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Archives of Sexual Behavior, Vol. 30, No. 6, December 2001 (

c 2001)

Hand Preference, Sexual Preference,

and Transsexualism
Richard Green, MD, JD,1,2,4 and Robert Young, BSc (Hons) PgD3

Atypical handedness patterns, i.e., persons being less exclusively right-handed,

have been found previously in large samples of male and female homosexuals
and in small samples of male and female transsexuals compared to controls. The
posited role of prenatal androgen influencing both cerebral hemispheric domi-
nance and psychosexual development warrants further study with large samples
of transsexuals. 443 male-to-female transsexuals and 93 female-to-male transsex-
uals were studied for their use of the right or left hand in six common one-handed
tasks. Both male and female transsexuals were more often nonright-handed than
male and female controls were. Results suggest an altered pattern of cerebral
hemispheric organisation in male and female transsexuals.
KEY WORDS: handedness; cerebral dominance; transsexualism; homosexuality.

Handedness or hand use preference has been observed as early as Week 15

of gestation (Hepper et al., 1991). It may be influenced by prenatal androgen
levels. One suggestion is that elevated levels of testosterone, perhaps during the
second trimester of pregnancy, affect foetal brain development and increase asym-
metry via accelerating the growth of the right hemisphere resulting in nonright-
handedness (Galaburda et al., 1987; Geschwind and Galabruda, 1985a,b). In partial
support, persons with known atypical prenatal sex hormone levels show alterations
in handedness. Females with congenital adrenal hyperplasia, with elevated prenatal
androgen, show increased nonright-handedness (Nass et al., 1987), as do females
1 Department of Psychiatry, Imperial College School of Medicine at Charing Cross, Gender Identity
Clinic, Charing Cross Hospital, London, United Kingdom.
2 University of Califonia, Los Angeles, California.
3 MRC, Social and Public Health Sciences Unit, University of Glasgow, Glasgow, Scotland, United
Kingdom. Study conducted while at Charing Cross Hospital.
4 To whom correspondence should be addressed at Department of Psychiatry, Gender Identity
Clinic, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, United Kingdom; e-mail:
Richard.green@ic.ac.uk.

565
0004-0002/01/1200-0565$19.50/0
C 2001 Plenum Publishing Corporation
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566 Green and Young

with intrauterine exposure to diethylstilbestrol (DES), a masculinising synthetic

oestrogen (Schacter, 1994). However, Klinefelter syndrome (karyotype XXY)
males show a high proportion of left-handers (Netley and Rovet, 1982) but have a
postnatal, and perhaps prenatal, deficiency of androgen.
Alternative mechanisms accounting for handedness include genetic models
and range from single to multiple gene models (Annett, 1985; Jones and Martin,
2000). Another proposes two mechanisms by which individuals may become left-
handed; natural or genetic left-handedness and pathological left-handedness, a con-
sequence of diffuse neurodevelopmental difficulty. Elevated rates of birth stressors
such as Rh incompatibility, higher rates of caesarean sections at birth and multiple
births are associated with left-handedness (Coren, 1995).
Left-handedness is associated with indicators of reduced Darwinian fitness
such as a smaller number of offspring, lower birth weight and shorter life span
(Yeo et al., 1993) and is found more commonly in persons with mental retardation,
autism, schizophrenia, cerebral palsy, and epilepsy (Coren, 1993a). It is found
more commonly in association with indicators of developmental instability such
as fluctuating asymmetry of bilateral body features expected to be symmetrical,
e.g. finger length (Yeo and Gangestad, 1998). Fluctuating asymmetry can result
from disruptive events in pregnancy (Wilber et al., 1933; Kieser et al., 1997) and is
associated with neurodevelopmental dysfunctions (Naugler and Ludman, 1996).
Homosexual orientation in the male has been posited to result from atypical
levels of prenatal androgen. Usually the alteration is proposed as a deficiency
(Dorner, 1988). However, rodent research suggests that an increase in intrauterine
testosterone at one period of human foetal development could result in a decrease
in hormone at subsequent periods (Ward and Weisz, 1980). Taken together with
theories on the development of cerebral asymmetry, these fluctuations could direct
the developing individual to both nonright-handedness and homosexuality.
The relation between sexual orientation and hand use preference has received
considerable recent attention. Although not all studies have found a difference
between homosexual and heterosexual subjects, a meta-analysis of 20 studies com-
paring 6,182 homosexual men and 805 homosexual women with 16,808 heterosex-
ual men and 1,615 heterosexual women found a 39% greater odds of homosexual
persons being nonright-handed (Lalumiere et al., 2000).
Transsexualism and handedness has also received attention. A higher inci-
dence of nonright-handedness was clear among a sample of 85 female-to-male
transsexuals with a trend in that direction for 15 male-to-female transsexuals
(Herman-Jeglinska et al., 1997). Another study of 44 female-to-male transsex-
uals found more nonright-handedness (Orlebeke et al., 1992) and two studies of
male-to-female transsexuals, with 45 and 93 subjects, also found elevated rates of
nonright-handedness (Orlebeke et al., 1992; Watson and Coren, 1992).
The etiology of transsexualism remains enigmatic although there is increas-
ing speculation among researchers for an inborn basis rather than its being the
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Hand Preference and Transsexualism 567

