emergent nuance of ‘sex’ in strict terms of ideation, and sex in the narrator’s own consistent terms of Gefühl or Zwangsgefühl guiding their ideas of self. A new clash over narrative authenticity and delusional content had been emerging at this point, complicated by the narrator being a colleague physician. One reviewer illustratively preferred to trace the content of the ‘delirium’ of cross-’sex’ awareness back to the author’s intimate medical knowledge: ‘No one other than he [sic] who by profession was acquainted with all the physiology and pathology of woman would have been capable of a delirium similar to that which he [sic] presents.’Footnote ⁶⁷

As seen, appraisal of the ‘Wahn das Geschlecht geändert zu haben’ as an instance of melancholia/mania metamorphosis long predates Krafft-Ebing’s earliest work, going back to the middle of the eighteenth century and ending up as a nosological commonplace in Krafft-Ebing’s youth, during the middle of the nineteenth.Footnote ⁶⁸ Relevance of nosology to legal medicine within the new frame of sexual inversion – ‘psychosexual degeneration’ – became increasingly apparent. A reviewer of the eighth edition of Psychopathia sexualis praised Krafft-Ebing on this particular belated elaboration of Westphal: the seeming deterioration, or decursus, of the invert from the habituated or occasional pederast (gezüchtete Päderast) to the Wahn vollkommener Geschlechtsveränderung. ‘We see this gradual transition in a series of cases in which the same actions [‘coitus-like’ acts] must still be described in the first case as crimes that cannot be excused, and in the latter as expressions of illness by incurable madmen.’Footnote ⁶⁹

Krafft-Ebing replicated Arndt’s inversion of Westphal’s unelaborated musing that contrary sexual feeling was ‘also simply about the feeling of being alienated from the whole inner being with regard to one’s own sex – as it were a less developed stage of the pathological phenomenon’.Footnote ⁷⁰ Westphal’s unpacked allusions to ‘progression’, or rather deterioration at this point of symptomatic divergence, had hitherto remained unelaborated, as merits brief review. Simply inverting the allusion, in 1878, Heinrich Schüle, a close colleague and intimus of Krafft-Ebing, had captured ‘psychic hermaphroditism’ in terms of ‘delusion of altered personality’ (Wahn der geänderten Persönlichkeit) with respect to birth-assigned Geschlecht, footnoting the Scythian anarieîs to the cryptic characterisation of ‘the delusion of altered personality as the highest allegory of abnormal sexual feeling’.Footnote ⁷¹ Schüle recognized both cross-dressing and ‘sex’-crossing as possible manifestations of sexual inversion but shied away from inferring a stage model: ‘Contrary [sexual] feeling can even dominate the experience of self [Persönlichkeitsgefühl] of the patient, in such a way that the male patient feels transformed into a woman and the female patient into a man, and each optima fide carries out their metamorphosis in clothing and occupation.’Footnote ⁷² In the best faith: patients in question were ‘constitutional defectives’ (Defectmenschen in ihrer Anlage), he opined, anticipating Krafft-Ebing’s later parlance of ‘degenerate reaction’ and ‘functional symptoms of degeneration’ (funktionelle Entartungssymptome).Footnote ⁷³ Schüle notably also mentioned cross-dressing in his degeneration-based stage-model of hysteria – an emergent differential-diagnostic concern.Footnote ⁷⁴ Drawing from aforementioned Bastian, one of the founders of developmental psychopathology Hermann Emminghaus (1845–1904) insisted on a cleaner differential diagnosis: ‘From Westphal’s contrary sexual sensation as an ‘innate perversion of sexual feeling with awareness of the pathological nature of the appearance’ one must clearly distinguish the delusion of sex change [Wahn der Geschlechtsumwandlung], which occurs not infrequently in the mentally ill’ – telling ‘analogies’ of the latter, again, to include the anarieîs and various modern-day indigenous comparanda. Footnote ⁷⁵ Emminghaus had earlier cited these analogies as the many ‘equivalents’ or ‘parallels’ to be found between primitive psychology, developmental psychology, and mental illness, suggestive of a common structure of stepwise cognitive evolution (Stufen des Denkens).Footnote ⁷⁶ In comparison, Prague psychiatrist Pick characterised the Scythian illness as ‘a side piece to contrary sexual feeling’ but failed to elaborate.Footnote ⁷⁷ Russian venereologist Tarnowski’s remarks at this point, finally, also remained poorly developed. Under ‘inborn sexual inversion’ Tarnowski spoke only loosely of Bestreben or Neigung dem weiblichen Geschlecht zu ähneln, writing:

In summary, then, during the 1870s and early 1880s, Westphal’s ‘sexual inversion’ was breaking apart along the typological, differential-diagnostic, and comparative lines he himself only faintly hinted at, however resulting in little unanimity.

