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Ulm University, Germany

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University of Minnesota, USA

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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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Symposion Publishing

ISSN 1434-4599

Harry Benjamin, M.D.

Conversation Operation next

Part I. Technique of the operation

In the majority of cases the operation consists of three principal steps: (1) Castration; (2) penis amputation; (3) plastic surgery to create an artificial vagina and external genitalia, which should resemble those of a female.

1. Castration. The technique is well known to every urologist. The question faced by some surgeons is, however, whether to remove the testicles or preserve them, yet make them invisible. A surgeon who prefers the preservation described his technique as follows:

The patient has first one and then the other inguinal ring opened. The testicle is isolated from the scrotal sac and is pressed upward through the inguinal ring into the abdomen. The inguinal canal is then closed as in a hernia operation. The testicle now lies like an undescended one outside the perineum, but inside the abdominal cavity. It is hidden from sight and touch. It loses its procreative, but retains its glandular function.

The reason why some surgeons may wish to retain the testes is chiefly endocrine, based on the theory that the testes in transsexual men may produce more estrogen than they do normally. The findings reported in Chapter 5 strengthen this view, although they have as yet found no confirmation.[1] In any event, this reasoning supports the patient's intended feminization.

Another reason for a surgeon's wish to preserve the testes is because of a legal technicality. He cannot be accused of a (possibly illegal) castration operation.

In most conversion operations, I believe, the testes are discarded, that is to say, the patient is castrated. The consensus would probably be in favor of this procedure.

While most transsexuals themselves prefer to be castrated in order to remove more of their masculinity, an occasional patient wants to see the testicles retained with the strange, completely unfounded idea that they are necessary for a future climax during sex relations. It is astonishing how often the wrong information, superstition, and gossip circulate among transsexuals when they are those who should want correct information more than anyone else.

2. The removal of the penis is called penectomy or penotomy. The principal technical difficulty is the preservation of a functionally normal though greatly shortened urethra. I have seen poor results in this respect, the urethra requiring constantly repeated dilatations, or even corrective surgery. Unskilled surgeons have also left a penile stump, which resulted in later complications.

3. The plastic surgery is a challenge to the urologist, the gynecologist, and the plastic surgeon. It can be divided into two parts: the creation of female-looking external genitalia and of a functionally useful vagina.

Scrotal tissue is used to fashion the labia majora and, in the hands of a skillful surgeon, the appearance ultimately can indeed be deceiving. I know of a case when even a gynecologist was fooled. He had made a vaginal examination (undoubtedly superficial ) and exclaimed: "I cannot find any uterus in this girl."

Occasionally the skin of the penis is utilized to form labia minora-like folds. All these tissues contain sensory nerve ends which later may help to convey sexual satisfaction, possibly climaxing in orgasm.

The creation of the artificial vagina is for many transsexual males (those with a primary sex motive for the conversion [2]) the crucial part of the operation. Its success or failure may spell the success or failure of the entire sex change undertaking.

In years past the creation of the artificial vagina was performed as a separate stage of the conversion, that is, months or even years after the first stage, which was castration and penectomy. With greater perfection of the surgical technique, all this is now done in one operation.

For the vaginal plastic, a pouch, eight or more inches deep, is dissected in the perineum, close to but well above the rectum, so that a firm floor of the vagina may later exist, eliminating or minimizing the danger of a vaginal-rectal fistula. This pouch or channel passes behind the posterior aspect of the prostate. The incision extends upward from the apex of the perineal wound to the posterior surface of the seminal vesicles. The question then arises how to line this channel so that it can remain open and serve as a permanent vagina.

