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University of Minnesota, USA

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University of Ulster at Coleraine, UK

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University of Liverpool, UK

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University of Minnesota, USA

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University of Minnesota, USA

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ISSN 1434-4599

Harry Benjamin, M.D.

Nonsurgical Management of Transsexualism next

The management of transsexualism is, in the majority of cases, radically different from that of transvestism. Although this volume does not deal with transvestism specifically, a few remarks as to the therapy of this less serious deviation, in comparison with TSism, may be in order.

Therapy in transvestism

The true transvestite as a rule does not want any treatment. Doctors do not see them except in rare instances. They want nothing from the medical profession. They merely want to be left alone to pursue their own particular form of happiness, that is to say, "dressing," and rather want society to be treated educationally so that a more tolerant attitude would gradually emerge.

There are instances, however, when transvestism may be a great handicap for the patient and he would then be ready to undergo treatment with the hope of being cured of his strange and embarrassing compulsion. He may be in love with a girl whom he wants to marry and who would not tolerate transvestism. He may be disturbed and annoyed with himself or feel that his job is endangered. Or his family may have found out and may urge him to seek psychiatric help. Psychotherapy, possibly with hypnosis, would then be the method of choice, and if the patient persists long enough in an honest wish to be cured ("honest" at least in his conscious mind), success may be attained. There are former transvestites who claim that they have overcome their desires, but relapses have occurred so often that the state of an actual cure must, at least for the first few years, be considered uncertain.

Furthermore, a form of "substitute" deviation or neurosis may develop. Overt homosexual behavior or alcoholism have in some instances taken the place of the former cross-dressing and a return to it may finally be the lesser evil.

The form of psychotherapy applied in transvestism depends entirely on the attitude of the therapist. He may be permissive and merely guide the patient to accept himself as he is and to live with his peculiarity without getting into trouble with society or the law. That, of course, would not be curative. Or, more often, he may use almost any kind of psychotherapy, including deep and long-continued analysis or hypnosis, for effecting a cure.

For any success, much will also depend upon the atmosphere in which such patients continue to live. Part of the curative treatment would have to be removal from transvestitic temptations, friends, transvestitic literature, and the like, as completely as possible. To continue in the old surroundings would be like trying to treat an alcoholic inside a brewery or a bar.

Transvestites are known to have stopped "dressing" completely while in the armed services, although frustration may have been more or less severe. But a return to transvestism was almost unavoidable when they returned to their former environments or even to ordinary city life.

The alcoholic may join Alcoholics Anonymous and may find help that way, but the transvestite has, at least as yet, no parallel institution to cling to. Wherever he goes, he is surrounded by attractively dressed women whom he envies passionately, by lingerie shops, by shoe stores (fascinating if he is a shoe fetishist), and so on. The enticement is all around and his plight is a serious one. He would have to retire to a lonely island to be free from outside temptation.

It has been said that transvestites can simply use will power and stop "dressing" and then they will be cured. That is nonsense. Many have tried, have burned their female wardrobes, "purging" themselves, so to say, but without psychiatric or other help, a relapse was almost unavoidable. If the transvestitic urge (no matter whether basically fetishistic or latent transsexual) is forcibly suppressed, it is likely to find a different outlet through some other, perhaps more serious neurotic syndrome unless, of course, it is successfully treated psychiatrically, or a completely new interest such as marriage to the right kind of girl will prove strong enough to act as a cure.

The uncertainty of psychotherapeutic results is illustrated by some new and rather outlandish form of therapy that was recently publicized in the medical [1] as well as the lay press. It has been called "Behavior" or "Aversion" therapy.

The transvestitic patient is given an emetic drug (such as apomorphine). As soon as nausea develops, he has to view slides of himself dressed as a woman, prepared beforehand, and at the same time he has to listen to tape recordings describing in detail the mode and technique of "dressing." This form of treatment continues until vomiting occurs or acute illness prevents continuation.

