|The TRANSSEXUAL PHENOMENON
Harry Benjamin, M.D.
|The Male Transsexual
Readers of the
foregoing chapters already should be fairly well acquainted with the (transsexual) man who
wants not only to appear as a woman by dressing as one, but who actually wants to be a
woman in appearance as well as function and wants medical science to make him such as far
as that is possible. In other words, it is the man who suffers from a reversed gender role
and false gender orientation. He wants to change sex.
As we have seen, these persons, in a strictly scientific sense, fool themselves. No actual
change of sex is ever possible. Sex and gender  (to repeat for the
sake of clarity) are decided at the moment of conception, when either two X
chromosomes, one from the father and one from the mother, lay the foundation for a future
girl, when one Y chromosome (from the father) and one X chromosome (from the mother)
insure the birth of a boy.
Nevertheless, the wish to change sex persists, and for all practica1 purposes such can and
has been accomplished as far as the individual's future life and position in society are
concerned. This alteration, from male to female, concerns only the visible genitalia and
secondary sex characters. To the extent of external apearance it can be successful and
If a chromosomal study should be made, however, the true (chromosomal) sex would be
discovered and this remains true no matter how long the person may have lived as a member
of the opposite sex or what operations or hormone treatments may have been applied.
The transsexual in life and love
There is hardly a person so constantly unhappy (before sex change) as the
transsexual. Only for short periods of his (or her) life, such as those rare moments of
hope when a conversion operation seems attainable or when, successfully assuming the
identity of a woman in name, dress, and social acceptance, is he able to forget his
misery. It is not always the frustrated, passionate sexuality, but more so the
heart-breaking anguish of the transsexual's gender disharmony that makes him forever a
candidate for self-mutilation, suicide, or its attempt. The false relief obtained from
alcohol and drugs is not an infrequent complication.
Self-mutilations are no rarity and have occurred in at least four of my patients out of a
total of 152 transsexual males. Two of them tried to castrate themselves but had to give
up and call a doctor. One succeeded with the help of a friend in completing the job. One
mutilated the penis, requiring several stitches to repair the damage. Many more such
incidents have been reported and still more can be safely assumed.
The three patients who castrated themselves or attempted it eventually succeeded in being
operated upon in the United States, having testicles and penis removed and a vagina
constructed. They are now living as women. The fourth patient is still hoping to find a
courageous and understanding surgeon in the United States or, otherwise, to raise the
money for a trip abroad.
Sometimes these acts of self-mutilation are done in desperation. Others are more
deliberate and are meant to force the surgeon's hand to complete the genital alteration
which he had refused to undertake for reasons of his ethical concepts, or for lack of
hospital facilities (where the necessary permission was withheld by the hospital
board), for fear of criticism or out of consideration of existing laws.
Finally, surgeons untrained in this type of surgery may lack confidence in their own skill
and may be fearful of consequences if a satisfactory (to the patient) outcome should not
ensue. Lawyers too are known to have advised the surgeon against operating. Suicides with
"motive unknown" have undoubtedly occurred because of the inability to procure
surgical help for the sex change.
I remember only too vividly thirty-year-old Juan, a true TS, who much preferred to be
called Juana. Aside from his gender unhappiness, his greatest physical handicap was a very
heavy dark beard which would have taken much time and money to remove. He was also
handicapped by extreme, almost paranoic sensitiveness to remarks referring to the feminine
impression he made and to his assumed homosexual inclination. In addition, there was great
poverty and inferior education. It all added up to deep unhappiness without hope for the
The time came when my psychological help and estrogen treatment had reached the limit of
what they could do. Then the surgeon should have taken over to try to salvage this
patient. But no surgical help was available.
I did not hear from Juan for several months, but at Christmas time 1963, the following
note was received:
Dear Dr. Benjamin:
Finally I have to give up my struggle. Now I just exist waiting in misery for the moment
to take leave of this earth in which I have been so miserable.
My regards to Virginia, God keep you all in health and good will, so that you can be,
someway or another, of good to your fellow man.
Good-bye forever, J.
Attempts to get in touch with him failed. I would like to believe his note to be not
more than a hysterical outcry, but the probability is he did find the only solution that
he could see for his problem.
Sympathy, understanding, and especially any degree of empathy is found for transsexuals
generally only among their own. Therefore they are always anxious to meet someone with the
same problem or at least correspond with one. Close friendships are often formed, two
transsexuals for instance living together before or after the operation. Contrary to
popular assumptions, these friendships are without overt sexuality. They are like two
lonely, "normal women" living together, each one wishing for a man as a sex
partner, unless asexuality prevails.
To their families, these transsexuals are often an enormous problem. Such a person may
dress and behave in an embarrassingly feminine manner, let the hair grow long, may have
love affairs with normal men, threaten suicide when opposed too much, speak of his future
life as a woman after the operation without much regard for the feelings of others,
especially parents, who cannot easily accept having a daughter instead of a son, or
siblings who may respond in the same way to having a sister instead of a brother. The
patient, however, feels that it is his own future life that is at stake and he does not
want to sacrifice it to please somebody else. Relatives often fear being embarrassed
through gossip among friends and neighbors more than anything else, and for that reason
oppose the "change," the possible happiness of the child taking second place.
Psychological state and
sex life in transsexuals
"The need for recognition, attention and acceptance, coupled with inner
feelings of being rejected and ignored is prominent in all subjects," said Drs.
Worden and Marsh  with full justification.
Many transsexuals have no overt sex life at all. As Burchard 
has said, the sex drive in some of them is turned inward toward their own ego.
Masturbation is then occasionally practiced, but the urge for it is low and under estrogen
treatment gets even lower, to the point of zero.