result of early life experiences (Zhou et al., 1995). Favored theories, as with ori-
gins of homosexual orientation, are those of an alteration in prenatal sex steroid
levels. Thus the association between atypical prenatal sex hormone levels and
cerebral dominance suggests value in studying transsexuals for cerebral laterality
differences as reflected in hand use preference.

METHOD

Participants

Participants were patients attending the Gender Identity Clinic at Charing

Cross Hospital, London. The Clinic is essentially the sole National Health Service
facility for gender dysphoric patients in the United Kingdom seeking hormonal and
surgical sex change. Those recruited included 443 male-to-female transsexuals and
93 female-to-male transsexuals. All met the Diagnostic and Statistical Manual-IV
(DSM-IV ) diagnostic criteria of gender identity disorder (American Psychiatric
Association, 1994). Average age of the male-to-female transsexuals was 38.6 years,
average age of the female-to-male transsexuals was 30.9 years. Nearly all were
Caucasian. They signed an informed consent to participate in the research with the
understanding that participation or refusal would not influence treatment. A total
of 284 nonpatient volunteers, undergraduate and graduate students, unselected for
sexual orientation, comprised the control groups.

Measures

Sexual Orientation

Sexual orientation of patients was determined by responses to questionnaire

items on sexual fantasy and sexual behavior during blocks of time from the present
back to early adolescence. This was categorized as heterosexual (sexual attractions
and sexual behaviors exclusively or nearly exclusively with persons of the opposite
birth sex), homosexual (sexual attractions and sexual behaviors exclusively or
nearly exclusively with persons of the same birth sex), bisexual (a substantial
mix of same and opposite sex attractions/partners), and asexual (a dearth of sexual
attractions or behaviors). Two raters independently judged sexual orientation using
this method. Nonconcordant judgments were settled by agreement between raters
without access to handedness information. Inquiry concerning sexual preference
was not conducted with the control groups. Based on samples recruited from
the general population over 95% of the control sample would be expected to be
heterosexual (Diamond, 1993).
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568 Green and Young

Handedness

Handedness was determined by a six-item questionnaire that asked respon-

dents to indicate for each task whether the task was performed exclusively with the
right hand, exclusively with the left hand, or with either or both hands. The tasks
were: cutting, throwing, writing, holding a toothbrush, holding a glass, combing
hair. These items were selected because they are similar to those used in previous
studies investigating handedness and its association with either transsexualism or
sexual orientation (Becker et al., 1992; Holtzen, 1994; Oldfield, 1971; Orlebeke
et al., 1992; Satz et al., 1991; Watson and Coren, 1992). Research has shown that
short and extended hand measures show high correlation with each other (Coren,
1993a). Measures composed of 4 and 12 items show a correlation of r = 0.948
with a 98.8% concordance in dichotomous categorization of handedness. Even a
single item showed a correlation of r = 0.886 with the extended measure.