A brief reconstruction of Krafft-Ebing’s taxonomy demonstrates a gradual buildup of courage in distinguishing clinical variation in terms of progressive underlying pathology. Krafft-Ebing actively worked on psychosexual nosology from 1875 and, like others during the early 1880s, alluded to the idea of a ‘stage’-model for sexual inversion already in 1882.Footnote ⁷⁹ Case 24 of Psychopathia’s 1886 edition only documented passing cross-‘sex’ identification in a ‘congenitally’ sexually inverted woman. In the 1887 and 1888 editions, Krafft-Ebing developed a concept of effeminatio (rechristened eviratio from 1891) covering, rather, ‘more profound and lasting changes in the psychic personality [i.e. identity, sense of self]’, and typically caused by masturbation. He discussed the concept, seemingly first, at the March 14, 1887, monthly meeting of the Verein der Aerzte in Steiermark (Austria).Footnote ⁸⁰ A patient assigned male at birth experienced ‘a profound change in his character, especially his feelings and tendencies in the sense of a womanly self-identity [einer weiblich fühlenden Persönlichkeit]’.Footnote ⁸¹ In 1888, Krafft-Ebing elaborated that ‘permanent change of identity’ (dauernde Umänderung des Persönlichkeitsbewusstseins) would only be seen in the case of a full-blown ‘paranoid’ condition, and as such would constitute a ‘capstone of all physio-psychic transformations’ (Schlussstein all der physiopsychischen Umwandlungen).Footnote ⁸² This closely followed the progressive nature of intellectual/systematised insanity generally entailing, in Emil Kraepelin’s terms, ‘a permanent, profound transformation of the psychic personality, which manifests itself mainly in a pathological perception and processing of external and internal impressions.’Footnote ⁸³ To Krafft-Ebing, the phrases Metamorphosis sexualis (as used from 1887) and Transformatio sexus (as used from 1888) named a passage from a pre-existent cis-‘sexual’, to cross-‘sex’, identification: one symptomatic dimension of several. An early, implicit outline of his later Gradstufen-theory came in 1888. Two Stufen became explicitly distinguished in 1890: homosexuality per se and effemination, the latter covering all sexed crossings. Only in 1891, these became more formally divided into three consecutive steps in ‘psychosexual degeneration’ (Etappe[n] auf dem Wege der psychosexualen Entartung … Entwickelungstufe[n]). These stages were now more explicitly than before situated beyond what is here newly nominated the last outpost of (male) normality: the gezüchtete Päderast, perhaps indifferent in his inclinations but who, where homosexually active, still ‘feels himself in an active role corresponding to his real sex’. Normality was now sex role conformity, the degree of pathology now being the extent of role switching. In 1892, this, finally, made the definitive four steps of a now singular ‘somato-psychic transformation process’ (eines körperlich-seelischen Umwandlungsprocesses) where a person gradually retires from their natural embodied sex role, beyond mere deviating from the Sexualrolle (sexual role-taking: topness/bottomness) natural to their sex.