Three types of material have been and are still being used for that purpose. The oldest method is to use the skin from the thigh, buttocks, or back. Such skin is soft and contains relatively few hairs but has no natural lubrication. It is cut in thin transplants with the help of a special instrument, the dermatome. The transplants are placed around a rubber form, about two inches in diameter. The skin sections are then inserted into the pouch and are stitched to the skin of the perineum to prevent slipping. If all goes well, the skin segments will heal in and, with the help of artificial lubrication, the patient will then have a functioning vagina. The most striking studies in the physiology of the vaginal function and vaginal lubrication were made by W. H. Masters and V. E. Johnson. Those particularly interested in this special field would do well to peruse the pertinent articles by these two scientists.[3]

Dilatation, however, first with one or two fingers, then with an instrument, a test tube or a plastic mold, is essential. Some patients have to wear a mold for several months. If they do not or if they do not dilate regularly, the vagina is likely to contract more and more and eventually close up entirely. A new operation would then be required. Only if the wall between vagina and rectum is thin, the wearing of a mold would be inadvisable as the constant pressure could produce a fistula.

In recent years a rather ingenious and, from what I have seen, so far the most successful method, has been perfected and is exelusively used by Dr. George Burou, a French surgeon in Morocco. Instead of using skin from the body to line the vaginal canal, the skin is stripped from the amputated penis and is inverted like the finger of a glove. This tubelike organ is then inserted into the previously prepared canal and utilized to form the inside of the tunnel that is destined to be a vagina. Penile skin offers advantages over skin from other areas because it has no hair at all and has nerve endings which cause it to bear the closest resemblance to that of a sexual organ. The two wound surfaces usually heal together without difficulty but dilatation is required the same as previously described. An uncircumcised penis is better because more skin is available, thus permitting the vagina to be made deeper. In any event, the outside skin of the penis, later on, represents the inner wall of the vagina.

Complications in the form of contractions through scar formations, occasional granulations (keloids), and insufficient depth of the vagina can occur after either method. They may necessitate additional minor surgery. Major surgery would be required only if the vagina has become obliterated and useless for normal sex relations.

As a third technique a more complicated procedure has been devised that is rarely, employed for the first attempt to form a vagina. It is probably more often the logical method when others have failed.

This third method utilizes a part of the gut, a loop of ileum, to serve as a vagina. The operation is a more formidable one as it requires not only the opening of the abdominal cavity but also a more intricate technique to insure the proper blood supply for the implant. The advantage is that a mucous membrane (with natural lubrication) and not skin forms the vaginal wall and that this wall may be less likely to contract.

In one patient undergoing a fourth attempt of vaginal plastic after others had proved unsuccessful, the method seems to have worked well. I have only the patient's written report; there was no personal inspection, nor an examination by a gynecologist.

One other patient had his initial operation recently performed with an ileal loop implant. The early outcome was unfortunate. The new and hopeful young "girl" suffered intensely for weeks afterward with abdominal pain and discharge from a vagina that had much too narrow an entrance to serve its intended purpose. It was found that an abdominal abscess had formed and a new operation was required for its removal. At the same time the entrance to the vagina was widened.

It is evident to me, a nonsurgeon, that the ultimate techniques for a successful conversion operation for male transsexuals are yet to be perfected. Perhaps there has so far been too little opportunity for surgeons to acquire the skill that future experience may bring. One handicap to be considered is that lack of complete success may discourage continued acceptance of these patients for surgery. The highly sensitive nature of most transsexuals, their precarious emotional stability, and the uncertainty of counting on their cooperation would more fully explain the hesitancy of doctors to venture into this - for many - controversial field.

An added difficulty for American patients is the fact that they have to leave the country to seek this particular surgical help abroad. Being anxious to get home as soon as possible, they deprive the surgeon of sufficient time for observation and themselves of the important follow-up care.

Whenever, in the future, a conversion operation will be recognized as legitimate surgery, perhaps even as a specialty within a specialty, and then become respectable therapy, improved techniques are bound to follow and with the improvement, perhaps more regularly obtained good results.

Blessed and burdened with their ability to choose, transsexuals may then face a future that holds fewer risks and greater rewards.

