British Medical Journal, 9 April 1966

This two-page summary of the then professional view of transsexuality was published in the British Medical Journal in 1966, just a few months before Harry Benjamin’s The Transsexual Phenomenon was published, ++and three years after Georgina Turtle's Over the Sex Border (which is not mentioned).  This was period of liberal reform in Britain.  In the next few years the ruling Labour Party led by Harold Wilson introduced no-fault divorce, legal abortion, partially decriminalized homosexuality among consenting adults and reduced the voting age to 18.   However nothing was done by legislation for transsexuals, and in Corbett vs Corbett 1971 the legal rights of transsexuals were set back for decades.

Looking back after almost fifty years, there is much that is reasonable, although there are reactionary components especially the referring to trans women as ‘male transsexuals’ – a practice also found in Benjamin’s book.

At the beginning the author regards transvestism as a symptom and not a syndrome like transsexuality.  He then enumerates 3 kinds of transvestism: 1) as a masturbatory ritual associated with erotic excitement 2) a symptom associated with other anomalies such as homosexuality 3) a means of gratification without genital excitation or interest in homosexual behaviour.   He follows Kinsey in that a transvestite may or may not be homosexual.  He quite likely had not then heard of Virginia Prince who was attempting to redefine transvestism as something that was by definition not homosexual.  He would have been aware of the psychoanalysts who regarded transvestism as a fetishistic or masturbatory activity, but rejects their assumption that such is the main form of transvestism.

The statement re transsexuals that “Many experience an intense desire to have their bodies altered so as to take on the appearance of the opposite sex anatomically, and this may be the most prominent feature of the disorder” is of course axiomatic.    However the claim that transsexuality is “more frequently reported in men than in women, the excess varying from 50 to 1 to 3 to 1 according to different estimates” seems to us to be a quaint historical report as subsequent decades brought out more and more trans men.  The next two reported claims that “true transsexualism occurs only in men” and that “that women seeking a surgical change of sex are invariably active and dominant partners in a homosexual relationship” have become totally unviable.

It is sometimes said that it was in reaction to the university gender clinics (and of course the Charring Cross clinic long pre-dated the US clinics) that transsexuals learned what doctors wanted to hear and thus told them that.  This was always an inevitable consequence of psychiatrists setting themselves up as gatekeepers, but it is interesting to see it stated so early.  The wording: “desire for surgery may result in a conscious or unconscious distortion of the account that transsexualists give of their early life and personality development” is quite polite compared to Maxine Petersen and  Michael Bailey’s later assertion that “Most gender patients lie”.

Pre-WWII (see Peter Farrer’s Cross Dressing Between the Wars: Selections from London Life 1923-1933 ) “parental disappointment over the sex of the child” was often taken as a cause of transvestism, and it is disconcerting to see that this folk etiology recycled at a professional meeting in New York as late as 1960.  In rejection of this, it is said that early cross-dressing results from the choice of the child – a coherent word choice that was quite acceptable in 1966.

The influence of psychoanalysis was still strong, and the author uncritically informs us that “The history almost invariably shows an unusually exclusive relationship with the mother and a negative relationship with an absent or abnormal father”, a view almost totally rejected today.  And we can say the same about “Though often described as a good husband, the transsexualist becomes intensely jealous of pregnancy and motherhood in his spouse”.

“The sincerity and conviction with which these people describe their predicament has inclined many physicians who have studied the disorder to regard transsexualism as an inborn tendency, but the men patients show no chromosomal abnormality and in every possible measure are anatomically and physiologically male.”  This was almost 50 years ago.  Despite considerations of hormonal washes and epigenetics, the advances in regard to this question have been rather small in the period since.

”J. Wålinder has also found a high prevalence of electro-encephalographic abnormalities among unselected transvestists.“  Joanne Proctor, in her admiration for Wålinder, said very little about this.  Nor has there been follow-up by neurologists.

“Psychotherapy is at best supportive for these patients, behaviour therapy of unproved value, and the indications for surgical operation often based on opinion rather than facts.   Many transsexual men achieve a real sense of contentment for the first time if, despite the social and administrative problems, they can live and work as a woman. … Some maintain that operation is the most effective means of treatment available, yet the evidence is by no means clear.”   Close, but the author will not simply endorse transgender surgery.  He continues: “A distinct danger is the polymorphously perverse psychopath who succeeds in obtaining a surgical operation during a chameleon-like change. Such individuals may indulge in exhibitionistic publicity, become prostitutes, or engage in litigation against the surgeon”.  The intervening 50 years with its vast increase in the number of persons having transgender surgery have shown  that it is indeed the most effective means of treatment, and the numbers of polymorphously perverse psychopaths have remained a very small percentage.

