The Female Transsexual

It is probably very unfair to devote only one chapter in this volume to the female transsexual: unfair because her emotional problem is in every way as serious as that of her male counterpart. However, the frequency of female transsexualism is considerably less than that of the male. While the clinical experiences described in the preceding pages are based on 152 cases of male transsexualism, the female transsexuals here reported number only twenty (by the end of 1964). Even so, sometime in the future she may merit a book devoted to her alone.

• Frequency of female transsexualism
• Symptomatology
• Sex life
• Etiology
• Physical data
• Social position
• Management - treatment
• Surgery
• Results of therapy

Frequency of female transsexualism

The proportion between male and female transsexuals in my series is approximately one to eight. According to the international medical literature, carefully scanned by I. S. Pauly, [1] other investigators have found this proportion: one to three or one to four. I myself in a previous publication found the proportion in my own practice at that time to be one to six.

All these figures, however, are of little value as they merely indicate the accidental frequency with which these patients appeared in a particular doctor's office. More significant is the figure of one to three that Dr. Christian Hamburger gives and that was arrived at from letters he received after the world-wide publicity of the Jorgensen case.

Hamburger reported [2] on 756 letters written by 465 patients. There were "three times as many men as women desiring the change of sex." Hamburger believes the reason for the one to three proportion "may be biological in nature"; he continues: "a contributing factor may also be that the case we reported involved a change from man into woman."

While this particular publicity dealt indeed with the case of a male transsexual, the female patients who wanted to be males may have been equally awakened to the possibility of a sex change, thanks to modern medical advances described in newspaper and magazine articles of thirteen years ago.

If a female transsexual, after having been changed into a male, should receive the same publicity as Christine Jorgensen, it is possible that a greater number of female patients might apply for treatment. How many of them might do so merely as a passing mood, and would then not be acceptable for treatment, is conjectural.

It is interesting to mention in this connection that in our culture about twelve times more women would have liked to have been born as men than vice versa. They said so when they were questioned in a Gallup-type poll. These were normal women, normal in their sex and gender identification. Among them may quite naturally be a very small and statistically insignificant number of female transsexuals.

With this statistic in mind, it may appear puzzling that transsexual women are so much rarer than transsexual men. The more intimate, maternal relationship, however (with its exposure to the mother's female hormones during the nine months of gestation), may offer a possible explanation. (Hamburger's "biological" reason?)

In this connection, the lesser frequency of female homosexual behavior as compared to male deserves to be mentioned again. According to the Kinsey et al. studies, there are about 50 per cent fewer female than male homosexuals and only about 30 per cent reporting overt homosexual activities. Dr. Wardell Pomeroy, [3] coauthor of the "Kinsey Reports," adds the further observation that probably only one eighth as many females as males appear to the public to be "obviously" homosexual ("obvious" are those ordinarily described as "butch" or "dyke").
  

Symptomatology

The female transsexual has many symptoms in common with the male and much that was said in the previous chapters could apply equally to her.

The female transsexual's conviction that she "was meant to be a man" is as strong as the reverse is in our male patients. She resents her female form, especially the bulging breasts, and frequently binds them with adhesive tape until a plastic surgeon can be found who would reduce the breasts to masculine proportions.

Transsexual women fall deeply in love with normal or homosexual girls, often those of a soft, feminine type. Besides wanting to be lovers, they want to be husbands and fathers.

One of my patients so much desired to be a father that she allowed one particular man to have sex relations with her until he could impregnate her, but this man then had to relinquish all claims on her and on the child. She reared the child, a boy, as a father would and wanted him to consider her his father, although the child, when old enough, was informed of the fact that "father" was really his mother, but his "natural parent." The psychological impact on the child's mind of this confusing situation is worth studying. The persistent demand of this patient to be treated, operated upon, and "made" a man, and her hostile reactions to the refusals by doctors, have brought her several times into mental institutions with the diagnosis of schizophrenic reaction. For patients of this type, Pauly coined the term "paranoia transsexualis," an apt label but naturally only a label. Whether the patient "reacted" with a psychosis to her transsexual problem with its frustrations, or whether the TS problem should be considered part of her psychosis, is still an unsolved question.