Part II. Nature of the operation

Such a major and irrevocable procedure as the surgical alteration of the male genital organs cannot be undertaken lightly. The indication for the operation must therefore be made strictly and with the greatest caution. The patient's request for surgery may be most impressively presented to the doctor; yet, before consenting to it, the doctor has to be certain he is not dealing with a passing erotic mood of an immature personality, but with a deep and honest conviction gained after long and mature consideration.

A psychiatric evaluation should precede all such operations to establish not only the possible existence of a psychosis (which may or may not be a contraindication for surgery), but also a reasonable degree of intelligence and emotional stability. Furthermore, it must be the psychiatrist's opinion that there is no other way to help this particular TS patient to a happier future.

Repeatedly, I have received reports from psychiatrists stating these facts. Here are some abstracts of psychiatric reports that I have received, or that came to my attention.

A professor of psychiatry at a large university wrote to the surgeon to whom he referred the patient:

In addition, as a result of this extensive psychiatric evaluation, I do not feel that any form of psychiatric treatment could make her either more masculine or content with a masculine role. Such treatment would be doomed to failure.

In the course of this evaluation, no evidence of serious mental illness has been found. The patient is not psychotic, and I do not believe she ever will be. Her character structure is essentially that of a woman, and she has adjusted very well to the feminine role. A complete battery of psychological tests has confirmed the impressions I have noted above.

Another prominent psychiatrist with much experience in the field of transsexualism had this to say in referring a patient to a surgeon:

I can find no areas in this young man's personality that suggest any pathological anxiety. His whole emotional defensive symptom is definitely stable and I do not anticipate any emotional difficulty whatsoever.

I heartily endorse this young man's wish for the operation, and from a psychiatric point of view, I do recommend it.

Again, another psychiatrist expressed his opinion in these words:

There is no evidence of any gross psychotic process, and whatever course of action takes place in this next year, it is unlikely that he will become psychotic. On the basis of his superior intelligence he is able to make his own decision. I consider that any attempts at psychotherapy would be fruitless and that his character structure would be inaccessible to any change through any psychotherapeutic process available today.

Unfortunately, not all transsexual patients submit to psychiatric evaluation or wait for anyone's consent, but through friends and acquaintances find their own surgeon, usually abroad.

In order to have all transsexual patients realize what they are doing when they undergo a major, transforming operation, I wrote an "Advice" for them that Sexology Magazine [4] published first and which was reprinted in several other publications likely to be read by transsexuals. The magazine's identification of one is included in Footnote 4, together with that of the writer.

An interesting coincidence occurred in this connection. A reader of Sexology Magazine had written to the editor the following letter, which is rather typical and which I could duplicate many times from my files:

Dear Doctor:

What can I do to end my misery? In body I am looked at by others as a male, but in my mind and heart I see myself as a woman.

Life has played a dirty trick on me, forcing me to live with the outer appearance of a man, but the inner feelings and emotions of a woman. Although my sex is male, I really think I am very much on the feminine side. Except that I do not have breasts, I have a womanly figure. On occasion, while dressed as a female (something I feel compelled to do quite frequently to ease my emotional tension) I have been told that I am quite beautiful. People look at me with respect and admiration. Not so when I am dressed as a man.

Perhaps I could live always dressed in a woman's clothes; but then I would always live in fear of being recognized and arrested. That will not help. Even now, I feel that I am a true woman hiding in the false physical shell of a male.

I understand that some people like me have been able, after years of torment, to find relief and happiness by actually becoming female through treatments and an operation. I am convinced that this is what I really need to end my misery.

I want to change my sex. Can you help me? - F.T.S.

Just at the moment this letter was received, my "Advice" was submitted for publication. The editor promptly and logically used it as answer to the above correspondent; it is reprinted here for the particular benefit of all those who contemplate the operation or play with the idea:

Medical science and modern surgery have indeed helped cases like yours, although not too many and not always too well.