It is of course unfair to suggest those trans women who turn to prostitution do so because they are ‘polymorphously perverse psychopaths’ rather than that they live in societies that deny them other forms of work.

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Transsexuality.

Any clarification of our incomplete understanding of the anomalies of psychosexual development is to be welcomed. An example is the distinction which can now be made between transvestism as a symptom and the syndrome of transsexuality.^1-3

Transvestism may be defined simply as the propensity to dress in the clothing of the opposite sex. It may be practised as a masturbatory ritual associated with erotic excitement, as a symptom associated with other anomalies such as homosexuality, or often as a means of gratification without genital excitation or interest in homosexual behaviour. Many of these people live as ordinary males and cross-dress in secret or wear feminine undergarments under their regular male clothing. As A. C. Kinsey and colleagues⁴ indicated, transvestism and homosexuality are entirely independent phenomena, and only a small proportion of transvestists are homosexual in their physical relationships.

The transsexualists are a comparatively uncommon group related to the transvestists only in wearing the clothing of the opposite sex. These people wish to become members of the opposite sex and to be recognized and respected as such by others. Many experience an intense desire to have their bodies altered so as to take on the appearance of the opposite sex anatomically, and this may be the most prominent feature of the disorder. Often these unfortunate people hold a strong conviction that their sexual identity is misrepresented by their anatomy as a result of some cruel error of nature.⁵ They may conduct a relentless campaign to have this  "mistake" corrected surgically and are in consequence compelled to seek medical help. Transsexualism is more frequently reported in men than in women, the excess varying from 50 to 1 to 3 to 1 according to different estimates.^{2 6 7} J. H. Schultz⁸ goes further and asserts that true transsexualism occurs only in men, while M. Roth and J. R. B. Ball¹ believe that women seeking a surgical change of sex are invariably active and dominant partners in a homosexual relationship.

This desire for surgery may result in a conscious or unconscious distortion of the account that transsexualists give of their early life and personality development, but some distinct patterns can be identified. Males nearly always had an early preference for the company and activities of girls. Cross-dressing started young, but recent evidence ^{1 9} suggests that this is from choice rather than a reflection of parental disappointment over the sex of the child, as suggested by D. G. Brown.¹⁰ The history almost invariably shows an unusually exclusive relationship with the mother and a negative relationship with an absent or abnormal father.  Some behavioural abnormality is usually evident before the age of 10 years, and up to 15 or so there is a growing conviction of difference. Sex interest tends to be feeble, and masturbation begins late or not at all. Feminine inclinations and interest become more marked, and the transsexual boy, in contrast to the homosexual, is apt to be ill at ease among his fellows and do badly at school despite a relatively good intellect.

By adolescence cross-dressing is usually well established but is devoid of fetishistic meaning, since feminine dress evokes not excitement but a feeling of well-being, serenity, and happiness. When cross-dressing is prevented for any length of time tension, anxiety, and irritability develop.  Despite all this the individual remains capable of heterosexual behaviour and usually expresses distaste for homosexual practices. In one series⁹ 30% were married and in J. B. Randell's⁷ rather heterogeneous group 57% were married. The marriages are frequently unstable and more than half end in divorce or separation. Though often described as a good husband, the transsexualist becomes intensely jealous of pregnancy and motherhood in his spouse, and persistent cross-dressing eventually makes the marital role untenable.

Extreme revulsion for their genitalia and all signs of masculinity often results in persistent importuning for surgical "correction," and in some cases self-castration may be attempted.^2-3 In schizophrenia bizarre self-castration may occur with or without delusional ideas about change of sex, but in the transsexualist there is no other evidence of the schizophrenic process.¹¹

By the time he reaches a hospital clinic the transsexualist has usually adopted feminine garb in public; facial hair is reduced and the testes are small and atrophic owing to self-medication with stilboestrol, which the patient often denies.⁹  Many authors comment on the exceptional intelligence, versatility, and artistic gifts of these patients.^{12 13} Though usually anxious to assert their feminine normality, many of the patients present frank neurotic features. ^1-9 On most psychological tests they show high scores for feminine interest, but their conviction that they have an attractive feminine physique is sometimes in ludicrous contrast to their hirsute muscularity.

The sincerity and conviction with which these people describe their predicament has inclined many physicians who have studied the disorder to regard transsexualism as an inborn tendency, but the men patients show no chromosomal abnormality and in every possible measure are anatomically and physiologically male.¹⁴ However, there is an excess of abnormal sexual behaviour among patients with Klinefelter's syndrome and in association with certain disturbances of brain function.