This patient, in spite of a short course of androgen treatment, is still in and out of hospitals, and the question whether to allow her (him?) custody of the child is undecided at this writing. Further studies of her case may deserve publication at some later date.

Menstruation constitutes a psychological trauma to the female TS. Its suppression under androgen therapy affords enormous emotional relief. Interests, attitudes, and fantasies take a masculine direction. Typically masculine occupations such as those of soldier, policeman, truck driver, would be their ideal, but only too often they have to be practical and settle for office work. Just like some of their male counterparts, they frequently show much ability in their work, can be highly successful in business or profession, profiting perhaps by the combination of male and female traits in their constitutional makeup and in their psychological development.
  

Sex life

Sexually, female transsexuals can be ardent lovers, wooing their women as men do, but not as lesbians, whom they often dislike intensely. They long for a penis, yet mostly understand realistically that the plastic operation of creating a useful organ would be a complicated, difficult, highly uncertain, and most expensive procedure. Only one of my twenty patients had the operation performed in several stages, but the final result is still questionable. The first surgical attempt, as his doctor explained to me, was ruined because the patient went horseback riding too soon!

I have had extensive correspondence with another intelligent female transsexual whom I never met personally. He described 33 plastic operations, but the male organ, although serviceable, still does not seem fully satisfactory. The technique of creating a penis varies greatly with the various surgeons who have attempted it. The textbook by Gillies and Millard [4] goes into considerable detail. The Russians are said to have more extensive experience with this type of operation than anybody else.

In some instances, a prothesis, an artificial penis made of a plastic material, has been successfully employed. In the United States it is available with difficulty and on a doctor's prescription only. It is easier in Europe, and simpler still in the Orient.

Of the twenty patients, five had been married as women before I ever saw them. These marriages were entered into either in the hope that it might reverse the psychological trend, or under pressure from the family, or to escape family supervision. All these marriages failed, ending in annulment or divorce, or, in one instance, in a reversal of roles with the wife becoming the husband and the former husband becoming the wife. Some were never consummated and were highly unpleasant experiences, probably for both partners. There were four pregnancies in three patients with one abortion, one miscarriage, and one ending in normal birth twice. This person, living as a male (whether married as a male is unknown) now has two children to which "he" is the mother.

The technique of sex relations naturally varies greatly. Petting and kissing are followed by some form of genital caressing. Mutual masturbation by manual stimulation is probably as frequent as oral-genital contact. Most desired and perhaps most frequently practiced is the face-to-face position of an imitation of the heterosexual coitus, the transsexual female on top, rubbing the clitoris against the partner's genital region. This is accomplished by the TS's closed legs between those of the girl, which are spread apart, or by intertwining the legs, known as "dyking."
  

Etiology

Much that has been said on etiological speculation for the male transsexual applies equally to the female, especially as far as conditioning is concerned. Definite conditioning could be proved in only two cases, and not at all in eleven. The remaining seven were considered doubtful.

The relatively large number of only children (five out of twenty) would lead one to think that the parents wanted the child to be a boy, because this is the more frequently desired gender for the first or only child (carrying on the family name, and the like). Accordingly, parents may be tempted to rear the child as a boy, even if it were a girl. But those parents who could be questioned did not confirm this view. One mother especially insisted that she wanted a daughter and never became reconciled to the fact that this daughter, an only child, had made a successful change to a man. The same strong resentment of a mother against having a son in later life, instead of a daughter, was evident in at least three other cases.

Even if conditioning played its part in the development of female transsexualism, the constitutional "predisposition theory" is by no means refuted (see Chapter 5). As one mother told me: "In her earliest years, long before she became a tomboy, I knew there was something wrong with my little girl. She was always so much more like a boy." In such a situation, it would be easy to imagine that parents could be conditioned by their child, rather than the other way around.

In nineteen of the twenty patients, the first evidence of a false gender identification was reported in "early childhood." It is unknown in one case.
  

Physical data

The physical examination of the female transsexual usually reveals a normal girl except that, as in the male, hypogonadism seems to be more frequent than one would expect. Among my twenty patients, it was more or less distinctly evident in nine. There was no sign of hypogonadism in ten, and in one case it is unknown.