An operation to have your sex "changed" is probably foremost in your mind. Sometimes you may feel that such an operation is all you live for and that without it and without the change you can accomplish that way, life is not worth living. This is an understandable emotional reaction to your deep-seated urge to go through life as a woman.

You must realize, however, that emotion, especially if unusually intense, is not always rational and may well conflict with sound reason. Therefore, you should make an effort to think over your problem as unemotionally as possible, and to do so more than once. Let me help you to do it by supplying a little more knowledge and common sense. It may prove useful for your entire future life.

First of all, sex is determined at the moment of conception and therefore never can be changed. The so-called "change" by surgery concerns only those organs that make you physically and legally a man (or a woman). A serious major operation or series of operations are required to change the external appearance from male to female.

The difficulties of finding a competent surgeon are great. Few hospitals at the present time will allow such operations. Complications may arise afterward, more operations may become necessary, and the outcome is never certain. The artificial vagina that can be created by plastic surgery may or may not function to your later satisfaction in marital relations. I am speaking from experience with more than a single patient.

Furthermore, the operation, even if successful, does not change you into a woman. Your inborn (genetic) sex will remain male. You must be aware of this fact, although it may have no practical meaning for your later life as a woman. If the surgeon castrates you as part of the operation, you would be, technically and from the glandular point of view, neither male nor female. You would be a "neuter."

Only your psychological sex is female. (Otherwise you would not have wanted the operation in the first place.) If the surgeon merely places your testicles in the abdomen to make them invisible, you would have to be considered a male, from a glandular viewpoint as well as legally.

Yet, it is true, you could look like a woman in the genital region and function as one after the operation. Even a climax (orgasm) during sex relations has been reported by most such patients. But remember, a time may come when sex is no longer important. Would you still want to be a woman then? Furthermore, constant glandular treatment with hormone injections or tablets - off and on - probably would be necessary for the rest of your life.

Is your general appearance and physical build such that you can pass as a woman, or is it possible you will look more like a man dressed up as a woman?

Don't ask the mirror. Take the word of an objective outsider.

Masculine features, a heavy bone structure, a height above the average, a prominent "Adam's apple," a heavy beard could be handicaps because they would be difficult or impossible to change.

The law too may cause you many difficulties and complications, even after the operation. Much red tape stands in the way for you to have your birth certificate read "female" instead of "male." But you may need that for a new job, or if you should want to get married as a woman.

And then, please remember that you are not alone in this world. You undoubtedly have relatives, parents, brothers and sisters. You must ask yourself how they would feel, having a daughter instead of a son, a sister instead of a brother. Their attitude and their happiness deserve your consideration before you undertake such an irrevocable step as a "conversion operation." You can only hope that they will put your happiness before their own preferences.

Religious convictions may trouble your conscience. Find peace and clarity before you decide on something that cannot be undone.

Even if all obstacles (including the important financial one) have been overcome and the operation has become possible for you, you should remind yourself once more that when you awake from the anesthesia, you are not a woman by any means.

When you have recovered from the pain and the aftereffects of the operation, after a few weeks or months, your real work begins - to change into a "woman." You have to learn how to behave like a woman, how to walk, how to use your hands, how to talk, how to apply make-up, and how to dress. Existing handicaps would require special attention.

Of course, you may have had your experience with dressing, etc., for some time already, but it was then more or less a game. Now it would be so much more serious because it is permanent. Also, your beard and body hair may require long and costly electrolysis to be removed.

Finally, but highly important, how do you know you can make a living as a woman? Have you ever worked as a woman before? I assume that so far, you have only held a man's job and have drawn a man's salary. Now, you may have to learn something entirely new. Could you do that? Could you get along with smaller earnings?

Again, I ask you to think over all these problems carefully, sensibly, and unemotionally. If you could try, perhaps with the help of a psychologist, to adjust yourself to your present male status, making the best of it in whatever form or manner, you may certainly save yourself immense complications in your future life and probably many sacrifices too.