Other transsexuals, however, have a sex life. There are those who still preserve a normal
married life, that is to say, with a woman. They say they are able to have sex relations
with the help of fantasies, by taking a succubus (under) position in intercourse, or by
wearing a female nightgown. Some of these married transsexuals described to me a mental
state during intercourse in which the penis seems to lose its identity of ownership.
"The penis may just as well be my wife's being inserted into me as vice versa,"
one patient expressed it. Another one said bluntly, "I don't know whether I screw or
am being screwed." Psychoanalysts may find ingenious explanations for such a
Other transsexuals again have normal boyfriends who treat them as girls whether they live
as such or not. They hope, work, and save money for the conversion operation so that they
can marry legally. Occasionally, the two persons live beforehand as a married couple,
nobody but a few intimates knowing that they are actually two genetic males. Of course,
there is always the fear of discovery, arrest, scandal, and the like, which keeps their
emotional state in a precarious balance.
Sex relations vary, the "husband" most often substituting the anus for the not
yet existing vagina. Orgasm may be claimed by the "wife," but especially
under estrogen treatment, "she" has difficulty getting an erection, which is not
considered any handicap at all, rather the opposite, as all manifestations of masculinity
are abhorred. Erections are often described as painful, which may have a psychosomatic
explanation. Ejaculations gradually diminish and finally disappear as the prostate shrinks
under estrogen therapy.
The "husband" in such a union offers an interesting psychological study. Are
there actual or latent homosexual inclinations in him so that he can be attracted to a
transsexual man? Naturally, the attraction is to the "woman" in this man, but
could completely normal, heterosexual men be able to forget the presence of male sex
organs, or, if an operation has been performed, even their former existence?
Still other transsexuals find prostitution a useful profession for emotional as
well as practical reasons. I am not referring here to the male hustler, who may dress as a
woman for "business reasons," but only to the (unoperated upon) transsexual who
plays the part of an ordinary prostitute looking for normal heterosexual men as clients.
He hides his genitals rather cleverly with the help of a bandage that draws penis and
scrotum between the legs. A corset may further protect him against a too inquisitive
"John" to whom he offers anal or oral contact, explaining the refusal of normal
peno-vaginal relations by claiming menstruation or a too recent abortion or merely that he
prefers to "french." He invites playing with his breasts that have usually been
enlarged through hormone treatment or a plastic operation. This gives him pleasurable
sensations and allays any suspicion the customer may have. Much of the existing handicap
and danger are compensated for by the enormous satisfaction the transsexual derives from
being so thoroughly accepted as a woman. How much more can his femininity be reaffirmed
than by again and again attracting normal, heterosexual, and unsuspecting men and even
being paid for rendering sex service as a woman?
Aside from the emotional satisfaction that prostitution may afford (in spite of its
hazards as an illegal occupation) it has its decided practical advantages. Not only can
the transsexual make his living, but he may also be able to save enough money for the trip
abroad (usually Casablanca in 1965) that is his ever-present goal.
How many such male transsexuals are engaged in prostitution before any conversion
operation has been performed is impossible to estimate with any degree of accuracy. They
are rare, possibly not more than a few dozen in the whole country. Whether fewer
transsexuals become prostitutes, full or part-time, after their operations and after they
have become legally female, is difficult to judge (see Chapter 8).
It has happened in a few cases that all of a sudden, money became available to go abroad
(and come back a broad, as somebody quipped) without any evident source. Being aware of
the overwhelming, desperate urge of the transsexual to be made "female," doubts
have sometimes crept into my mind whether funds were not acquired illegally, other than by
prostitution. A parallel to the crimes committed by equally desperate drug addicts readily
comes to one's mind.
As far as the psychological state of the transsexual, not operated upon, is concerned, for
some of them even a restricted and only partially satisfying sex life seems better than
complete frustration and no sex outlet at all. Psychoneurotic symptoms seemed to me to be
the more pronounced the greater the sexual frustration. In several, perhaps six to eight
of the 152 transsexuals that I have observed up to the end of 1964, a paranoid state or a
schizophrenic reaction was diagnosed by psychiatrists, but it was always a question in my
mind how much of the psychotic reaction or how much of the psychoneurotic symptoms may be
due to the thwarted sex life and the gender discomfort of the transsexual state.
Doctor Ira S. Pauly, psychiatrist at the University of Oregon, said in a recent lecture
before the American Psychiatric Association's 120th Annual Meeting in Los Angeles (May 6,
1964): "Because of his isolation, the transsexual has not developed interpersonal
skills, and frequently presents the picture of a schizoid or inadequate
Improvement of the mental condition occurred under estrogen treatment as well as after the
corrective surgery, but by no means in all cases. Much is yet to he observed and studied
along these lines. As a general rule, however, transsexuals are nonpsychotic.
state of male transsexuals
The physical examination of transsexual patients usually reveals nothing
remarkable. With the exception of one female transsexual (with ovaries, a rudimentary
womb, and a small hypospadic penis), I have seen no hermaphroditic abnormalities. (In this
case, correction was made through operation and this patient is living as a reasonably
well-adjusted man.) Among my patients I discovered no so-called Klinefelter syndrome (a
chromosomal abnormality, characterized by gynecomastia, sterility, mental retardation, and
so on), although such combination of transsexualism and Klinefelter syndrome has been
observed and reported in the medical literature.
Otherwise the transsexual male and female are genetically normal. The chromatin pattern
was repeatedly examined in both sexes and was negative in all males and positive in all
females, which are the normal findings. In three of my rather outspoken cases, one male
and two female transsexuals, a so-called karyotype was made, which is a visualization of
all (normally 46) chromosomes, and no abnormality was found.
An interesting incident occurred with a female transsexual who was living as a
male. "He" was sent to a laboratory specializing in this type of work for a
chromatin test. Smears were taken from the mucus membrane of the mouth and the report came
to me: "Male."
