The collection of statistical data in the preceding pages was closed at the end of 1964. Toward the end of 1965, a total Of 307 cases of the transvestite-transsexual phenomenon were observed. Among them were 193 males (S.O.S. IV, V, and VI); 62 of them were operated upon. Besides, there were 27 female transsexuals; 11 of them had either hysterectomies or mastectomies or both performed. The rest of the males were transvestites.
The additional number of clinical observations has not materially changed a tentative facit drawn from the clinical material presented in this book. A few definite factors seem to have emerged.
The etiology of the transsexual state is still largely obscure, but a light seems to blink here and there in publications from the laboratories of brain physiologists.
Childhood conditioning and possible imprinting undoubtedly have a connection with the development and the intensity of the transsexual phenomenon, but can only be considered as contributory or as one of several possible causes. The presence of an inborn, organic, but not necessarily hereditary origin or predisposition appears more and more probable. Further research, aside from psychological and endocrine studies, will most likely have to concern itself primarily with work in two areas: genetics and neurophysiology.
Ever greater refinements in genetic (chromosomal) studies may find a clue. Brain physiological experiments and neurological investigations may hold even greater promise. Naturally, inborn, that is, organic, abnormalities in the structure of certain brain centers would have their genetic basis. The hypothalamic region of the brain seems to yield more and more information, linking its function (structure? chemistry?) with sex behavior. If it should be confirmed, for instance, that homosexual behavior can develop after organic changes such as the removal of a tumor from a certain brain region,  a new and startling aspect of human sexuality, including transsexualism, could emerge as factual, not only as speculative.
Psychological studies will have to continue to clarify the psychological structure of transsexuals. Endocrine studies likewise ,will analyze abnormalities, but they may have to be interpreted more as an accompanying factor and less as a causative one.
From the therapeutic end, it cannot be doubted or denied that surgery and hormone treatment can change a miserable and maladjusted person of one sex into a happier and more adequate, although by no means neurosis-free, personality of the opposite sex. The degree of such a change depends upon constitutional factors, as well as upon the environment in which the individual's new life pattern will develop.
Sex reassignment surgery, that is to say, a conversion operation, will be accepted eventually as a legitimate treatment for a selected group of transsexuals. Such is at least probable at this writing, unless radically new therapeutic procedures should succeed in bringing the psychological sex into harmony with the anatomical. No such procedures can now be visualized.
Operative techniques will have to be perfected so that the often all-important sex life as a female will be realized in a satisfactory manner.
Legal reforms will have to follow. After a conversion operation, for instance, a way will be found to allow life in the new sex status to be without illegality and such status will be made available without too many technicalities. Common sense will prevail and practical experiences will take precedent over theoretical considerations.
A very recent incident should be reported here, so that the necessity for a future, more realistic approach to the legal problem may be highlighted.
The Health Department in a large eastern city had received several applications from operated-upon transsexuals to "have their birth certificates changed" (and with it their sex status) because they are no longer anatomical males but are now living and functioning as females.
The director of this Health Department, very wisely, turned the matter over to a representative committee of physicians, who studied the novel problem conscientiously. In their report (October 4, 1965), they came to the conclusion that:
1. Male-to-female transsexuals are still chromosomally males while ostensibly females.
2. It is questionable whether laws and records such as the birth certificate should be changed and thereby used as a means to help psychologically ill persons in their social adaption. The Committee is therefore opposed to a change of sex on birth certificates in transsexualism.
The Committee would point out that there are other ways to help these persons by: relief by court order to change name and sex; or amendment of the birth certificate by showing the new sex, but still showing the original sex and the change of sex.
On the strength of this report, this Health Department passed the following resolution:
Resolved, that in view of all the evidence considered, including the report of the Committee of Public Health of the Academy of Medicine, it is the sense of the Board of Health that the Health Code not be amended to provide for a change of sex on birth certificates in cases of transsexuals.
This leaves the transsexual patient abandoned by the medical profession and dependent upon judicial decision.
In the collective opinion of the medical committee (in spite of dissenting voices), the invisible "chromosomal males" outweigh the very visible "ostensible females." In other words, a very practical evidence of sex change, that is to say, the ostensible female sex after a demasculinizing operation, was adjudged inferior to the genetic male sex, which nobody could possibly detect in a person's appearance. Vice versa, the same could apply to female transsexuals.
It shall be assumed that neither the medical committee nor the Health Department could have acted any differently under present circumstances. Eventually, however, this irritatingly academic attitude will have to collapse under the weight of reality. Either the welfare of patients will constitute this reality or new scientific evidence establishing, for instance, the constitutional nature of transsexualism, will do so.
In the latter instance, a similar procedure would appear logical that is now applied in those rare cases when an error has occurred in diagnosing the sex of a newborn baby. The Health Department is then authorized to correct certificates. The original (wrong) certificate is removed and replaced with a new one.
The only difference between a wrong sex-diagnosis at birth and (inborn) transsexualisim would then be the time element, that is to say, how soon after birth either fact is discovered and amply verified.
As far as the legal change of sex after a conversion operation is concerned, the
respective patient in the United States in 1965 has to be lucky. He has to have been born
in a state that proceeds from good will, cuts through red tape, and issues a new birth
certificate on application accompanied by medical testimony. If he is not lucky and has
been born. in a state like the one mentioned above, he has to have money, swallow his
sugar-coated pill of disappointment, entrust his fate to a judge, and hope for the best.
Footnotes Petit-Dutails, D., et al. Revue Neurologique 91: 129-133, 1954. (Homosexual behavior was observed in patients with temporal lobe lesion.) Anastasopoulos, G. Wiener Zeitschrift für Nervenheilkunde XVI: 131-161, 1959. (Draws attention to "the feminine behavior of male patients with temporal lobe lesions who had previously shown no homosexual tendencies.")
 Fortunately, a more favorable situation for transsexuals exists in several other states.