If you can, discuss the problem with someone who is understanding but who does not have the handicap of emotional involvement. If everything seems favorable, a doctor - preferably an experienced psychiatrist - should still be asked to approve of the step you want to take. If he agrees with you and recommends the operation, then I would say "by all means, go ahead and the best of luck."

The above advice was written with the male transsexual in mind who desires to become a woman. But there are also female transsexuals who want to become men and live and work as such. They are rarer, but their emotional problems are the same. My explanations and warnings, in principle, apply equally to them.

The operations they are seeking with the same emotional intensity naturally are different. They want a reduction in the size of their breasts, in order to appear masculine, the removal of the womb, and the ovaries, so that there is no menstrual period to fear anymore, and sometimes the closing up of the vagina.

More complicated plastic operations on the genitalia are very rarely requested. For instance, the construction of a penis that could be of use would require a series of complicated operations, costly through long hospitalization, and highly uncertain as to results.

Glandular treatment with hormones and psychological guidance are as important for females as for males, but naturally hormones produce no permanent changes. These can only be accomplished through surgery, which in turn requires as much mature and unemotional consideration as the parallel procedures in men.

Most important for my own satisfaction and consent to the operation was the belief that a reasonably successful "woman" could result and, naturally, that there appeared to be no other way to help this patient through any form of conservative treatment to a happier and mentally healthier future.

For a "successful woman," I had in mind particularly the outward appearance and the impression of the total personality.

A heavy masculine build, a height of six feet or more, and a strong, dark beard were causes for worry and doubt. But even with these handicaps, the operation was performed in several instances, with or without my consent. So far, all seems to have gone well with them. One patient who is now, several years after the operation, a decidedly masculine-looking "woman," with tattoos all over her body, is getting along well in an active business and is unrecognized as a former male. She is merely considered eccentric by her associates.

Under no circumstances, she assured me repeatedly, would she ever go back to living as a man. "This way I am at least myself and can relax," were her own words.

A couple of times she was arrested under the suspicion of "impersonating." When she was taken to a police station, examined and declared to be a woman, the arresting officers apologized and in one instance, bought her a dinner. Not all patients in such situations fared equally well, as will be seen in Chapter 9 on "Legal Aspects."

A reasonably good emotional stability likewise played a part in my prognostic considerations and also, quite prominently, the attitude of the family if there was one to be considered. If happiness for one individual has to be bought with unhappiness for several others, it is not an ideal situation.

Finally, last but not least, I was concerned with the economic prospects of the future woman. Could "she" make a living and blend into society without friction and failure? I have seen difficulties in this respect and therefore preferred (without actually advising it) to have the patient live and work as a woman, although illegally in a technical sense, for a year or so before taking an irrevocable step. But such a trial period was not always possible.

It is understood that general health considerations, physical and mental, likewise could influence the indication for a conversion.

A period of six months or longer of observation is rather imperative before the operation is undertaken, best under estrogen therapy, in order to reduce the emotional intensity. Hamburger and his associates [5] made the same suggestions and I found such an observation period invaluable to learn more about the patient's problem personality.


Contraindications are self-revealing when evaluating the indications but further objections are raised against the operation which deserve consideration. These objections can be psychiatric, psychological, philosophical, medical, moral, or plainly emotional. An active psychotic state may certainly give pause and may require at least a postponement of any surgical procedure. Psychotic reactions may or may not be the result of long-continued and often intense frustration. They may not respond sufficiently to estrogen and other conservative treatments. It is therefore always possible that psychotic symptoms or a condition actually appearing to be a psychosis (for instance, a "schizophrenic reaction") will improve after the operation.

Psychologists, and especially psychoanalysts, have emphasized that the basic conflict of the transsexual is fear of the opposite sex, which cannot be resolved by any operation. Under analytic probing, such a fear may indeed be found to persist after surgery without, however, disturbing the patient's life. Some further feminization wishes and fantasies may occupy the minds of these patients after the operation but they are not always verbalized and a realistic outlook usually gains the upper hand, especially with the help of some psychological guidance. Cosmetic procedures (breasts, nose, chin, Adam's apple, facial skin), have occasionally followed the conversion. They could be interpreted as motivated by further "feminization cravings."