Success has been claimed for this rather brutal and humiliating form of brain-washing, but the time of observation for the "cure" was, at the time of the report, only three months. And will such violent and undignified interference with an emotional life not again produce other, perhaps more serious substitutional symptoms?

Less degrading, although likewise rather brutal is the new type of aversion therapy utilizing painful electric shocks in place of the nausea. Patients are subjected to these shocks whenever they do something they are not supposed to do, for instance, enjoying women's finery, dressing in some, but also having homosexual inclinations, indulging in various sexual deviations as well as drinking or smoking too much. All these things are treated as bad habits. Successes are reported from England [2] but confirmation is still lacking.

Whether aversion treatments can be applied to transsexuals and with what result is not known.

A comparison with Antabuse in the treatment of alcoholism readily comes to one's mind. All transvestites, transsexuals, and alcoholics are problem personalities. If the emotional disturbance behind these personality disorders are rather superficial, an equally superficial symptomatic success may be accomplished at least for a while. But it seems to me that any more deep-seated disturbance (perhaps constitutionally anchored) would be quite unresponsive to this kind of aversion therapy, at least as far as any lasting benefit is concerned.

The transvestitic urge (fetishistic or transsexual) contains an element of addiction. Larger "doses" may be required for certain individuals as time goes on. Therein may lie a "progressive" nature of TVism in some instances. If untreated and uncontrolled, "dressing" may be desired more and more frequently and even the idea of physical changes through hormone treatment or through an operation may be gaining ground, particularly in unfavorable - that is to say, constantly stimulating - surroundings. Here psychotherapy and proper guidance at the right time may help, provided a transsexual tendency is not too deep-seated.

Such seemingly progressive aggravation of transvestism was rarely noticed under treatment, although it did apparently occur in a few cases. However, later on, these patients proved to be initially unrecognized transsexuals. The opposite was more frequently observed: under estrogen medication, the desire to "dress" became often less demanding and less sexual and the inability to indulge grew somewhat less frustrating. The explanation probably is that the libido was reduced in its intensity through estrogen and since the transvestitic urge is part of the libido, it was likewise lowered. But I am anticipating a later discussion.

The foregoing paragraphs (if repetition may be permitted) apply chiefly to that form of transvestism that is its own purpose, which is to say that it is not the chief symptom of transsexualism. As soon as physical changes are desired, it ceases to be true transvestism, and inclines toward transsexualism (Type IV of S.O.S.; table on page 22). The full and complete transsexual (S.O.S. V and VI) finds only temporary and partial relief through "dressing." I have even met transsexuals who would not "dress" at all."What good is it?" they said; "it does not make me a woman. I am not interested in her clothes; I am only interested in being a woman." That is the true transsexual sentiment.

Psychological guidance in transsexualism

If the transsexual does find relief in "dressing," to do so would be the first logical advice to be given therapeutically. Its permissive character can be questioned by those who may think of the law before they think of the patient, or who may have insufficient experience along these lines, or who are the type that, automatically, favors prohibition. Too many individuals are that way; what they do not like must be forbidden and punished. Then they are satisfied. I have even met transvestites who dislike (or pretend to dislike) transsexualism so much that they are against estrogen treatment and operation (for reasons of self-protection?). There are also transsexuals who dislike transvestites as well as homosexuals. Intolerance can be found in strange quarters.

It is my hope that this volume may induce doctors as well as laymen who may come across the transsexual phenomenon to assume a tolerant and rational attitude and let the light of facts replace the ever-present twilight of prejudices. Walter Alvarez [3] was right when he wrote in one of his newspaper columns in sympathy with a transsexual that he had met:

I know that for having written this column, I will get a number of vituperative letters from people who will think that I am foul-minded. No, I am just talking about these people dispassionately and scientifically. Let all of us who tend to look on these people as vile, remember that their mixup was obvious in early childhood when, surely, there was no vileness. We must all learn to have sympathy for these persons who were so badly gypped by Nature. But for the grace of God, we too might be caught in the same cruel trap.