Somewhat surprised at this finding, I phoned the laboratory and told the examiner that
he had found a genetic male in an anatomical female. The examiner who had seen this
patient and had assumed he was dealing with a man was taken aback and asked me:
"Is there a vagina?"
"Yes, indeed," I said.
"Then let me make a chromosomal visualization," he requested. "The
chromatin test was not too clear."
When such visualization was completed, the diagnosis was unmistakably "female."
All patients were examined routinely for possible sexual underdevelopment, immaturity,
or eunuchoidism. Diagnosis of such condition was based on the inspection of the genital
organs which naturally allows for a wide variety of individual sizes; on skeletal
measurements, for instance, the span being wider than the height; on a low secretion of
the 17-ketosteroids, which are the endproducts of male hormone production as they appear
in the urine. Naturally, subjective symptoms were taken into consideration, too: for
instance, a sex drive and potency below the average, a late start of any sex life
including masturbation, and so on.
Such more or less distinct underdevelopment, known as hypogonadism, but rarely to the
point of eunuchoidism, was found in 61 cases out of a total of 152 male
transsexuals, approximately 40 per cent. These findings may eventually prove to have
significance as far as the underlying causes of transsexualism are concerned.
The transsexual's plight
"I cannot stand all this any more," said one of my patients,
characteristically pointing downward. "It does not belong to me; it must go."
Another transsexual who had lived and worked successfully as a woman for years, was
accepted by her family, and had an excellent plastic breast surgery performed, wanted me
to send her finally to a surgeon for genital alteration. I could not help asking her why,
when she had already accomplished so much and seemed reasonably contented. With genuine
astonishment, she pointed below and said: "But girls don't have that!"
The greatest plight of any true male transsexual is the problem of where to turn to have
the conversion operation performed. Even if they find a surgeon who is willing and
competent to do the operation (and there are undoubtedly many urological surgeons in this
category in the United States), the problem is by no means solved. A hospital is needed
for this operation and hospitals have their boards. These boards are partly composed of
laymen; among them may be priests, ministers, and rabbis. Without the board's permission,
the operation could not be performed in that particular hospital.
One of my patients had a deeply disturbing experience, disturbing not only to him but to
every fair-minded person, including independent physicians. Being a highly articulate and
educated man, he wrote up his experiences for a magazine, Sex and Censorship, which
was published on the West Coast several years ago, but exists no longer. I was impressed
with this patient's truthful statements and agreed to write an introduction to his story.
In it, I explained the fundamental facts of transsexualism and discussed (regretfully)
medical censorship as it exists in this country and in this day and age. Here, in a
slightly abbreviated form, is what the patient wrote:
T H E U N F R E E
by William J. O'Connell
This writing is about Freedom. It is about how freedom was denied to one person and
thus potentially to all, not in Russia or Germany but in the United States dedicated to
its defense. It is about me, because I am involved. It is about how I was engaged in the
pursuit of happiness. How I chose a certain goal, being sure that my reaching it could not
harm anyone else in the pursuit of his happiness. And how I was frustrated in the pursuit
of my happiness by men who were bigoted and self-righteous, constituting themselves into a
sort of modern lynch mob, the more dangerous for being subtle. I do not ask you, reader,
to be concerned about my frustration. Be concerned, though, for freedom, mine and yours.
The happiness I chose to pursue - had to pursue, more precisely - was simply and
shockingly, an operation to change my ostensible sex; for I am a person, physically male,
whose mind and heart are feminine. If you, the reader, now turn away, muttering: "Oh,
one of them! You ought to be frustrated!" - then you are kindred to the lynch mob,
kindred to those who judge black men and Jewish men and freckled men because they are
different. The leopard cannot change his spots, and I cannot alter, if I would, the basic
femininity of my psyche. If there is indeed an eternal soul, then I suppose mine to be in
gender feminine. At all events, what is certain is that from babyhood I have known - call
it intuition, call it recognition - known beyond all doubt that I belonged among the
women, and have longed to take my place there. Englishmen born and raised in India go home
to England. So with me, always: to become a woman would be to come home. A dull home,
perhaps, that of a thirty-four-year-old spinster, but still and always home. This would be
my happiness: to wake tomorrow and find myself just such a woman. It is, you may think
(especially if you are yourself such a woman), a curious sort of happiness to pursue.
True; but plain water is more than champagne to one in desert lands.
The pain in my life is not merely that caused by prejudice and misunderstanding. Far more,
it is the pain of conflict, the profound dichotomy of mind and body. I have perforce
"lived a lie" as man and boy, always painful, always false. Yet to dress as a
woman, not being one, is equally false, as well as dangerous. What, then, to do? A problem
implies a solution: the solution to mine is to alter one of the elements, mind or body, to
conform to the other. Putting aside the possibility of an unchangeable feminine soul, I
still must say that my mind and heart - my psyche - have been shaped by a thousand million
longings and choices and feminine values; I could not acquire a masculine psyche without
ceasing to be myself. Any psychiatrist would admit, a "cure" is hopeless.
But, if mind-conforming is not the solution, there remains the alternative: changing the
body to fit the mind. This, within limits, is possible; and to a people that accept false
teeth and spectacles, plastic surgery and artificial limbs, it ought not to appear
unreasonable. A man may be made endocrinally female by the female hormones, which control
the secondary sexual characteristics of hair and breasts; and anatomically female by the
removal of male organs and the surgical creation of a vagina. She cannot bear children;
but, surely, if she is female in anatomy and hormones and psyche, she is woman. This
limited womanhood became my goal, this was the happiness I pursued.