The diagnosis of hypogonadism was based largely on the menstrual history, a gynecological examination, and laboratory data. Menstruation had never occurred in one case (primary amenorrhea). It started late (at sixteen or seventeen) in seven cases. At the same time, it was either unusually scanty or irregular or painful.

Gynecologically, a "small uterus" was found in six cases. Skeletal measurements did not reveal abnormalities as often as in the males. No ovarian dysgenesis (Turner syndrome) was seen, but the possibility of this genetic abnormality should not be forgotten if the usual symptoms of infantilism, small stature, and the like exist. (Patients of this type are usually although not always chromatin-negative, that is to say, genetic males. They were, for the most part, reared as girls. They have forty-five instead of forty-six chromosomes with only one X and no Y chromosome (XO).)

One case was that of a female pseudo-hermaphrodite who underwent corrective surgery late in life and had been happily married as a man for five years when he was widowed.

In addition to the gynecological examination, a chromatin study and a hormonal assay, whenever possible, should follow. The latter includes the determination of the 17-ketosteroids, estrogens, F.S.H. (follicle-stimulating hormones of the pituitary) in a twenty-four-hour urine specimen. Routine laboratory work, including liver function tests, should be added as well as vaginal smears for estrogen activity.
  

Social position

The social and education levels were divided into upper, middle, and lower levels. The upper level included those who bad graduated from high school or had some college education. The lower level never finished grade school, and the middle was in between. The social, economic, and cultural position of the family could, however, modify the classification so that a girl with a "middle" education but from a well-to-do or socially prominent family might be classified as "upper level."

Six of the twenty patients thus were upper level, twelve were middle, and only two were lower level.

The following occupations were ascertained:

Naturally there were changes in stated occupations, especially after treatment or operations, and even more so after a legal change of sex status had been accomplished: changes in the pattern of their lives, for instance disposing of female attire, occurred more gradually in the female because the "change" in the male is naturally more abrupt owing to his more visible conversion operation.
  

Management - treatment

The patients who came for consultation and possible treatment were mostly in their twenties (twelve), one in her teens, four in the thirties and three in the forties; 30.3 was the average age as compared to 29.3, the average age of the male transsexual when first seen.

If the patient is underage, the parent's or guardians written consent for treatment must be procured.

The most immediate help to these often very disturbed and deeply unhappy girls is to lend a sympathetic ear to the descriptions of their lives and their ambitions for the future. Ridicule, moralizing, or hostile rejection is as unethical, harmful, and ineffective as it is in the male TS.

Great emotional relief is obtained, if the doctor does not refuse offhand the hormonal (androgen) treatment, and does not try to eliminate the possibility of surgical intervention at some time in the future. If he insists on psychotherapy instead, he may do more harm than good. Mere psychiatric evaluation, however, is usually accepted.

The immediate method of choice as to therapy would then be a series of androgen injections to the point of suppressing menstrual periods and keeping them suppressed with the smallest possible dose. I found Squibb's Delatestryl the best preparation because it is highly potent and slow-absorbing, therefore requiring at most one injection a week; 1 cc. of Delatestryl contains 200 mg. of testosterone. I usually started with ½ cc. (100 mg.) to ¾ cc. (150 mg.) weekly until the first menstruation had been missed and the vaginal smear showed distinctly decreasing cornification (indicating lowered estrogenic activity). How soon this can be accomplished depends upon constitutional factors, but with 500 mg. monthly, menstruation usually ceases after perhaps one more period. As soon as amenorrhea is established, two injections a month of ¾ to 1 cc. each (150-200 mg.) were generally sufficient to preserve this - for the patient - happy state.

The masculinizing side effects of the treatment are likewise helpful for the patient's emotional balance. Very gradually, there may be more hair growth on face and body, a slightly deepening, somewhat husky voice, better physical strength as measured by a hand dynamometer and often a gain in weight which, of course, could be due to water retention. An occasional diuretic or a saltpoor diet is then indicated. It is wise to warn the patient that sometimes facial acne may develop and if severe enough, may require interruption of the treatment. A menstrual period may then promptly reappear. A thinning of scalp hair is a theoretical possibility under androgen medication, although in practice I have never seen it occur.