Krafft-Ebing’s rubric of ‘paranoia’ reflected considerable clinical problematization of people’s idea of sexed selfhood since Westphal’s 1868 talk. Krafft-Ebing’s paranoia (Esquirol’s intellectual monomania) was mid-1880s terminology replacing what in 1883 he, with Kraepelin, still preferred calling ‘primäre Verrücktheit’. The general term generally referred to a chronic mental disorder consisting mostly of delusions: fictions based on false premises which progressively organise themselves and end up accepted as incontrovertible facts.Footnote ⁸⁴ The patient acts as if their delusions were true, and comes to inhabit ‘a world of error and deception’ built around a core misconception. It required of the clinician knowledge of the truth that was sex, and a reconstruction of how, over time, the patient could have drifted from that truth as far as to assert that its arguable opposite was true. The condition would have to be engrafted on a degenerative basis: it betrayed some sort of hereditary taint, often a constitutional neurosis. Full recovery was not an attainable goal, but anamnesis was key to understanding it. Most relevantly here, it provided a lead to general sexual psychology. To Krafft-Ebing, the content of the paranoia betrayed a primordial abnormal development of the entire personality: it expressed a ‘hypertrophy’ of a deep psychological core. Disease developed out of ‘the innermost nucleus of the personality’ or ego (dem innersten Kern der Persönlichkeit … der charakterologischen Individualität des Kranken): the unconscious ‘depth of the soul’ (dem tiefsten Grund ihrer Seele) where dreamy, romantic aspirations are elaborated into guiding ideas.Footnote ⁸⁵ The sexual body was not trivial in the causal cascade: castration, puberty, menopause, menstrual and uterine disease, and onanism presented cardinal predisposing moments for melancholy/paranoia, various of Krafft-Ebing’s early texts asserted.Footnote ⁸⁶ These moments of sexual transformation, however, Krafft-Ebing saw as pristinely and universally psychological transformations, requiring a medical-psychological sensibility to psychological diathesis, beyond a focus on changeable ‘sexual sensations’ highlighted by Kraepelin among many others.Footnote ⁸⁷ The climacteric, which is to say, women’s ‘sexual role (geschlechtliche Rolle) being played out […] cuts deeply into the sense of personhood [Persönlichkeit], [it] does not go unnoticed in any woman’s consciousness. The loss of those [sexual] feelings, which form a large part of the moral self-concept [ethische Persönlichkeit], and are ultimately rooted in sexual sensations, is felt by every woman at least as a defect.’Footnote ⁸⁸ Various mundane shifts in the sexual biography, then, shared a common, dual ground in changing somatic sensibilities and challenges to the continuity of a sense of socio-sexual selfhood.

Krafft-Ebing’s reasoning here needs to be seen in light of the unacknowledged precedents in clinical-psychological reasoning regarding mania metamorphosis, as discussed above. These rendered the condition of ‘progressive melancholy’ of specific psychological interest, as Krafft-Ebing agreed with contemporaries who were citing Griesinger at this point of délire d’interversion sexuelle. Footnote ⁸⁹ Krafft-Ebing’s ‘paranoia’ variants invariably betrayed a basis in sexual disorder, which the clinical course would clearly demonstrate. Paranoia (sexualis) masturbatoria – originally filed under hypochondric-persecutory madness, or masturbatorische Verrücktheit – was to account for the slow descent of the young onanist into various ideas of supposedly consequent nervous disease and imaginary social censorship. A continuity here with older German literature on ‘abuse of the sexual function’ (Geschlechtsmissbrauch) is evident. Compare, for instance, a lively description of demonomania in an onanist by Rudolf Leubuscher in 1848, and various forms of melancholy attributed to genital disorders (melancholia uit de organa generationis), including onanism, by pioneering Dutch psychiatrist Schroeder van der Kolk.Footnote ⁹⁰ The problem proved a durable one; an increasingly psychological sense of Masturbantenwahn is seen in various early twentieth-century texts, for instance. Krafft-Ebing’s take seems crucial for the present discussion, given that from 1886 he named neurasthenia ex masturbatione a key proximate cause for acquired ‘homosexual sensation’. From 1889, he added venereophobia (‘hypochondriacal fear of infection from sexual intercourse’) as a possible factor. One of the earliest Dutch cases of an urning, published in 1893, was a lifelong onanist whose clinical presentation was largely taken up by that onanist’s acute regret and a guilt-ridden impression that all people in the street knew of his homosexual condition and surely were referring to his person when using corresponding epithets.Footnote ⁹¹ Other discrete exemplars of paranoia included paranoia hysterica, sexualis (including delusional contestations of sexual reputation and delusional jealousy), and erotica (erotomania). In their joint bridging of genital disturbance, nervous deterioration, and psychosexual angst, these diagnoses all pinpointed patients’ self-caricaturing within the gendered and generational realms of sexual conformity and reputability. Though never formally extended to a paranoia Scythica/sexus, it is indeed under Verrücktheit/paranoia that Krafft-Ebing situated some of the melancholic identity ‘transformations’ of old, such as lycanthropy: an established and receptive canvas for his evolving conception of identifications concerning Geschlecht.