My decision was made in the clear perception that my life was quite intolerable in its
falseness. After some hard, realistic thinking, I went to a sexologist, a man wise in the
ways of glands and their secretions. He received me with kindness and understanding, and
sent me to a psychiatrist who confirmed his judgment that I was of sound mind and quite
competent to decide where my happiness lay. Then he carefully began the process of
feminization by the administration of estrogen and other female hormones. Months went by
while my breasts began to develop and other changes took place and while my doctor studied
me and tested and observed. Then at last - a glorious day - he approved me for surgery.
The surgeon, skilled and courteous, was not to be rushed; it was necessary that he be
certain in his own conscience that what he was doing was best for me. I could not doubt
that this great gentleman, like the sexologist, truly intended, in the words of
Hippocrates, to govern his treatment by the needs of the sufferer. To make assurance
doubly sure, he sent me to another psychiatrist who, in turn, convened a panel of his
brethren. After many hours of discussion and questioning and study, these three
psychiatrists unanimously recommended the operation, adding that they were powerless to
alter my feminine psyche and that the surgeon would be doing me a great service by
operating. Even then the surgeon was not wholly convinced and there were further
discussions with him before he at length consented. "Now," I thought, "now
at last, the long waiting and the long anxiety are done. Now my life will take on harmony
and meaning. Now my great adventure . . ."
But I reckoned without bigotry and prejudice and timidity.
After a fortnight's wait for a bed, I went to the hospital that had agreed to the
operation being done provided, I was told, their psychiatrists approved. One of them
turned up the first day and, after conversations and tests, endorsed the views of his
colleagues. This made a total of five psychiatrists unanimously in favor of the operation.
The staff surgeon, who would collaborate in doing it, also came round, friendly and
sympathetic. But then there was a delay. A staff psychiatrist was supposed to come by,
but, it seemed, he was unwilling to do so. Day after day I lay there, existing on the
meatless diet, having to go outside to smoke - rigors imposed not by my religious beliefs
but by the hospital's. Finally a member of the all-important Tissue Committee appeared:
the Committee, because of protest from the "religious elements" of the hospital,
were to review my case. But my visitor, although he was perhaps to present my side of the
matter to his colleagues, seemed much more interested in talking than in listening; I
think his mind was made up, and I think that neither justice nor "the needs of the
sufferer" found any room there.
The Tissue Committee refused to permit the operation. They did not ask me to present my
case; indeed, it was quite obvious (as I was told by one of the doctors) that they did not
consider me at all but only considered placating the "religious elements." Thus
the careful, conscientious studies of sexologist, surgeon, and a battery of psychiatrists
went for nothing. The hospital had sacrificed their honor (since I had been admitted under
an implicit agreement) and their mission (to help those in need) for the sake of a bigoted
few. For all that, they did not hesitate to charge me two hundred of the dollars I had so
laboriously saved for the operation - two hundred dollars for discomfort and profound
disrespect. No other hospital, now, would accept me after this one had turned me out; in
any case, my short vacation was gone for another year. There was nothing to do but accept
defeat and go home to Seattle. Later I wrote twice to the Committee, protesting, offering
religious reasons for the operation. There was no reply at all - perhaps they had carried
out an ecclesiastical excommunication with bell, book, and candle. More probably, the
individual soul was not important to these "Christian gentlemen."
Where does the blame lie for this fiasco? I had sought my own happiness, a happiness that
could harm no other living person; and I had been stopped by the bigoted and the
self-righteous; my freedom had been denied. Not very much can be said in extenuation of
the particular hospital involved, for they had admitted me and charged me under an
agreement which they dishonored; and the gentry who voted not to allow the operation were
manifestly false to their oath to be governed in their treatment "by the needs of the
sufferer" - they were governed by bigotry and timidity and my needs were not
considered. But other hospitals, though less dishonorable, are as timid. What lies behind
their unwillingness to permit an operation that, in the considered judgment of nearly a
dozen doctors, is necessary? There are, it seems to me, three elements of their timidity:
legality, religion, and disrespect for freedom.
The law is not lucid in matters of this sort. The common law and certain ancient statutes
forbid mayhem. Mayhem is depriving someone of limbs necessary for self-defense - a sword
arm or a trigger finger. It is somewhat difficult to regard sexual organs as being useful
in self-defense. Moreover, such laws had in view, of course, maiming by force, without
consent. In short, the law of mayhem is not automatically applicable, if at all, to the
removal of sexual organs with the patient's consent. Especially since the courts
themselves castrate certain criminals. Nevertheless, a prejudiced district attorney might
drag out this law and attempt to apply it to a hospital which was a party to the
operation. Whether there could be a conviction and, particularly, whether any higher court
would sustain such conviction, is perhaps doubtful. The surgeons were willing to risk it,
if their consciences approved. It is difficult to believe that the hospital refused me
because of this law.
Religion, not necessarily genuine religion, is the force behind the hospital attitude;
indeed, it would be the force behind the public opinion that might persuade a district
attorney to invoke the law of mayhem. Public opinion is undoubtedly hostile to this
operation, as witness the covert sneers surrounding the recent celebrated case of an
American soldier who became a woman; people are shocked at femininity in a man and at
castration (far more so than at the removal of a woman's ovaries). Undoubtedly this
attitude is based on ideas of the inferiority of women, ideas that receive a certain
sanction in the writings of St. Paul. Obviously, an operation never dreamed of in early
Christian times is not forbidden in the Bible, nor is there any verse that can be
construed to forbid it in spirit. Thus the vaguely religious hostility to the operation
does not at all mean that Christianity is really opposed to it. Being myself a devout
Baptist, I've had some reason to think about the morality of the operation, more deeply
perhaps than the "religious element" at the hospital, more deeply than many who
condemn out of hand. I do not assert my reasoning to be valid; indeed, 1 shall do no more
than suggest the lines of such reasoning. Christian belief in the immortality of the soul
does but strengthen the view that, if there is conflict between body and soul, the
corruptible body ought to yield. Some have argued that to remove organs is mutilation -
but "if thine eye offend thee . . ."? In truth, if the soul is feminine, this
operation is a species of healing. But all this is an argument that need not be made; for
nearly all Christians agree that man has free will to choose Heaven or Hell and the way
thereto. When the hospital imposed their religious views upon me, without so much as a
call from the Chaplain to learn mine, they denied me the exercise of that free will.
