Views of inherent impairment and distress in transvestism and transsexualism follow the same threads of deviance from presumed biological function and association with other psychopathology. Rado (1962), in rejecting Freud's theory of constitutional bisexuality, stated that "every individual is either male or female," rejecting the possibility of more than two natural genders. Zucker and Blanchard (1997) noted in studies of clinical subjects that transvestic fetishism impairs the ability to form pair bonds, but admitted that "systematic empirical studies have been scant." Accepting wives of male crossdressers have been characterized as having poor self-esteem (Feinbloom, 1976) or as angry toward men (Stoller, 1967), reminiscent of Socarides' (1962) description of homosexual relationships as "destruction, mutual defeat," and "exploitation." Gender dysphoria has been clinically associated with borderline personality disorder (Wise & Meyer, 1980) and crossdressing with various Axis II disorders (Zucker & Blanchard, 1997), as had been homosexuality twenty years earlier.

Rebuttals to theories of inherent transgender distress and impairment closely paralleled those in the case of sexual orientation. Beginning with Ford and Beach (1951), anthropological research has revealed a long list of supernumerary gender roles among many non-European cultures (Bolin, 1987; Bullough, 1993; Williams, 1986). These were accepted, often highly respected, societal roles difficult to characterize as pathological. The medical presumption of gender essentialism, exactly two natural sexes determined by genitalia, has been challenged by a growing body of socio-cultural literature that considers gender a social construction, not a biological imperative (DeBeauvior, 1952; Kessler, 1978; Butler, 1990; Garber, 1992; Lorber, 1994). Psychiatric studies of clinical populations, like those of clinical gay and lesbian subjects in previous decades, failed to consider the incidence of functional, well adjusted transgendered people and couples in society. [emphasis added - C.N.] Conversely, a long-term survey of members of a heterosexual cross-dressers' support organization (Prince & Bentler, 1972) suggested a high degree of education, vocational success, and self acceptance. A recent study (Cole, et al., 1997) of 435 gender dysphoric individuals found no significant Axis I or Axis II comorbidity on the basis of clinical interview and the Minnesota Multiphasic Personality Inventory (MMPI). [emphasis added – C.N.] This is remarkable given that the study was limited to a clinical population, two-thirds of which were undergoing hormonal treatments and committed to a real-life transition subject to considerable discrimination.