Cross-dressing and a conviction of sex change may occur in toxic states due to amphetamine,¹⁵ psychosis,¹¹ and temporal-lobe epilepsy. ^16-18 Of particular interest are those cases associated with clearly defined lesions of the temporal lobe, in which normal sexuality was restored after temporal lobectomy.^18-20 J. Wålinder²¹ has also found a high prevalence of electroencephalographic abnormalities among unselected transvestists.

Psychotherapy is at best supportive for these patients,² behaviour therapy of unproved value,²² and the indications for surgical operation often based on opinion rather than facts.  Many transsexual men achieve a real sense of contentment for the first time if, despite the social and administrative problems, they can live and work as a woman. But once this step is taken the patient rarely goes back to his former way of life, and his demands for surgery may become more insistent.  Some authors have reported cases in which castration, with or without other surgical procedures, has been followed by greater emotional stability and improved social effectiveness.^1-3  Some maintain that operation is the most effective  means of treatment available, yet the evidence is by no means clear. Patients have sometimes deteriorated after operation, or have continued to importune for further surgical changes, while others have demanded reversal of the operation and threatened legal action when this was shown to be impossible.^{2 23 24} A distinct danger is the polymorphously perverse psychopath who succeeds in obtaining a surgical operation during a chameleon-like change. Such individuals may indulge in exhibitionistic publicity, become prostitutes, or engage in litigation against the surgeon. The legal status of the converted transsexualist so far as marriage and inheritance is concerned has yet to be tested in the courts. This uncommon but tragic anomaly presents many problems which are unlikely to be resolved until we have more detailed and objective accounts of the complete life history of affected persons.

1. Roth, M., and Ball, J. R. B., in Intersexuality in Vertebrates Including Man, ed. C. N. Armstrong and A. J. Marshail. 1964. London.
2. 'Pauly, I. B., Arch. gen. Psychiat., 1965, 13, 172.
3. 'Benjamin, H., West. J. Surg., 1964, 72, 105.
4. 'Kinsey, A. C., Pomeroy, W. B., and Martin, C. E., Sexual Behaviour in the Human Male, 1948. Philadelphia and London.
5. 'Hamburger, C., Sturup, G. K., and Dahl-Iversen, E., J. Amer. med. Ass., 1953, 152, 391.
6. Kinsey, A. 9., Pomeroy, W. B., Martin, C. E., and Gebhard, P. H.,
   Sexual Behaviour in the Human Female, 1953. Philadelphia and London.
7. Randell, J. B., Brit. med. J., 1959, 2, 1448.
8. Schultz, J. H., in Intersexuality, ed. Claus Overzier, 1963. London and New York.
9. Ball, J. R. B., Transsexualism. M.D. Thesis, University of Newcastle upon Tyne. 1965.
10. Brown, D. G., Childhood Development and Sexual Deviations: Part II, Homosexuality. Paper read at the Annual Meeting of the National Council on Family Relations, New York, August, 1960.
11. Blacker, K. H., and Wong, N., Arch. gen. Psychiat., 1963, 8, 169.
12. Lukianowicz, N., J7. nerv. ment. Dis., 1959, 128, 36.
13. Delay, J., Deniker, P., Lemperiere, T., and Benoit, J. C., Enciphale, 1954, 43, 385.
14. Barr, M. L., and Hobbs, G. E., Lancet, 1954, 1, 1109.
15. Connell, P. H., Amphetamine Psychosis (Maudsley Monograph No. 5), Institute of Psychiatry, 1958. London.
16. Thompson, G. N., J. nerv. ment. Dis., 1955, 121, 374.
17. 17 Davies, B. M., and Morgenstern, F. S., J. Neurol. Neurosurg. Psychiat., 1960, 23, 247.
18. Hunter, R., Logue, V., and McMenemey, W. H., Epilepsia (Amst.) 1963, 4, 60.
19. Mitchell, W., Falconer, M. A., and Hill, D., Lancet, 1954, 2, 626.
20. Hill, D., Pond, D. A., Mitchell, W., and Falconer, M. A., J. ment. Sci., 1957, 103, 18.
21. Wålinder, J., Int. J. Neuropsychiat., 1965, 1, 567.
22. Eysenck, H. J., and Rachman, S., The Causes and Cures of Neurosis, 1965 London.
23. Muhsam, R., 1926, quoted in Asexualisation, by J. Bremer, 1959. Oslo University Press.
24. Hertz, J., Tillinger, K. G., and Westman, A., Acta psychiat. scand., 1961, 37, 283.