A rather extreme but actually published objection to the operation by a psychoanalyst was expressed in this hypothetical question to a hypothetical doctor:

"If a patient came to you and wanted you to remove his normal eft eye or his right hand, would you do that, just because he asked you to?"

The illogic of this comparison is evident to an objective oberver. First of all, a patient who comes in with such a request is, on the face of it, acutely psychotic. Transsexuals as such are not psychotic unless one wishes to interpret the gender disharmony as a "partial" or "localized" psychosis, hardly an acceptable diagnosis. Furthermore, the transsexual does not want a useful organ (such as a normal eye or hand) removed, and thereby reduce his efficiency; but he wants a more or less (to him) useless sexual equipment altered so that a more or less useful (to her) equipment will result. Could thoughtless comparisons like this one be due to an unconscious antagonism on the part of the doctor? Or could even a self-protecting mechanism be at work?

There are of course many more psychoanalytic arguments against a conversion operation, especially having to do with the "castration complex," but this would not be the proper place (nor the proper author) to enlarge upon them.

Philosophical objections are probably based to a large extent on the violation of a tabu, that of interfering with the sacredness of man's physical sex. The gravity of this tabu has become more evident only since sex changes have been requested and undertaken in recent years.

The religious objections cannot be analyzed in a predominantly medical and secular text. For the devout, their beliefs are paramount. As such, they defy all argumentation. Objections, even from the side of the doctors, are sometimes made so passionately that they betray the high emotional potential that accompanies the violation of a tabu as well as that of cherished prejudices. ( See page 62, Chapter 4)

Medically, or rather endocrinologically, we are reminded that no "female" can ever result from the operation but merely a castrated (or mutilated) male, with artificially created sex organs resembling those of a female and, if successfully created, allowing normal peno-vaginal sex relations. These comments and explanations are naturally correct. Patients are always made aware of them but I have yet to find a transsexual who would be deterred from his goal by these considerations. Their identification with the female is evidently so complete and their psychological (female) gender-feeling so deeply ingrained (imprinted?) that the morphological sex has to yield.

Other emotional objections, based on the general antisexual culture in which we live, cannot be analyzed here in any detail. Sentiment mixes with sentimentality. Particularly the often violent protests by women may have their roots in an idea of personal loss, or the psychoanalytic theory of "penis envy" may be at work unconsciously. Its mere mention may suffice here.

There are, of course, legal implications too, which will be considered in a later chapter.

Four Motives for the Conversion Operation

My clinical impression of the more specific reasons why transsexual men want conversion surgery caused me to identify four principal, fundamental motives within the general picture of sex and gender disorientation.

The first, foremost, and most frequent is the sexual motive. It concerns particularly the younger transsexuals. Their sex drive is not that of a homosexual man but that of a woman who is strongly attracted to normal heterosexual men. In love-making, their male sex organs are in the way and must be altered so that the lover can be accommodated in as normal a manner as possible. A wellfunctioning vagina is therefore indispensable. Marriage with the adoption of children is the goal for most. But not infrequently, promiscuity, prostitutional or nonprostitutional, appears tempting for a period of time. "Let me try out my new toy for a while," one very attractive young "convert" pleaded with me when I pointed out to her the disadvantages and risks of promiscuity and prostitution.

The second motive, always present, but often overshadowed by the sexual, is the gender motive. Especially for the older transsexuals, the urgent need to relieve their gender unhappiness can be powerful and impressive. "Would you want the operation," I frequently asked, "if there could never be a chance for any sex relations with a normal man?" Some hesitated to answer, then said they would have to think it over. Those were the younger ones in whom the sex motive predominated. But others replied unhesitatingly, "Yes." They admitted they might lose something of their future happiness, but the gain would still be much greater than the loss. "I will feel free for the first time in my life," said one forty-year-old, referring to her "imprisonment" in a male body.

