These patients remember puberty as a painful confusing period, during which erections and emissions for the male, and breast development and menstruation for the female shattered the illusion that they were to grow up in the preferred body. Crossdressing begins in early life, usually on the patient's own initiative and without associated sexual gratification. Crossdressing produces a sense of wellbeing which cannot be obtained by any other means. Passing successfully in the opposite gender role reinforces the belief of being trapped in the wrong body and makes imperative the request for hormonal and surgical treatment. Some transsexuals have a very limited or absent sexual life.
Heterosexual activity is accompanied by the fantasy of being a woman made love to by a man.
This fantasy is necessary in order to achieve arousal and orgasm. In clinical practice transsexuals should be differentiated from fetishistic transvestites and effeminate homosexuals, who often present with gender dysphoria and crossdressing behaviour and who can request treatment. Crossdressing behaviour is accompanied by sexual excitement, generally masturbation and orgasm. For the transvestite, the penis as a source of erotic pleasure is an essential element in his rituals, which he does not want to lose. Most transvestites are primarily heterosexual men who prefer women to men both in reality and in their sexual fantasies.