A chapter on the ‘Wahn der Geschlechtsverwandlung’ in the second edition of Krafft-Ebing’s Neue Forschungen auf dem Gebiet der Psychopathia sexualis shows a watershed moment at this point of aetiological deliberation on what he here called ‘the awareness of representing a particular gender-personality [das Bewusstsein, eine bestimmte geschlechtliche Persönlichkeit zu repräsentiren]’.Footnote ⁹² This concept formed the basis for purported pathology in its purported end-stage: ‘delusion of really being another person sex-wise’ (‘Wahn eine andere sexuelle Persönlichkeit wirklich zu sein’).Footnote ⁹³ In the German literature a virtually unprecedented discursive manoeuvre (except for Arndt, as seen), Krafft-Ebing here briefly conjectured about normal gender identity development, which, however brief and ineffective, made it into Psychopathia’s subsequent editions.Footnote ⁹⁴

The core nosological quandary was that this descent into cross-sex identity at once reflected, and betrayed, an underlying ‘degenerative’ ‘feminization’. A degenerate, neuropsychologically ‘feminized’, man is not necessarily wrong in saying that he was, or had been, passing from male, man, to female, woman. In an 1889 new case interestingly dating back to Krafft-Ebing’s time at Illenau Heilanstalt in the mid-1860s and evidently seen by Heinrich Schüle up until 1872, a complete example is described as a purely psychological resolution: ‘From the time of the Transformatio sexus, a new era begins for the patient. In memory, he conceives his previous identity [Persönlichkeit] as that of a cousin’.Footnote ⁹⁵ Yet as many nineteenth-century cases, in this case description and an additional contemporaneous one introduced in 1890, various psychotic elements were noted: female identity, but suggested by voices; preceded by masturbation, but more interestingly by paranoia masturbatoria persecutoria; all next to clinically observed delusions and hallucinations seemingly unrelated to sex/gender.Footnote ⁹⁶

Coda: between paranoia and transvestitism

An 1893 paper that seemed to confirm Krafft-Ebing’s 1891 nosological suggestion did not cite Krafft-Ebing, illustrating that his work took time to disseminate and to dominate 1890s clinical thinking, and that it articulated theoretical elements independently pondered by many others. In a paper presented June 7, 1893, to the American Medico-Psychological Association, medical superintendent at the Eastern Michigan Asylum and lecturer in mental diseases Colonel B. Burr (1856–1931) discussed a female long-term inpatient with a rich spectrum of delusions (royal heritage, pseudocyesis, poisoning), a two-year unstable insistence on having a male identity beginning years into admission, as well as an apparent sex operation delusion (‘asserting that many years ago an operation was made with the effect of unsexing her’).Footnote ⁹⁷ The ‘paranoia’ in this case was considered to have arisen with the growth of a uterine fibroid tumour (explaining pseudocyesis, though not the coexisting cross-gender identification), and to have attenuated somewhat after its removal, which effectively meant a hysterectomy. Burr evidently was most impressed by the durable ‘delusions of change in sex,’ and briefly sought to make sense of it by reaching out to Ribot, not Krafft-Ebing – despite Burr’s choice of diagnostic terms: ‘If, as Ribot contends, ‘the personality results from two fundamental factors – the bodily constitution, with its tendencies and feelings, and the memory,’ we must, I think, seek for the genesis of this delusion in the changed sensations arising from the sexual organs in consequence of its [neoplastic] presence’.Footnote ⁹⁸ ‘Sex’ self-identity assertions could betray a ‘systematized delusion’ as part of a heterogeneous spectrum of fixed ideas, and not necessarily as an advanced stage in sexual inversion or as paired with same-sex erotic interests.

A proper differential-diagnostic moment had emerged, in other words. Krafft-Ebing’s very limited experience admitted two seemingly separate types of ‘degenerative’ disorder related to ‘sense-of-sex’: sexual inversion and original paranoia. Yet his integration of either within the prevailing nosological frame of Wahnsinn/paranoia remained curiously minimal. Psychopathia’s brief section on sexual forms of paranoia never cross-referenced ‘sexual inversion’, while even the last (the posthumous seventh, 1903) edition of his general psychiatry textbook did not mention ‘Metamorphosis sexualis’. ‘Paranoia’ pertaining to Geschlecht, then, was of a symptomatic, noncanonical kind, and, one could easily object, another class of disorders altogether. Munich specialist in nervous diseases Leopold Löwenfeld (1847–1923) illustratively dismissed such cases from the realm of sexual disorders: ‘Since this is a form of paranoia, we can no longer consider the cases in question to belong here, as we are merely dealing with the anomalies of the sex drive.’Footnote ⁹⁹