The third motive is even more universal. It is the legal motive. The constant fear of discovery, arrest, and prosecution when "dressing" or living as women is a nightmare for many. They want to be women legitimately and have a legal change of their sex status. Alas, red tape, if not personal antagonism of some bureaucrats, is their powerful enemy. The impossibility (in the great majority of cases) of changing name and status (on the birth certificate) while male genitalia are still present, is a strong incentive for surgery. The legal change is somewhat easier afterward, but by no means easy. Red tape is a rather enduring adversary, especially in some states of the Union. (See Chapter 9. )

The fourth motive is a social one and applies only if the transsexual patient happens to have a conspicuous feminine physique, appearance, and manners. It may constantly embarrass him through snickering, pointed remarks, and knowing looks. It has even endangered some of them through physical attacks by moronic, would-be "he-men," sometimes undoubtedly latent homosexuals who were "protesting too much." The appearance of the very feminine-looking young man could also be a serious handicap in procuring a job.

"I hated to go out with my son," a mother once remarked to me. "He embarrassed me no end by his looks. Now he made the change and lives and works as a girl (waiting and hoping for the operation). Now I am proud of my new and attractive 'daughter.' A former nasty remark from someone is now - if anything a wolf whistle. I love to be seen with her."

From personal observation, I could certainly verify the attractiveness of this otherwise completely inconspicuous "young lady."

In many patients, all four motives, especially the first three, play a part, merging and overlapping according to individual traits and circumstances.

Procuring the Operation

It seems almost unbelievable that in the United States, with all its resources and abundance of surgical talent, the operation is not available for a TS patient, at least not legitimately, in spite of valid indication and psychiatric recommendation. He has to leave the country and go to Europe, Africa, or Asia to find surgical help.

Nevertheless, a breakthrough in attitude, although not in performance, occurred during the summer of 1964. Dr. J. B. de C. M. Saunders, the chancellor of the University of California in San Francisco, issued a rather startling, courageous statement in response to inquiries from the press, relative to sex change operations.

While largely describing the corrective surgery in hermaphroditic conditions, he also spoke of transsexualism where

. . . the normal, firm establishment of gender role has failed to occur. Psychiatric treatment rarely if ever has helped transsexual patients to accept a male role in life. A small number of male transsexual patients are knows to have been provided with treatment, facilitating their lives as women - the techniques involved are similar to those used in correcting physical anomalies of sex, hormone therapy and extensive surgical alterations, together with continuing psychiatric support. Although favorable results have been obtained in terms of mental health and social adequacy, these measures are undertaken with reluctance in transsexual patients. They have been advocated only as a course to be embarked upon when there is no other means of salvaging the patient. . . . Among such patients provided with endocrine, surgical, and psychiatric therapy in the United States, three have been treated at the San Francisco Medical Center, all within the past decade. In each instance, expert consultants concluded after prolonged study that no alternative course of treatment would suffice, and that the patient (already living as a female) could never adapt to a male role. . . . Such patients are extremely rare, and are not to be confused with homosexuals or the great majority of transvestites seen by psychiatrists. However, long-term study of the three patients treated here, and of those treated elsewhere, may provide a useful approach in the efforts of medical science to understand the many remaining questions about normal and abnormal sexual differentiation.[6]

I have quoted at such length from this official document issued by one of the foremost universities in the country, because it is the first of its kind. While, to the best of my knowledge, no transsexual patients are being accepted by the Medical Center of the University of California for surgery, I feel the first step has been taken to help these patients and, at the same time, provide the opportunity for further studies. A change in attitude always has to precede a change in policy.

Another startling development along the line of progress occurred in Baltimore in January, 1965. According to newspaper reports (verified through personal information), a judge issued a court order to have a sex change operation performed on a seventeen-year-old transsexual boy, relieving a surgeon of responsibility. This followed the repeated delinquency of the boy (who stole wigs for personal use). An application by the parents and by the probation officer as well as the endorsement of an outstanding psychologist at Johns Hopkins University had brought the case to court.