And freedom, both religious and secular, was denied me, by that hospital specifically, and
by every hospital tacitly, that refuses to allow the operation. It is necessary to be very
clear about this. What is this freedom we cherish? Someone has said that to define freedom
is to limit it, and to limit it is to destroy it. This is not quite true. There is one,
and only one, necessary limit to freedom: one must not exercise it so as to infringe on
the rights of others. Thus one may not put arsenic in the salad, or sell atomic secrets to
smiling Soviets, or run down old ladies with one's car. There is no other rightful
limitation of human freedom. As to defining freedom, it can be said at least that it is
not a negative thing, not "freedom to conform" or "freedom from want";
a slave has those - and still he is unfree. Freedom is the right to choose, to act, to
pursue one's happiness. "The philosophy of the First Amendment is that man must have
full freedom to search the world and the universe for the answers to the puzzles of
life" - so wrote one great jurist; and another: "The essence of an individual's
freedom is the opportunity to deviate (from the norm)."
I searched for an answer to the puzzle of my life, but the answer I found was denied me. I
chose, but my choice was denied me. "Yes, but what you chose was abnormal," I
hear someone say. And, yes, I agree; precisely so; a deviation from the norm. Freedom is
freedom to differ, or it is nothing. No one would have been harmed by my attaining my
happiness; I've no dependents except an indifferent cat. And Society, which has so much to
fear from criminals and bombs and too much government, would certainly not be harmed by
one woman, no longer young, having a cup of tea with a friend or growing a geranium in a
pot. If the day comes in America when one who is different is condemned for that reason
only, when courts (and hospitals) have no courage to defy such irrational condemnation,
then freedom will be dead.
Ought you, reader, to be concerned about this, since you do not want - certainly not! -
what I want? Of course you should, for freedom is indivisible. If it is denied to me in
this, it is precedent for denying it to you in your deviation from the norm. Does the fact
that what I want is wanted by few rather than many alter in the slightest degree my right
to have it? If you love freedom, you should paraphrase Voltaire and cry: "I do not
agree with what you do, but I will defend to the death your right to do it." I tried
very hard to do it, and skilled men stood by to help me: but between me and the happiness
I sought there stood a formless specter compounded of bigotry and self-righteousness and
disrespect for freedom, supported by all the Little Timid Men - and it won. That's what is
so horrifying - it won! We frequently hear an anthem rendered with spirit if not
precision, which includes the inspired phrase, "the land of the free." But
freedom here has been denied me.
To bring this tale to a close and up to date, this patient, after another year or so,
did find a skillful surgeon abroad. The operation was successful as I was able to convince
myself. This is a more contented person now.
Before discussing further the handicaps and plights of transsexual patients, an example of
each of the three types (S.O.S. IV, V, and VI) may be in order. (See table one [chapter 2]).
types of transsexuals
The first type to be described under "transsexual" would be one
of the intermediate stages, one that wavers between transvestism and transsexualism, and
in whom the cross-dressing is in all likelihood not of fetishistic but of basically
transsexual origin. He lives as a transvestite but, if honest with himself, he would want
to be sex-changed, that is to say, operated upon. External factors or fears of pain may,
however, prevent him from actually seeking surgery. With "dressing" and under
estrogen treatment, he manages to live in reasonable comfort.
Such a person is Peter A. (who, however, much prefers to be called Irene). He is a rather
well-known musician from Oregon, married for twenty-five years, with a grown-up daughter
who knows nothing of her father's hobby. The wife knows and makes the best of it, but does
not want to see him "dressed," except perhaps on occasion of a masquerade ball.
Peter is in his late forties, dark of complexion and with hair that is just turning gray,
somewhat overweight, but with a skin that could be the envy of any normal woman. As a man,
he is softspoken and gentle, though not an effeminate type. As a woman, he is attractive,
fully believable, and could be taken for a school principal, a housewife, or a dowager.
He is an only child who had the desire to dress in girl's clothes from early childhood,
was reared as a normal boy, and had a good education, graduating from college. He travels
a good deal and then "dresses" as much as possible. Without it, he says, he
would be "a nervous wreck." Estrogen medication is almost equally as necessary
for him. After much experimentation, he has found the dose that gives him a calming
effect, with slight fullness of his breasts, but that does not interfere too much with his
potency. He claims to have satisfactory sex relations with his wife and with her only. He
had rare homosexual contacts during his college days, but none since, although he thinks
he might enjoy them.
When asked about the conversion operation, he admitted that if he were alone in the world,
nothing could keep him from undergoing it. But as things are, he would harm too many
people, could not continue in his profession, or preserve his present standard of living.
Therefore, he does not consider surgery and a complete changeover. He manages to continue
his present "pursuit of happiness" with "dressing" and estrogen.
Peter's classification on the Kinsey scale (K.S.) would be a 2 or 3. On the S.O.S., IV.
Ricky V., in his late fifties, is more of a true transsexual. Genetically and anatomically
a normal male, Ricky has lived and worked as a woman in a business office for seven years
(and will therefore be referred to as "she"). She owns no male clothes. No one
in the office knows of her true status. She has had one unhappy marriage as a male, has
two children, now grown up, and is a grandfather. Ricky is most anxious to have corrective
surgery in order to legalize her position as a woman and also to feel her body to be more
in accord with her mind. The presence of the male sex organs bothers her considerably. A
psychiatrist agreed that the operation would be indicated in her case. So far, Ricky has
been unable to accumulate sufficient funds to make a serious effort to be operated upon.