Living completely as a woman (though illegally) can actually be a life-saving measure for those transsexuals who find an operation unattainable. I know at least a dozen who are in this situation right now. They work as women in offices, factories, beauty salons, as nurses, domestics, and some, alas, as prostitutes, all quite unknown to their employers, associates, or clients. They would best have psychological as well as medical help in addition to living in their female gender identity; but very few actually have such help. Merely the opportunity to talk to somebody about their problems has its therapeutic value. To find some understanding from a doctor instead of coldness, rejection, or ridicule goes a long way toward easing their burden.

Psychotherapy in transsexualism

Psychotherapy with the aim of curing transsexualism, so that the patient will accept himself as a man, it must be repeated here, is a useless undertaking with present available methods. The mind of the transsexual cannot be changed in its false gender orientation. All attempts to this effect have failed. Dr. Robert Laidlaw, chief psychiatrist at Roosevelt Hospital, New York, has studied a number of transsexuals and has come to the conclusion that "psychotherapy has nothing to offer to them," as far as any cure is concerned. In numerous conversations and in psychiatric reports, Dr. Laidlaw considered the transsexual's state "inaccessible to psychotherapy." Dr. John Alden, a prominent psychiatrist in San Francisco, fully concurs with this opinion and has repeatedly stated so. Numerous other psychiatrists aggree, to my own personal knowledge. (See psychiatric reports in Chapter 7.)

In my own practice, I have seen ten or more patients who have been in analysis for as long as three and more years without the slightest change in their transsexual attitude.

Since it is evident, therefore, that the mind of the transsexual cannot be adjusted to the body, it is logical and justifiable to attempt the opposite, to adjust the body to the mind. If such a thought is rejected, we would be faced with a therapeutic nihilism to which I could never subscribe in view of the experiences I have had with patients who have undoubtedly been salvaged or at least distinctly helped by their conversion.

This help has been given by two therapeutic measures aside from psychological guidance and living as a woman: first, estrogen medication and second, surgery. Most of the time, both.

Estrogen therapy

Estrogen, the principal female hormone, in sufficient dosage over a sufficient length of time, acts on the male body in two ways. It produces partial chemical castration and hormonal feminization. Both are temporary results unless treatment is continued for years. Then some permanent changes like a degree of testicular atrophy and more or less distinct gynecomastia may remain. Ordinarily, however, when estrogen treatment is discontinued, a return to the former state can gradually be expected.

I know of one patient who was moderately feminized by estrogen but, being bisexual and not a true transsexual, fell in love with a girl, gave up the idea of sex change, married, and now has two children. The question remains whether he will stay free from transvestism, and for how long.

The clinical results of estrogen (to which I usually add progesterone), can be dramatic for the deeply disturbed transsexual. These results are by no means entirely psychological as may be suspected. They are also distinctly endocrine. The hormonal castration produced by estrogen reduces androgen (testosterone) output and activity. In consequence, it lowers libido, it calms the patient, and acts as a biological tranquilizer. The transsexual drive, being part of the transsexual's libido, decreases in intensity, although in the "intensive type" (S.O.S. VI), not always sufficiently to give the necessary comfort. Then ordinary tranquilizers may have to be added.

Side effects of estrogen therapy, most of them greatly welcomed by the patient, depend upon individual responses, upon dosage, and chiefly upon length of treatment. Foremost among such side effects is breast development, the appearance of which provides tremendous emotional relief to the transsexual patient. The degree of gynecomastia that may be achieved depends upon the patient's constitutional physical build, that is to say, the amount of glandular breast tissue that is present and could respond to estrogen and progesterone, the breast being the target organ for these hormones. A further important factor is how readily an underweight patient may gain weight and in this way increase the fatty part of the breast.

