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The Transsexual Phenomenon

H. Benjamin



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Symposion Publishing

Harry Benjamin, M.D.

The Male Transsexual next

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 [1] (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 convincing.
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 future.
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 [2] with full justification.
Many transsexuals have no overt sex life at all. As Burchard [3] 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 phenomenon.
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 personality."[4]
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.

The physical 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.[5]

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.[6]

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]).

Three different 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 initial H.
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 suggested.
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 transsexuals

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." [7] 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 persists.
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 bought.
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 observation.
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 choosing friends.

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 estrogen medication.
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 occasionally admitted.
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 an injection.
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 [8] 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 own.

"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.


[1] 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."

[2] Worden, F. C., Marsh, C. T., "Psychological Factors in Men Seeking Sex Transformation," J.A.M.A., April 9, 1955.

[3] Burchard, J., Lecture before the Society for the Scientific Study of Sex, New York, November 2, 1963.

[4] Archives General Psychiatry, August 1965, page 172.

[5] A study to investigate the nature of the hypogonadism (primary or secondary) is now in progress.

[6] Reprinted from Sex & Censorship Magazine, 693 Mission St., San Francisco 5, Vol. 1, No. 2.

[7] "Sexual Aberrations on an Organic Basis, " Modern Medicine, July 5, 1965.

[8] "The Desire for Change of Sex as shown by Personal Letters from 465 Men and Women," Acta Endocrinologica 14, 1953, pp. 361-375.

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