With the help of psychological guidance and rather constant hormone (estrogen) treatments,
she lives in a fair although somewhat precarious emotional balance. At present there is no
sex life and Ricky would have to be called asexual and anorgasmic. Her past life, of which
she hates to talk, was bisexual and would be a 3 on the Kinsey scale. The S.O.S. would
show a rather typical V.
An example of a full-fledged transsexual, a S.O.S. VI, is that of Harriet, whose childhood
in foster homes and similar abodes is related among the Case Histories. As this
twenty-eight-year-old patient still, as this is written in 1964, lives and works as
a male, he shall (for the beginning of his story) be referred to as such, and with the
Hoping to cure his TVism and TSism, H. married at the age of nineteen a completely
unsophisticated, seventeen-year-old girl whose femininity he envied with irrational
possessiveness. With the help of fantasies, he succeeded in fathering three children.
Although a good provider as a successful salesman, the marriage was in an "off again,
on again" state when he and his wife came to see me first. His transvestism (on the
surface) was the principal stumbling block in the marriage and appeared much more
prominent than any transsexual urge. (He admitted later that he purposely failed to
mention his transsexual desires, fearing he might antagonize me as he had other doctors in
the past.) Brave attempts to preserve the marriage for the sake of the children were
doomed to failure. When H. told me that he had been under psychiatric treatment in his
home town, I suggested that I consult with the psychiatrist by phone to get his
psychiatric diagnosis and see what possibly could be done to calm his emotional turmoil
with estrogen in addition to the psychotherapy he was receiving.
The doctor did phone me, but to my astonishment he took a nonmedical, strictly moralistic
stand. "This man wants an operation," he said, priestlike, "and naturally
we cannot tamper with our God-given bodies. His wife should leave him, children or no
children. H. is a degenerate and a no-good scoundrel," or something to that effect.
The doctor had no psychiatric diagnosis to give me. A letter in which I asked again his
medical (psychiatric) opinion remained unanswered.
H., a deeply disturbed and bewildered young man, then told me that his sessions with this
psychiatrist had been expensive hours of nothing but argumentation and berating on the
part of the doctor without any psychological benefit to him . After every session he was
worse than before.
Another psychiatrist examined H. later at my suggestion, found him to be nonpsychotic, of
superior intelligence, a greatly disturbed transsexual for whom psychotherapy in present
available forms would be useless, as far as any cure might be concerned. Operation was
Since H. had made two attempts at suicide, psychological guidance with estrogen treatment
was undertaken in order to enable him to continue - though precariously - in a rather
responsible job with a good enough salary, to save money for the operation abroad. Various
attempts to have the operation performed in the United States had failed.H. was a slightly
built, attractive, feminine-looking man, when examined in 1964, whose appearance is much
more acceptable when in female dress. On Kinsey's hetero-homosexual scale, he could be
classed as a 4 during his married life, but would now be a 6, that is to say,
completely homosexually oriented. On the S.O.S. he is likewise a VI.
Early in 1965 the great day arrived at last and H. flew to Europe for the operation that
was to change him into the woman that he wanted to be all his life. After an insufficient
time at the hospital, following the rather major operation, and after an unusually
strenuous plane trip home, H. arrived utterly exhausted but happy nevertheless. He had
been compelled to travel as a man and being overanxious to get into female attire, he had
unduly hurried the homecoming. Complications (an internal abscess) developed and some
further surgery was required. At the end of the summer, however, a much improved and
"deliriously happy" attractive young lady presented herself at my office.
A clerical position was soon procured and H. was evidently accepted and treated like any
normal girl. The consequences of a not too successful operation, however, continued to
cause a good deal of discomfort as healing was delayed. Otherwise life seemed good indeed
and during the fall H. met her Prince Charming.
A responsible and understanding older man (a far cry from the seventeen-year-old girl of
her past life) who is fully aware of the entire situation is now her devoted
husband. They are planning the adoption of a child. Household duties have replaced office
work and although some minor surgery may still have to complete the physical
transformation, true happiness seems to have dictated the following words in H.'s most
recent letter to me (November 1965):
I have found happiness that I never dreamed possible. I adore
being a girl and I would go thru 10 operations, if I had to, in order to be what I am now.
A girl's life is so wonderful. The whole world looks so beautifully different. The only
thing that could add to my life now, would be a baby girl. D. (her husband) says that
after all legal matters are settled, maybe we will adopt one.
So far, this case seems to have found a happy ending.
Further handicaps of
The difficulty in procuring surgical help is not the only plight of the TS
patient. Any medical help, including hormone treatment, may be denied him by overcautious
and overconservative physicians. Dr. Walter C. Alvarez said in one of his recent
editorials: ". . . because of our national ignorance, prissiness, and lack of
sympathy for a person terribly gypped by nature, no one will help."  For these physicians (and they are usually quite unfamiliar
with the problem) transsexuals are "mental cases" and should be under
psychiatric care, possibly institutionalized. But, alas, the failure of
psychotherapy to achieve any change in the patient's attitude is fully acknowledged by
those who have had any pertinent experience. With a rather unprofessional antagonism, some
physicians are known to have hurt these patients psychologically. Here is an example:
Recently, during an absence from my practice, a transsexual patient of mine was sent
through an error to a doctor unfamiliar with the subject for which the young man consulted
him, that is to say, to receive estrogen injections. Unfortunately, this doctor's
sparkling ignorance was evidently combined with such unphysician-like manners that the
patient wrote me as follows: "The doctor's attitude toward me was sullen and
indignant, making me feel like some kind of terrible creature he did not care to be in the
same room with. . . ."