RESULTS

Table I shows male and female transsexuals by sexual orientation subgroup

vs. male and female control groups. Handedness is categorized as all six tasks
right-handed, one task not right-handed and two tasks not right-handed. Male
and female controls do not differ from each other. All male transsexuals combined
differ from control males, 2 (2, N = 587) = 23.205, p < 0.001, and control
females, 2 (2, N = 583) = 15.785, p < 0.001. Transsexuals are more often
nonright-handed.
Extending analysis by subgroups demonstrated that asexual male transsexu-
als, heterosexual male transsexuals, homosexual male transsexuals, and bisexual
male transsexuals all differ from both male and female controls, p < 0.02. Substi-
tuting female for male controls gave similar results, p < 0.02, with the exception
of the homosexual subgroup, which showed a trend in this direction, p < 0.091.
Thus male transsexuals, whatever their sexual orientation, are more often nonright-
handed.
Female-to-male transsexual subgroups are small as nearly all are homosex-
ual and tests of significance are inappropriate. All female transsexuals combined
differ from both female and male controls separately, p < 0.041, female controls,
p < 0.007, male controls.
A further measure of handedness, a handedness score, was computed and
scored in a manner similar to that by Coren (1992). Thus for each of the six items
a score of 1 is given if the respondent uses the left hand predominantly for that
particular task, a score of two is given if the respondent has no hand preference for
that task and a score of three is given if the respondent uses the right hand predom-
inantly. The sum for the six tasks was used as a measure of handedness, and was
considered an interval level variable for the purposes of data analysis. This summed
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Table I. Handedness by Transsexual Group and Controls

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Handedness group Comparisons vs. control group ( 2 )

Group n All tasks right-handed One task not right-handed Two tasks not right-handed Control males Control females

Male transsexuals
Asexuala 45 13 (28.9%) 10 (22.2%) 22 (48.9%) 10.83 7.79
Heterosexualb 137 66 (48.2%) 14 (10.2%) 57 (41.6%) 18.29 13.45
PP243-344336

Hand Preference and Transsexualism

Homosexual 107 43 (40.2%) 21 (19.6%) 43 (40.2%) 8.14 4.79

Bisexual 154 48 (31.2%) 27 (17.5%) 79 (51.3%) 24.24 17.87
All male transsexuals 443 170 (38.4%) 72 (16.2%) 201 (45.4%) 23.21 15.79
Female transsexuals
Asexual 5 1 (20.0%) 4 (80.0%)
Heterosexual 5 2 (40.0%) 3 (60.0%)
Homosexual 70 31 (44.3%) 14 (20.0%) 25 (35.7%)
Bisexual 13 7 (53.8%) 6 (46.2%)
August 30, 2001

All female transsexuals 93 41 (44.1%) 14 (15.0%) 38 (40.9%) 6.30 9.80

Controls
Control male 144 70 (48.6%) 40 (27.8%) 34 (23.6%) 0.49 ns
Control female 140 66 (47.1%) 36 (25.7%) 38 (27.1%)
11:11

All controls 284 136 (47.9%) 76 (26.7%) 72 (25.4%)

Note. The percentages of cases in each handedness category by group are shown in parenthesis. For all statistics, (2 3), 2 , df = 2, two-tail.
a Male asexual transsexuals significantly different from male heterosexual transsexuals, 2 = 7.02, p < 0.03.
b Male heterosexual transsexuals significantly different from male bisexual transsexuals, 2 = 9.56, p < 0.008.
p < 0.1; p < 0.05; p < 0.01; p < 0.001.
569
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570 Green and Young

Table II. Handedness Score by Transsexual Group and Controls

Group n M SD

Male transsexuals
Asexual 45 15.44 2.94
Heterosexual 137 15.77 3.27
Homosexual 107 15.74 3.17
Bisexual 154 15.34 3.27
All male transsexuals 443 15.58 3.21
Female transsexuals
All female transsexuals 93 15.72 3.49
Controls
Control male 144 16.53 2.49
Control female 140 16.54 2.17

method of constructing handedness measures has received some support over the
quotient method. Bishop et al. (1996) demonstrated that the different methods
of calculation, summed vs. quotient, categorized individuals who are weakly one
handed or mixed handed in a different manner. Using evidence from behavioral
midline crossing tasks they concluded that the summed method is to be favored.
Table II shows the mean handedness scores.
A series of ANOVA analyses were conducted to investigate the relationship
between sexual orientation and handedness score. We excluded from further analy-
sis male asexual transsexuals because of the relatively low frequency of this group.
Additionally, all female transsexual groups were collapsed, because of the very
low frequency of the nonhomosexual groups.
A one-way ANOVA using the three remaining male transsexual subgroups
and male and female controls showed a statistical difference between the groups,
F(4, 677) = 5.37, p < 0.001. Post hoc LSD test revealed that all male transsex-
ual subgroups differed from both male and female controls, p < 0.05, with all
transsexual subgroups less right-handed. A one-way ANOVA using the collapsed
female transsexual subgroups and male and female controls showed a statistical
difference between the groups, F(2, 374) = 3.76, p < 0.024. Post hoc LSD test
revealed that all female transsexual subgroups differed from both male and female
controls, p < 0.022, with transsexuals less right-handed.
Age can be a confounding factor when comparing different groups on mea-
sures of handedness with fewer older subjects being nonright handed (Coren and
Halpern, 1991; Davis and Annett, 1994). This could affect the relation between
sexual orientation and handedness within transsexual subgroups because of the
common finding that male homosexual transsexuals show an earlier age of clin-
ical presentation (Green and Blanchard, 2000). As expected, in our sample, age
showed the typical gradient for male transsexual subjects (Homosexual mean age:
M = 33.25, SD = 8.81, years, n = 107: Bisexual mean age: M = 38.70, SD
= 9.20, years, n = 153: Heterosexual mean age: M = 43.22, SD = 9.95, years,
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Hand Preference and Transsexualism 571