It may take many months, even a couple of years, to develop a breast that would resemble that of an average, normal female. Chest measurements must naturally be correlated to body weight and can show increases of five or more centimeters a year with weight being constant.

Frequently transsexuals are too impatient and insist upon quicker results through breast surgery with implants of various kinds. The outcomes are not always satisfactory. I have seen bad infections develop, painful and abnormally hard breasts, but also satisfactory results that helped the patient's emotional status. At best, breast surgery is a gamble.

Accompanying the development of the breast is an increase in the size of the nipples and a distinct, measurable increase in the areola, the pigmented area around the nipple. Oversensitiveness of the nipple, sometimes to the point of discomfort, occurs with some regularity, especially during the first few weeks of estrogen therapy. Gradually, however, the sensitiveness subsides, or dosage would have to be reduced.

Another side effect of estrogen therapy concerns hair growth. Body hair almost invariably decreases and after enough time actually disappears, with the exception of pubic and axillary hair. The beard is rarely affected and would have to be removed by electrolysis. Scalp hair is favorably influenced. Usually it grows faster and heavier; baldness may or may not be prevented; probably this is dependent upon hereditary factors.

I have often seen skin texture improve distinctly under estrogen medication and an acne condition was occasionally cured.

Fat may shift from the shoulders to the hips in feminine fashion so that hip measurements increase by as much as five to seven centimeters within a year's time, in spite of stationary weight.

Strikingly affected are the sex life and the sex functions. Within a few weeks of treatment, some patients report they no longer feel like masturbating, their sex urge, including the desire to "dress," being much reduced. There are no or fewer involuntary morning erections and after six months or so, voluntary erections also become difficult to elicit and about one out of ten patients describes them as distinctly painful. If orgasm can still be reached, there is in more than 50 per cent of the cases no ejaculation, which may to a large extent be due to prostatic shrinkage.

The physical examination reveals a reduced size of the prostate and after about a year of treatment a somewhat smaller penis also (from disuse?) and perhaps a moderate testicular atrophy. The 17-ketosteroids almost regularly sink below the normal level of the female. Abnormally large estrogen values are found in the urine.

All these changes make the transsexual happy, as he despises each and every manifestation of male sexuality.

This may be the occasion to mention the fact that, in about one quarter of my patients, androgen in the form of testosterone injections had been administered at some time in the past, the doctor evidently hoping to cure the transsexualism and the effeminacy of the patient through masculinization. Alas, it is the wrong treatment. The conflict is aggravated when the body becomes hairy and the libido increases without, of course, changing its direction. Androgen is to my mind contraindicated in male transsexualism.

In hypogonadal young boys, an attempt may be made to help the maturing process through injections of the gonadotropic hormone of the pituitary (APL). Hoping to influence nature in this direction, I continued in a few cases weekly injections Of 500 to 2000 units for several months, but saw no influence on the transsexual drive.

Estrogen therapy is either given as the substitute for a conversion operation or, in accordance with the suggestion of Hamburger et al., in preparation for the operation in order to test the patient's psychological reaction to feminization. "Let us have it on a temporary, reversable basis first, before an operation would make it irrevocable," has been my argument.

Per Anchersen suggests the following: "Treatment with oestrogen hormones to suppress the internal secretion of the testicles and in this way try to feminize the patients by a hormonal castration. This treatment must always be tried for a long time before one decides on a surgical castration." [4]

Close observation and repeated examinations are essential during treatment. Liver function tests may be advisable, the so-called BSP (bromsulphtalein) being probably the most valuable. The liver is the organ that metabolizes ("digests") the estrogen and it is conceivable (although not actually shown) that it may be unfavorably affected by long-continued medication. A hazard may possibly exist if there is a history of hepatitis.