Whether notions of Geschlecht were tethered to or followed from Sexualempfindung was now a proper differential-diagnostic question, puzzling at least some physicians already at the moment Krafft-Ebing was only finalising his thinking on the matter. In 1891, neurologist-psychiatrist Christian Roller (c.1843–1897), seemingly uninformed by Krafft-Ebing’s Neue Forschungen, presented three ‘cases of contrary sexual ideas’ (Fälle von conträrer Sexualvorstellung), stressing that these cases ‘do not show the actual contrary sexual sensation [by which he means homosexuality; but rather] the delusion of belonging to the opposite sex’:Footnote ¹⁰⁰

The suggestion throughout has been that Krafft-Ebing’s attempt to coerce homosexuality, androgyny, and identification of sex-of-self into a single aetiological framework took time to develop, and was on the whole hardly original. Rather, the 1880s nosological and aetiological responses to Westphal rendered psychological sex an even more layered medical palimpsest than it had already been for centuries. As argued, Krafft-Ebing came in at the tail end of centuries of modern takes on the ‘Scythian malady’, which had started out somatic and occasionally neurophysiological but had long been gravitating toward exercises in historico-environmental neuropsychiatry, well before nineteenth-century alienists began to claim a professional identity. By the 1880s, it had been conceptualised for over a century in terms of feminisation, pathicism (sexual passivity understood as a condition), and intellectual monomania. The Index-catalogue of the Library of the Surgeon-General’s Office had the neologistic, undefined heading of morbus Scythicus from 1888, featuring a bibliography that was considerably more complete than Krafft-Ebing’s.Footnote ¹⁰² Although seemingly only a fraction came to his attention, Krafft-Ebing’s citations to this ancient problem can be seen multiplying by the year, refracting it quite differently during all stages of his thinking. In his 1879 psychiatry textbook, he had only briefly and anachronistically characterised the Scythian malady as an example of ancient psychiatry, specifically of ‘epidemic mental confusion’ (epidemische Geistesverwirrung). This unoriginal call echoed a consensus between authors ranging from Morel to Von Feuchtersleben and Maximilian Leidesdorf (1816–1889), the last of whom Krafft-Ebing later succeeded as chair of the psychiatric clinic of the Niederösterreichische Landesirrenanstalt. Footnote ¹⁰³ The reference and qualification were retained as late as Kraft-Ebing’s textbook’s third (1888) edition but removed from the fourth (1890): Krafft-Ebing’s nosology had been refined, superseding his medical history.Footnote ¹⁰⁴ The ancient ‘feminine disease’ had been absent from the first, 1886, edition of Krafft-Ebing’s Psychopathia sexualis, and its rethinking appears substantively inspired by discussions at the American Neurological Association. As shown in both his citations and his nosology, only in 1889 did Krafft-Ebing see clear cause to dig up and read additional literature on the Scythian malady, clearly via Hammond’s 1882 article, from which he gleaned and traced multiple earlier sources. The question only now became central to Krafft-Ebing’s clinical thought and re-reading of case material: which cases of gender-crossing did, and which cases did not, allow a psychosis verdict? Krafft-Ebing seemed to have required a period of build-up of courage in his decision-making at this point: while in Psychopathia’s fourth edition the matter still only seemed likely, in the fifth edition he definitively interpreted the Scythian anarieîs as evidencing ‘superstitious interpretation of effeminatio, as already indicated by Hippocrates’ – unlike more ‘progressive’ cases of true delusion (‘paranoid sexual transformation’) where culture did not support such interpretations. Hammond’s two-spirit mujerados, too, did not warrant the latter reading.Footnote ¹⁰⁵ Where Krafft-Ebing’s initial consideration had been Hippocratically epidemiological (psychosis was rare, historical and endemic psychosis rarer), in 1890 Krafft-Ebing appears to simply have agreed with Hammond’s 1882 ethno-psychological opinion, rendering gender-transing a uniquely Western problem of sexual degeneration.