n = 137). There was a significant overall difference between groups in age, one-
way ANOVA F(2, 394) = 34.10, p < 0.001. A Scheffe test showed no homoge-
neous subsets and all groups differed from each other, p < 0.001.
Using ANCOVA, with age as a covariant, we tested whether age differences
between male transsexual subgroups could be masking any differences in hand-
edness scores. Even after adjusting for age differences in the subsamples, no male
transsexual subgroup differed from each other on handedness scores, one-way
ANCOVA, F(2, 393) = 1.07, ns. The age of the control group was not recorded,
however they were undergraduate and postgraduate students. Given the typically
low age of this group and the negative relation between handedness and age, it is
likely that we would inflate our type II rather than type I error rate and underesti-
mate differences between the control and transsexual groups.

DISCUSSION

That all transsexual subgroups, not just the homosexual subgroup, were more
often nonright handed suggests that some pattern of atypical central nervous system
laterality organization is associated with both transsexualism and homosexuality.
Handedness differences between transsexuals and controls did not appear
due to familial handedness patterns (Chamberlain, 1928). The incidence of left-
handedness in the general population is about 10% (Springer and Deutch, 1989)
and based on nonassortive mating of left- and right-handed parents, approximately
80% of the general population should have both parents right-handed. With our
transsexual patients, 19% reported at least one nonright-handed parent. When only
transsexual subjects who did not have a family history of nonright handedness were
analysed, transsexual subjects and controls continued to differ significantly.
Differences between male transsexuals and male nontranssexuals are not con-
sistent with an explanation that transsexuals hand preference reflects a female
pattern. This is because typical males are more often reported as less exclusively
right-handed, although some studies, including this study, find no sex difference.
However, the difference between female transsexuals and female nontranssexuals
is in the more common male pattern. The parsimonious explanation for both sets
of findings and the reports of handedness patterns in the clinical samples reviewed
above invokes explanations positing a disruption in typical cerebral organization.
The association of atypical prenatal sex hormone levels and alterations in
cerebral dominance reflected in handedness patterns is consistent with the theory
of an altered prenatal sex hormone origin for transsexualism. It is consistent with
evidence found in other clinical conditions most likely to exhibit androgen ef-
fects on the brain, such as females exposed prenatally to diethylstilbestrol (DES),
females with virilizing congenital adrenal hyperplasia and possibly males with
Klinefelter syndrome. Congenital adrenal hyperplasia and prenatal DES expo-
sure in females is also associated with elevated rates of homosexual or bisexual
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572 Green and Young

experience (Ehrhardt et al., 1985; Money et al., 1984). Klinefelter syndrome males
may have elevated rates of transsexualism (Money and Pollitt, 1964).
Alternatively, modification of cerebral laterality, gender identity, and sexual
orientation could all reflect developmental instability, not necessarily resulting
from atypical levels of prenatal sex steroid, but from a range of stressors found in
association with instability.
Fluctuating asymmetry, associated with nonright handedness and reflecting
developmental instability, may also be related to birth order. Higher scores of
fluctuating asymmetry have been found in association with more older brothers
(Lalumiere et al., 1999). Homosexual males have been found to have more older
brothers (Blanchard, 1997) as do homosexual male transsexuals (Green, 2000).
The developmental perturbation hypothesized to account for the older brother
phenomenon in atypical male sexuality is the maternal response to the foreign
HY antigen of the male foetus, with an increasing response to successive male preg-
nancies (Blanchard, 1997). Though the evidence for a progressive immunological
reaction is not consistent (Green, 2000), at this time the developmental instabil-
ity hypothesis merits as much research attention as does the prenatal hormonal
hypothesis.

ACKNOWLEDGMENT

Research supported by the Wellcome Trust.

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