Alas, an experience like that can be duplicated many times when an emotional reaction on
the part of the doctor defeated the healer, the gentleman, and the scientist.
The family physician is often the first one to whom a parent brings the child who behaves
differently from expectation. Usually he advises them to take the boy (or girl) to a
psychiatrist. In adolescence, or later in life, the same may happen, and I was told again
and again that the psychiatrist then diagnosed "homosexuality" and - at best -
advised the patient to accept himself (or herself) as he or she was. The "gay"
life, however, is no solution for the transsexual. He does not like it. He actually
dislikes homosexuals and feels he has nothing in common with them. His loneliness
therefore becomes more and more evident and painful.
Cross-dressing is a help, but not always and not enough. The law forbids them to
"dress" and hold a job as a woman. Yet this would be the most effective form of
therapy (together with estrogen) until an operation can be had, provided the demand for it
At least ten or twelve male transsexual patients that I could observe lived and worked as
women in legitimate jobs, usually office work. Most of them still do at this writing,
their true sex status unknown to their employers or associates. A few of them have been
unusually successful in their work in spite of the handicap of their emotional
instability. Sometimes I have wondered whether their success may not be due to a fortunate
mixture of male and female traits in their psychological makeup (male logic and
aggressiveness, plus female intuition). One such patient told me, in describing her work,
"When I am engaged in a business deal, I still feel and act like a man."
Another patient, living after her operation the woman's life that she always wanted, once
- as her surgeon related to me - bought a car from a used car dealer, and paid for it in
cash. The salesman had assured her that she had made a good buy. After driving only a few
blocks the car proved to be defective and could hardly be driven back to where it was
The salesman listened to the complaint, but refused a refund or an exchange for a
different car. "You have bought yourself a car, lady," was all he had to say.
The "lady" saw red. With a "We'll see about that, you bastard," she
proceeded to give that salesman the beating of his life. Perhaps with memories in her
subconscious mind of the Chevalier d'Eon drawing his sword from under his petticoats to
defend his honor, her masculinity, aided by army training, had evidently reasserted itself
temporarily. She also got her money back.
To help patients in possible legal difficulties, and to give them at least some feeling of
security when they go out "dressed" or live as women, I wrote a certificate that
they were to carry with them. It read as follows:
To Whom it May Concern:
This is to certify that the bearer, ____ ____, is under my professional care and
This patient belongs to the rather rare group of transsexuals, also referred to in the
medical literature as psychic hermaphrodites. Their anatomical sex, that is to say, the
body, is male. Their psychological sex, that is to say, the mind, is female. Therefore
they feel as women, and if they live and dress as such, they do so out of an irrepressible
inner urge, and not to commit a crime, to "masquerade," or to
"impersonate" illegally.It is my considered opinion, based on many years'
experience, that transsexuals are mostly introverted and nonaggressive and therefore no
threat to society. In their feminine role they can live happier lives and they are usually
less neurotic than if they were forced to live as men. I do not think that society is
endangered when it assumes a permissive attitude, and grants these people the right to
their particular pursuit of happiness.Like all patients of this type, ____ ____ has been
strictly advised to behave well and inconspicuously at all times and to be careful in
This certificate was actually used very rarely. In one instance, of an arrest on the
charge of "impersonating," I was told that the policeman tore it up and threw it
into the patient's face. In another instance, the detective was sympathetic and let
the patient go. ("She" had been pointed out as a disguised man by a jealous
friend.) In two other cases, my certificate procured dismissal in court. In one case,
however, a conviction for "impersonating, " was obtained by the District
Attorney who later on complained to the County Medical Society, of which I am a life
member, about my certificate. The complaint was referred to the "Division of
Professional Conduct" of the respective State Department and I was politely but
firmly asked by two attorneys not to write such certificates any more. They may be
adjudged illegal and therefore "unethical." And so, one little help for the
transsexual's plight was nullified.
Another handicap for some transsexuals is their masculine appearance. With almost
unbelievable energy, they attempt to alter it. A flat chest is the worst feature. If
hormone treatment is too slow or not effective enough to produce the semblance of a bust,
plastic surgery is employed. Their beards are removed by longcontinued electrolysis,
applied occasionally also to body hair unless the latter can be influenced sufficiently by
A large nose is made smaller and more feminine-looking. Exercises and massages are tried
to change objectionable body contours. A beginning baldness and a receding hairline have
been treated with implants of hair taken from other parts of the scalp. Voice training is
resorted to in order to change a baritone into at least a contralto. In one instance, a
successful operation reduced a too prominent Adam's apple and in another the shape of the
chin was altered.
While all these measures are more often applied after a conversion operation than
before in order to complete the transformation and perhaps satisfy the urge for more and
more feminization, they illustrate nevertheless the transsexual's burden, which becomes
particularly heavy if economic factors prevent some of or all these measures.
Another handicap for many transsexuals is their character and their behavior. From a
so-called "character neurosis" to outspoken hostile, paranoic demands for help
from the doctor, all kinds of objectionable traits may exist. Unreliability,
deceitfulness, ingratitude, together with an annoying but understandable impatience, have
probably ruined their chances for help in more than a few instances. Many transsexuals are
utterly self-centered, concerned with their own problems only and unable to consider those
of anyone else. A surgeon wrote once to me: "Our experience is growing in regard to
the fact that most of them (transsexual patients) are willing to do anything on earth
before operation, but nothing at all afterwards."
On the other hand, there are also those patients who are touchingly appreciative,
grateful, and eager to cooperate. They compensate the doctor for many of his
disappointments. Alas, they seem to be in the minority.