The fear of developing cancer through hormone treatments crops up from time to time, especially if there are irresponsible newspaper reports, for instance, of the results of someone's experiments with mice and rats to produce cancer artificially with estrogen. Such experiments admittedly have no bearing on the reactions of the human organism. Is the attempt to apply experiments with the cancer-susceptible mouse to the human area anything but ludicrous?" asked Dr. Robert A. Wilson, whose extensive work has thoroughly debunked the cancer fear of women receiving estrogen during their change of life.[5]

In my own clinical material of 152 male transsexuals, 141 of whom were treated with medium to fairly large doses of estrogen, some over several years, no incident of breast or any other cancer was observed. One may argue that these are mostly young men, less apt to develop a malignancy. The experiences of urologists, however, who treated elderly and old men with even much larger doses of estrogen for cancer of the prostate, must then be recalled. With the exception of one disputed case of breast cancer (it may have been a metastasis of the prostatic cancer) reported in the medical literature, no such incident was observed in hundreds if not thousands of cases. In a personal communication from Dr. Elmer Belt, one of the outstanding and most experienced urologists in the country, he said:

In regard to the taking of Stilbestrol as a cause for cancer of the breast, we have placed several hundred men on this material (I imagine if we were to search our records we would find the number to be in excess of two thousand) and in all of these cases we have not seen a single occurrence of cancer of the breast, although the dosages we used were of a very high level.


Estrogenic Preparations

Parenteral use
As to the particular estrogenic preparations and dosages to be employed in transsexualism, a good deal of experimentation was and will still be necessary. There are so far very few leads in the medical literature.

In my own practice, Squibb's Delestrogen for intramuscular injections was employed with much satisfaction and positive results. This is a slowly absorbing, well-tolerated, potent preparation (chemically, Estradiol Valerate), and was applied in doses of 20 to 60 mg. (½ to 1½ cc.). Usually 30 to 60 mg. of Delalutin (Squibb) was added, an equally potent progesterone. This combination was given once a week or once in two to three weeks, according to the response as measured by the patient's emotional balance and physical feminization symptoms. Generally I found that dosage seems less important than length and regularity of administration.

Another preparation of even higher potency is Squibb's Delestrec, which at this writing is not yet on the market in the United States, but is well known in Germany and other European countries under the name of Progynon Depot (Schering). It is chemically Estradiol Undecylate in oil, likewise slowly absorbing, and containing 100 mg. to 1 cc. Injections of 1 cc. once or twice a month can be sufficient. Occasionally, however, larger doses are required to influence the patient's emotional distress.

These estrogenic preparations are solutions in oil. There are also suspensions of tiny estrogenic crystals in water (aqueous) available for intramuscular injections. They are of much lesser potency and would have to be given more frequently (twice weekly or more) over many months to produce sufficiently feminizing results.

In general, injections, as compared to oral medications, are justified for more easily measurable dosage, and usually prompter effects, but also for the fact that some psychological guidance or even brief psychotherapy can take place during the patient's visits, not to speak of the important physical checkups. Selfmedication by patients is definitely to be discouraged.

Oral use
Of the oral preparations, there is a considerable choice. They can be employed together with injections or in their stead.

Diethyl Stilbestrol is the cheapest, but has the most frequent side effects in the form of nausea and gastrointestinal upsets. Better borne and rarely causing nausea is ethinyl estradiol in the form of Schering's Estinyl. The largest dose of 0.5 mg. daily or three times a week is usually necessary to accomplish positive results. Occasionally a patient may not tolerate Estinyl and then Premarin (Ayerst) or Amnestrogen (Squibb) in doses of at least 5 mg. daily could be employed. These are excellent preparations of so-called natural female hormones, of somewhat lesser potency but often useful and sufficient, especially in patients operated upon and castrated, to prevent castration symptoms, and to further their feminization.

Potency and dosage of the estrogen preparation is not always the deciding factor in this type of hormone therapy. Many patients have the unfortunate tendency to believe that the more estrogen they take the more they will accomplish. They may actually do the opposite. Doses that are too large for a particular patient may not only constitute certain hazards for the liver but, by suppressing the pituitary gland function with its growth hormone, may actually accomplish less, for instance, in breast development. Smaller doses may do more; the regularity and length of treatment has appeared to me more important than the dose. The optimal dose will have to be determined for each patient individually.