Having discussed the Scythian malady since 1891, Albert Moll weighed what he gradually found out were multiple accounts of it, and refrained from pinning himself down, although in 1899 he did maintain, as had other authors including aforementioned Emminghaus, that, ‘of course, contrary sexual sensation must be completely separated from mental disorders in which the insane man considers himself a woman [sich … für ein Weib hält] and consequently dresses accordingly and wants to associate with men’.Footnote ¹⁰⁶ That the Scythian disease was ‘an affection consisting in the performance of homosexual acts has been made probable by [Julius] Rosenbaum’, he wrote in 1893 and still in 1899. So, even preeminent sexologist Moll at this late point still had little interest in questioning and probing the cross-cultural and transhistorical nuances between cross-gender identification and cross-sex delusion. But it was in this undertheorized sense that Moll, among many others, as seen, clearly did beat Hirschfeld to the explicit separation between cross-‘sex’ identification and same-sex sexual inclination. American authors, in comparison, were on the whole less discerning still, despite 1890s translations of Krafft-Ebing and Schrenck-Notzing, and Havelock Ellis’ Sexual Inversion. First published in 1906, Joseph Parke’s American sexuality textbook still elaborately discussed Krafft-Ebing’s notions of ‘delusional eviration’ and ‘delusional masculinity’.Footnote ¹⁰⁷ Parke claimed to know of two such ‘delusional’ cases. At the same time, in an attempt to conform to 1890s Anglophone sexology, he arranged both the anarieîs and mujerados under a separate makeshift ethnopsychiatric heading: ‘religio-mystical inversion’.Footnote ¹⁰⁸ Even Iwan Bloch initially grouped them under the ethnological heading of religious ‘pederastic effemination’.Footnote ¹⁰⁹

Understanding clinical nuance and relevance at home long proved challenging. Moll’s reading in 1891, retained in 1893, was the following: ‘Perhaps we can think of the matter in a similar way to delusions and obsessions [Wahn- und Zwangsvorstellungen]; while the latter is an awareness of the disease or at least the desire to suppress the pressing ideas, in the case of delusions these are no longer recognized as pathological.’Footnote ¹¹⁰ These considerations were not trivial: where male same-sex sex seemed in play, ‘paranoia’ spoke to vital legal dimensions of the Urningsfrage. As one American doctor proposed in 1897, though not without inviting discussion, ‘If there is here a true delusion of sexual transformation, it is equivalent to a monomania and the subject should receive asylum treatment’.Footnote ¹¹¹ And as one author had noted already in 1882:

In other words, at least some indicted inverts could prove to be not only comorbidly psychotic (and this possibly in nontrivial numbers) but psychotics by clinical definition. The at least theoretical problem was interestingly left unsolved by Krafft-Ebing, who, in 1901, rolled back the blanket psychiatric verdict on Conträrsexuale. The ‘people who believe they belong to the opposite sex’ he had left in a legal limbo, as others later observed.Footnote ¹¹³

Barring much explicit reflection on this medicolegal point, actual cases of metamorphosis sexualis paranoica remained rare until Hirschfeld’s Die Transvestiten. Eulenburg illustratively agreed that such a condition constituted an ‘end-stage of sexual inversion’ (Endstufe psychosexualer Inversion), whereas bisexuality was a preliminary stage (Vorstufe).Footnote ¹¹⁴ In 1895, he offered a brief but purportedly typical example of his own. Here was an intelligent and otherwise lucid thirty-seven-year-old man who ‘because of certain physical changes observed over the past 4-5 months’ relating to secondary sexual characteristics ‘had come to the “firm conviction” that he “was a 37-year-old man, husband and father of a son, who will become a woman”’. A letter revealed ‘he’ had been reading, and thus must have been ‘apparently significantly influenced’ by, a passage on the feminising effects of industrialisation in Ellis’s Man and Woman (1894), which had appeared in German translation that same year. It seems that Eulenburg was suggesting we understand this account of distressing, purportedly recent, sudden, and even paroxysmal feminisation as self-deluding intellectualisation of a pre-existent, though disavowed because shameful, androgyny. If we presume the distressing symptom could have been gynecomastia, any condition sufficiently altering the oestrogen/androgen ratio could have explained the symptoms. Regardless, sex-paranoia remained a more layered, more psychological, and more diverse set of conditions than could be appreciated from unsolicited letters. Their relation to ‘sexual inversion’ remained a concomitantly qualified one.