Reports of isolated cases that were operated upon in Europe appear from time to time in the medical and lay press. Recently one came from Russia under the heading: "Sex Change in Moscow." "Soviet physicians have changed the sex of a twenty-seven-year-old male by surgery and hormone treatments. . . ." "The operation was reported in papers read at a recent Academy of Medical Sciences conference in Leningrad." The newspaper said a photograph of a mustachioed male taken before the operation was shown together with a postoperative picture of a smiling woman. The story said the man's mustache and beard disappeared after the operation and hormone treatment and the facial oval, skin, figure, eyes, and walk also changed.[7]

It is not too difficult to visualize a possible future when extended scientific investigation might show that transsexual patients in the end - say after twenty years' observation - had not been materially benefited by the surgical alteration of their genitals. In such case, the operation would fall into disrepute and would be largely abandoned.

If, on the other hand, a prolonged observation period should reveal the patients operated upon to be - at least in the majority - happier and better adjusted persons in the role of the opposite sex, that is to say, in the case of men living reasonably normal lives as women, then the conversion operation would emerge from the medical doghouse and become "respectable" as an accepted procedure. Some surgeons may actually specialize in such surgery and develop techniques compared to which the present ones may appear crude. All observations so far (as will be shown in the following chapter) point to the likelihood of this latter eventuality.

Older surgeons and physicians in my own age bracket will readily remember the history of plastic surgery.

Fifty years ago, when I was a medical student in Germany, plastic surgery began to shape noses and perform face-lifting operations for cosmetic purposes. I remember a surgeon in Berlin who specialized in nose operations. His name was Joseph and he was referred to as the "Nasen Joseph" (Nose Joseph). He was bitterly criticized for what he did. Surgeons such as he were refused membership in medical societies and were branded as quacks by some of their particularly orthodox collegues. And then, sex was not even involved.

A sex change operation will naturally make emotions run much higher, not only on account of the aforementioned tabu but also because procreation is prevented. It is difficult to reconcile this argument with the only too well justified fear of overpopulation. The following chapter will provide a brief survey of my own observations during the past thirteen years with patients who have undergone a surgical alteration of their (male) sex organs.

They are only a relatively small number (51), not enough to allow final conclusions. More case histories over a longer period of time should be reported, especially by different observers. That may take time as there is still much hesitation on the part of the doctors and medical editors to publish data dealing with such a controversial subject.


[1] "Testicular feminization" has been described repeatedly and is a well known though rare abnormality. It is a combination of a genetic male sex with testes or a testicular tumor that produces an undue amount of estrogen. The patients, therefore, appear to be normal women externally, with rudimentary sex organs internally. That differentiates them from male transsexuals. See Caffrey and Fitzlen, "The Problem of Intersex," J.A.M.A., Vol. 192, No. 7, May 17, 1965, pp. 641, 642.

[2] See Part 2 of this chapter.

[3] Masters, W. H., "The Sexual Response Cycle of the Human Female, II. Vaginal Lubrication," Annals N.Y. Academy Science, Vol. 83, 1959, pp. 301-317; Masters, W. H., and Johnson, V. E., "The Physiology of Vaginal Reproductive Function," West. J. Surgery, Obstetrics, Gynecology, Vol. 69, 1961, pp. 105-120.

[4] Sexology Magazine, December 1963. Dr. Benjamin is a prominent N.Y. endocrinologist and specialist in sexology. He was consulting endocrinologist of the College of the City of New York and has contributed to numerous scientific and medical journals.

[5] J.A.M.A., Vol. 152, May 30, 1953, pp. 391-396.

[6] Quoted from the release of August 6, 1964, from the office of public information of the University of California Medical Center.

[7] New York Herald-Tribune, December 10, 1964.

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