Still another handicap for transsexuals is their rather frequent immaturity in thinking
and acting. Driven by the pleasure of anticipation, they commit the most impractical
errors. I have seen grown-up men in their thirties or forties waste their savings on trips
abroad to surgeons they "heard about," without further information or
appointments. Others have fallen victim to quacks and fraudulent nostrums and rarely
learned by their experiences.
It cannot be surprising that among the dangers that transsexuals face, when frustration
and unhappiness seem unbearable, are alcoholism and drug addiction. I have only wondered
that these do not occur more frequently. In not more than three or four of my patients did
I become aware of an alcoholic problem. Undoubtedly some others were carefully kept from
me. In a few instances, excessive drinking was resorted to only when "dressing"
had to be suspended. As soon as it could be resumed, liquor was no longer necessary.
The same may be true of drug addiction. I have found telltale marks of
"main-lining" in only one instance, but the use of "goof balls" was
One tragic case is that of Joan. She was twenty-six when I met her and that was just after
she had her conversion operation as well as plastic breast surgery. She was then a
strikingly attractive redhead, vivacious, possibly somewhat reckless, making her living as
a call girl and cocktail waitress. I lost sight of her for several years. When I saw her
again, I was hardly able to recognize her. Her attractiveness was all but gone. She had
lost much weight, had aged considerably, and looked sick. She had become a "goof
ball" addict and was still "in the racket." One day, she was found dead in
her furnished room. There was a vague rumor of suicide but no evidence. The medical
examiner's office listed her death as "narcotic." In all probability, she died
from an overdose accidentally administered when she experimented for the first time with
In a few instances under my observation, criminality complicated the transsexual's life.
Aside from prostitution, there have been rare examples of theft, forgery, and attempted
blackmail, however only before the operation had been attained.
The great majority of transsexuals, let it not be forgotten, are merely utterly unhappy
individuals. Some of them have become misfits through their gender disorientation that
neither society, nor the law, nor the medical profession at present understands and
acknowledges as an undeserved misfortune.
Innumerable letters testify to the transsexual's often desperate plight. There are many,
many in my files, some pathetically infantile, crude and uneducated, others highly
sophisticated, intelligent, even brilliant.
Dr. Christian Hamburger of Copenhagen, Denmark received similar documents humains after
his name was mentioned as Christine Jorgensen's physician. He published  interesting statistics gained from 465 such letters and added
abstracts from them. Many letter writers, for instance, complained about the treatment
they had received from the medical profession. One wrote: ". . . here was no loving
hand reached out to guide me. It was more like a doubled-up fist."
Dr. Hamburger came to the following conclusions:
These many personal letters from almost 500 deeply unhappy
persons leave an overwhelming impression. One tragic existence is unfolded after another;
they cry for help and understanding. It is depressing to realize how little can be done to
come to their aid. One feels it a duty to appeal to the medical profession and to the
responsible legislature: do your utmost to ease the existence of these fellow-men who are
deprived of the possibilities of a harmonious and happy life - through no fault of their
(PLEASE READ THE LAST FOUR PARAGRAPHS AGAIN.)
"Each Day I Live a Lie," by Lorraine Channing, taken from Turnabout,
Vol. 1, No. 3, illustrates and echoes Dr. Hamburger's words.
From childhood´s hour I have not been
As others were - I have not seen
As others saw - I could not bring
My passions from a common spring.
- Edgar Allen Poe: "Alone"
Each day I live a lie. Mine is a life of deceit, for I am forced
to wear a mask, to be an actor on a stage not of my own choice. I cannot do . . . cannot
act as I would like or as I feel.
Yet, I am not evil. I am not criminal.
I desire, in fact, to be good in the highest sense. I long to give, to help, to protect,
to learn, to create, perhaps above all, to love. . . and to be loved.
I look about me and see all that I cannot be and cannot do. My heart cries with a pain
like no other, for my deepest desires - to me, my most natural wishes - cannot be
fulfilled. I am forced to be and act that which I am not.
I see other women. I see them with children and am reminded that I cannot bear children,
cannot give them life. Children are to have and hold, to cherish and caress, to nourish
and nurture. Without them, I shall always be incomplete. To be a mother, nurse, or
teacher, to be close with children - all this is denied me.
Oh, to be and to live as other women do! To do the things they do, to go to the places
they go - these are vital to me. I wish to dress as they do - to wear the clothes, the
jewelry, the cosmetics, all the things they wear - these are symbols of their femininity,
their womanhood, their very essence.
Would that I were as other women are! Yet I am not a woman either in body or in the life
they lead. I am a woman in my soul, in my fantasy. In the deep recesses of my being, I am
like them. Inside me, I am one of them. How can I be more in their likeness?
That is what I want, yearn for, seek more than anything. Now I live only incompletely. I
am in a prison - the prison of my body, the prison of a society which does not understand.
Until I can become more like other women - if I ever can - I must live a lie, day after
day. Physically I am a man; mentally and emotionally I am a woman.
I am a transsexual.
 As stated earlier, sex and gender
are synonyms according to the dictionary. But as it was well put by Dr. Prince, sex is
"below the belt" and "gender is above."
 Worden, F. C., Marsh, C. T., "Psychological Factors in Men
Seeking Sex Transformation," J.A.M.A., April 9, 1955.
 Burchard, J., Lecture before the Society for the Scientific Study
of Sex, New York, November 2, 1963.
 Archives General Psychiatry, August 1965, page 172.
 A study to investigate the nature of the hypogonadism (primary or
secondary) is now in progress.
 Reprinted from Sex & Censorship Magazine, 693 Mission St., San
Francisco 5, Vol. 1, No. 2.
 "Sexual Aberrations on an Organic Basis, " Modern
Medicine, July 5, 1965.
 "The Desire for Change of Sex as shown by Personal Letters
from 465 Men and Women," Acta Endocrinologica 14, 1953, pp. 361-375.