The latest female hormone preparation that has been used in cases of transsexualism is Enovid (Searle), the well-known birthcontrol pill, containing both estrogen and progesterone. Promising results have been observed, but more extensive observations by a number of different clinicians is advisable. Enovid in doses of 10 to 20 mg. daily has served me well in the endocrine management, articularly of those transsexual males who were underweight. An increase in appetite and weight was almost regularly observed. The repressing influence on libido and sex functions seemed to me less pronounced than that of estrogen alone. Therefore combinations of Enovid with Estinyl or Premarin occasionally gave the best results.

Finally, in addition to the parenteral and oral routes of administering estrogen, the topical (local) use must be mentioned. A cream that can be easily absorbed and that contains a sufficient dose of estrogen and progesterone can aid the development of breast tissue. Goldzieher [6] and others proved conclusively that estrogen is absorbable through the skin and can aid the mammary development of hypogonadal young girls. The same is true in transsexual men although only as contributing treatment.

A twenty-six-year-old male transsexual had used rather liberally a commercially available hormone cream on his breasts without any other treatment. There was only a modest response (if any) of the breast tissue, but when this patient came under my observation and a hormone assay was made of a twenty-four-hour urine specimen, the 17-ketosteroids were found to be normal but the estrogen contents very high (110), when the normal is considered to be from 0 to 30.

Some years ago, workers in a chemical factory that produced estrogenic preparations complained of developing gynecomastia, impotence, and other feminization symptoms. They had constantly, over a considerable period of time, handled this estrogenic material without protection for their hands. The steady hormone absorption, through the skin, although in minimal doses, was found to be the cause. Such factory or laboratory work is now continued with glove protection of the exposed parts of the hands.

In presenting the above experiences, it is my wish merely to give the doctor some general lines of a possible therapeutic approach to this largely untrodden field of medicine. A better system of treatment may well be evolved, larger or smaller doses of estrogen may be found advisable, and more suitable combinations. It is my own conviction that "much does not help much" and that the general tendency should be to use the smallest possible doses that give sufficiently satisfactory results for a particular patient.

Finally, and to conclude the discussion of the nonsurgical therapy for transsexuals, it may be most interesting in future years to watch these patients who have received estrogen over a long period of time. Will they be less prone to develop coronary heart disease and other circulatory ailments that go with the process of aging? A well-known cardiologist, noted for his research in cholesterol metabolism, who had occasion to see a number of transsexuals under estrogen therapy, remarked jokingly, "These people will probably live forever."

Another question may be asked and possibly receive an answer in years to come. Will "chemical castration" with estrogen act similarly to surgical castration? Will estrogen-treated or operated transsexuals become bald as rarely as eunuchs do and less often than the average man? The sexologist as well as the endocrinologist of the future will undoubtedly find fascinating new avenues of study in the management of transsexualism.


[1] Raymond, M. J., British Medical J., Vol. 11, 1956, p. 854, and Lancet, March 4, 1961, p. 510.

[2] Dr. J. C. Barker, British Joumal of Psychiatry, March, 1965.

[3] New York Herald-Tribune, July 1, 1957.

[4] Acta Psychiatrica et Neurologica, Scandinavica, Suppl. 106, 1956, p. 253.

[5] Wilson, Robert A., "The Roles of Estrogen and Progesterone in Breast and Genital Cancer," J.A.M.A., Vol. 182, October 27, 1962, pp. 327-331.

[6] Goldzieher, Max A., J. Gerontology, Vol. 1, 1946, p. 196; McBryde, C. M., "Production of Breast Growth by Local Application of Estrogenic Ointment," J.A.M.A., Vol. 112, 1939, p. 1045.

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