Sexually, a heightened libido is almost regularly reported and a more or less distinct increase in the size and sensitivity of the clitoris takes place. In some patients, the clitoris grew enough to serve as a small penis.

Whenever the libido seemed to become unduly strong, one may add small doses of progesterone to the testosterone injection, but that again may counteract to some extent the suppressing influence on the menses. It is therefore rarely useful before a hysterectomy has been performed. A tranquilizer by mouth can help.

I have seen little help from oral androgen preparations. Besides, several of them contain methyl testosterone which should certainly not be taken for any length of time as it may be dangerous to the liver.
  

Surgery

A total hysterectomy, including the removal of the ovaries, is often as ardently desired by the female transsexual as the male desires his conversion operation. It is almost as difficult to obtain because surgeons, quite naturally, are reluctant to remove healthy organs.

After a more or less extended period of androgen treatment, a physical state resembling pseudohermaphroditism (enlarged clitoris, body hair, etc.) develops, so that some surgeons at times felt justified in operating, especially if the social status (male) of the patient is already well established. In several instances, the patient was not fortunate enough to find a surgeon in the United States and had to go abroad or to Mexico for the operation.

Of the twenty female transsexuals here reported, nine had a hysterectomy performed. In eight it was total and in one the ovaries were retained. The average age of the nine patients at the time of the operation was 35.5. Four patients were in their twenties, two in their thirties, two in their forties and one in the fifties, at the time of operation. The corresponding average age in male patients was 33.2.

It seems strange that the conversion operation for the female does not, as a rule, include the closing of the vagina. To the best of my knowledge, it was done in only one instance. Such closing would justify the statement later on that the patient, could no longer function as a female, even sexually, and that in turn, should make the legal change of the sex status (for instance, by issuing a new birth certificate or amending the original one) a good deal easier.

A mastectomy, the reduction of the breasts so that they resemble the male, is at least as important to many patients as the genital surgery. It all depends upon how large the breasts are (even after androgen treatment may have caused a shrinkage) and how disturbing the "bulge" is for the patient's particular mode of living and for the sex life. The sex partner's taste in this respect may be a decisive factor. This plastic operation is almost as difficult to obtain in the United States for the female as the hysterectomy. Some surgeons have refused the patient's request until after a hysterectomy and androgen treatment had created a more masculine personality and with it, an acceptable indication.

Mastectomy alone was performed in five of the twenty cases, both mastectomy and hysterectomy also in five cases. Four patients bad a hysterectomy but no mastectomy. Since I have unfortunately lost contact with several patients, it is possible, even probable, that more of them have had either one or the other or both operations performed.

Sixteen of the twenty patients received androgen therapy. The doses of testosterone after ovariectomy can be considerably smaller than before, when menstruation had to be suppressed. Further masculinization post-operatively is advisable for the patient's emotional state. It is also useful to prevent the symptoms of an artificial menopause. Sometimes tablets alone of testosterone propionate are sufficient. Buccal tablets such as Schering's Oreton Propionate are to be preferred. They are not swallowed but put under the tongue or between the cheek and gums, where they are absorbed by the mucuous membrane of the mouth. The use of methyl testosterone tablets is not advisable because, as previously mentioned, their prolonged administration may harm the liver.
  

Results of therapy

Psychotherapy with the purpose of having the patient accept herself as a woman is as useless in female transsexualism as it is in male. Psychotherapy can be helpful only as guidance and to relieve tension, provided there is a permissive attitude on the part of the doctor regarding masculinization. If the patient is of age, not acutely psychotic, and reasonably intelligent, the doctor might best say: "as to masculinization and your future life, you have to make your own decision."

The results of either androgen therapy or operations or both have generally been decidedly satisfactory. With one doubtful exception (to be mentioned later), all patients under my observation (and I know the fates of fifteen of the twenty fairly well) were benefited. They still have problems. There still can be spells of depression (mostly reactive) and more or less distinct neurotic or psychoneurotic traits. They were unhappy, disturbed persons before any treatment and they are not boundlessly happy and free of disturbance afterward. Who is? But they are better off; better able to find a satisfactory niche in life, perhaps in a job or profession as a bachelor or as a married man.

A person born with a congenital hip disease is a cripple. After an operation, he is not orthopedically normal, but he can get around with reasonable ease and comfort. That would be a comparison.