Hirschfeld’s circle, too, only slowly gravitated to an appreciation of gender crossing as a differential-diagnostic problem. In 1902, Eugen Wilhelm, the Wissenschaftlich-humanitäres Komitee’s legal expert, found occasion to explicate, inaccurately, that ‘Of course, no one has thought of throwing the contrary sexual sensation together with delusional ideas’.Footnote ¹¹⁵ However: ‘Contrary-sexuals [Konträre] would suffer from delusional ideas if, for example, he took another man to be a woman or himself to be a woman, if, for example, contrary-sexual [i.e. homosexual] sensations and the sex change delusion [Wahn der Geschlechtsverwandlung] were identical’. The spectrum of Konträrsexualismus clearly did not include transgender identification or gender dysphoria, or for some other reason, warrant more ‘clinical’ nuance, at this point.

Hirschfeld later agreed with the existence of Krafft-Ebing’s ‘paranoia’ cases, of which Hirschfeld himself claimed to know two. Unlike transvestites, these people had delusions about their primary and secondary sexual characteristics, their real sex (wahres Geschlecht).Footnote ¹¹⁶ Transvestitism was defined in contrast with such cases: a successful, if melancholic, grappling with the reality that was sex, specifically the historical fact that was natal sex, requiring a mild, self-pleasing self-deception that one could pass ‘entirely’ – as had one been born that way. Transvestitismus, at least in this 1910 formulation, included, though it was not defined by one’s relating to the unrealistic idea, the unreal, unattainable scenario, of fully embodying another sex, entertained but never fully believed.

Sexual nonconformity and sexual realism, in summary, share a long and eventful medical history. In Krafft-Ebing’s casuistics from 1888 onward, both delusions (Wahnen) and hallucinations related to genitalia and masturbation became confounded by a new nuance of identity – the lasting awareness of self. Some of Krafft-Ebing’s early pertinent cases, especially the earliest, case 51 of 1888, would in a later timeframe have risked being diagnosed with what Eugen Bleuler, in 1908, came to call schizophrenia. In 1911, Bleuler himself paid lip service to ‘delusional ideations of sexual transformation’ (Wahnideen der Geschlechtstransformation), an unreferenced and by now woefully undertheorized expression lacking case studies.Footnote ¹¹⁷ The question of ‘doubt about sexual identity’ in male schizophrenics would remain a distinct clinical problem, eventually alongside the emergent concept of ‘gender identity’.Footnote ¹¹⁸ Psychodynamic theorising provided a dual backdrop. Where in 1953 Manfred Bleuler opined that his father Eugen would have agreed that ‘schizophrenics are almost invariably, if not indeed invariably, in doubt about the sex to which they belong’, this seems to echo grand psychodynamic hypotheses, such as that ‘in man every case of emotional neurosis or psychosis is the result of more or less conflict and confusion involving bisexual differentiation.’Footnote ¹¹⁹ During the 1920s, ‘delusions’ were indeed repeatedly considered material for psychodynamic and symbolic readings.Footnote ¹²⁰ Various early twentieth-century case studies of cross-dressing reported (pre-existing) delusions that are hard to reduce to identity issues. Such cases stood more of a chance to pique the interest of the law and of the clinical case reporter, certainly when considered to require hospitalisation. In any case, from the late 1880s, the onset, precise content, and course of atypical sexual ideations mattered, and these factors have continued to matter ever since. As explored to some extent by Rainer Herrn, Hirschfeld himself continued to wrestle with this problem of apparent heterogeneity well into the 1920s, and provided various solutions to subclassification, all little successful. Sex, by now, had of course proven less and less fixed. From 1910, the once far-out ideas of social and medical transitioning became increasingly thinkable, with various legal, opotherapeutic, cosmetic, and surgical avenues explored in Berlin.Footnote ¹²¹ What was real sex, and what realistic sexually, were proving changeable constructs. So was ‘the idea of having changed sex’. If we conceptualise psychosis as a discursive wedge between self (one’s inner dialogue) and non-self (e.g. voices inside one’s head), there is, naturally, considerable scope to historicize it in gendered terms of both aetiology and symptomatology.Footnote ¹²² As with hysteria and with sexual trauma, cultural-historical factors weigh in heavily on definition, causality, and presentation. Psychosis can be considered a gradual phenomenon for which most people, fully regardless of gender identity, have some degree of susceptibility, chronic exclusion and humiliation being potent risk factors. Furthermore, as with reasonably effective hormonal treatments, reasonably effective antipsychotic options in pharmacology did not become available until the 1930s.