The aforementioned young lady, a student and musician, who seems to have had a doubtful result from her treatment and operations (hysterectomy with the ovaries retained, and mastectomy), was seen about ten years ago. She had been married and divorced, had several years of psychoanalysis, but still wanted to change. After the operation she tried living as a man, then changed her mind and returned to her female role. She even had the shape of her breasts restored by plastic surgery. But she is not unhappy and has no regrets. Her "double sex" may give her a feeling of satisfaction. Unfortunately I have had no opportunity to see her in recent years, but I know from correspondence and from her physician that she feels her therapeutic attempts "basically have worked."

Of the remaining eight patients who underwent hysterectomies, the result in one is unknown. In the other seven, it must be called good, if not excellent.

Six patients are married as men to women. Two married before and four after their operations. There has been no divorce. Two patients experienced marriage both as female and male.

One twenty-six-year-old, disturbed, unhappy girl is now, four years later, a busy, handsome, bearded young man, proud husband of a beautiful wife and father of two legally adopted children.

One confused, unhappy girl, after two disastrous marriages, an attempted suicide, years of futile psychoanalysis is now, seven years later, a man in his early forties, of some importance in the art world, married to a highly intelligent woman and living in an environment where very few of the numerous friends of this couple have any idea of the husband's past.

Still another woman, prominent in society, the sports world, and business, but suffering intensely under her false gender identification, underwent treatment and operation at forty-six. Now, after three years of treatment and after surgery, this handsome, youthful man is married to an attractive woman, continues actively and energetically in more than one business, and is fully accepted as a man by friends and associates, many of whom "don't know."

George (formerly Ann), now forty-three, comes from a different environment. She has had a hard time all her life making a living. An only child, her mother was hostile to the idea that her daughter should follow her desire to become a man. The father was not interested and so George-Ann went her, or rather his, own way, lived as a man as best he could in different jobs, hoping and working for the day when finances would allow him to get rid of the "curse" of the female, the menstrual period, and live the life that he felt was the only one in which he could find peace of mind and a measure of happiness.

The day came when a surgeon with courage and compassion performed a hysterectomy. Androgen treatment had paved the way and is completing the transformation. An infinitely happier person is now looking for the right outlet for his many fine qualities. His chances, I feel, are ever so much better than hers were five years ago.

Bobby, formerly Mary, is a very similar person, even in appearance and manners, although there is no relationship whatever. When first seen ten years ago at the age of thirty-seven, he was living and working as a man. He had been successful in obtaining a complete hysterectomy as well as a mastectomy and his greatest problem was a legal change of sex status. Red tape offered formidable obstacles. After waiting several years, and with the help of various medical certificates, a new birth certificate was finally issued with strikingly good results on the emotional life and his job prospects. Bobby is now reasonably successful as an architect, gets along with people much better than in years past, and his only regret is that his aged mother never became reconciled to the change, although an older sister had readily done so. Bobby has some flair for writing. He is doing his autobiography now, the first one written by a female transsexual for possible publication as a book.

More cases could be related, almost equally satisfying. There are those for whom an operation is not yet attainable, but androgen treatment is at least a partial substitute. A great and deeply disturbing handicap for some is their inability to secure for themselves the legal change of sex status. But there are prospects that conversion operations and treatments will eventually be recognized by the medical profession as accepted therapy for the transsexual state, female as well as male. Legal and administrative processes would then have to follow suit and a way would have to be found to overcome the technical and bureaucratic barriers that now exist in almost every state in the United States. Those few states, however, that have cut through red tape, issued a new birth certificate (probably with retention of the old one in their files) and have therefore helped the patients greatly in their new lives, certainly deserve the highest credit for their logical and humane actions. (See Appendix A, page 165.)
  

Footnotes

[1] Pauly, I. S., Archives General Psychiatry, Vol. 13, August 1965, p. 172.

[2] Hamburger, Christian, "The Desire for Change of Sex as Shown in Personal Letters from 465 Men and Women," Acta Endocrinologica, Vol. 14, 1953, pp. 361-375.

[3] Sexology Magazine, May 1965, p. 653.

[4] Principles and Art of Plastic Surgery, Little, Brown, 1957.