A rereading of Benjamin: Part 3: trans women

• Harry Benjamin. The Transsexual Phenomenon. Julian Press, 1966. Warner Books Edition 1977, with a bibliography and appendix by Richard Green.  PDF (with different pagination).  Page references eg p32/13 mean p32 in the 1977 Warner edition and p13 in the PDF. 

Part I:  intro and the Scale
Betty (?1938 - ?) female impersonator, salesgirl, model. --- 2nd entry, Appendix D, autobiographies
Part II:  transvestites
Clara Miller (1899 - ?) fur merchant, office worker ---  3rd entry, Appendix D, autobiographies
Part III: trans women
Joe (1920 - ?) cattle breader, art dealer ---  4th entry, Appendix D, autobiographies
Part IV: photos, legal, trans men, conclusions
Comments

4. The Male Transsexual

The first problem is of course the title. In the 1960s all doctors referred to trans women as ‘male transsexuals’. Ray Blanchard still does. It does grate.

The quotes that one finds from Benjamin that are positive about trans persons are taken from later chapters. What is a surprise is how negative this one chapter is.

From the first four paragraphs:
“Readers of the foregoing chapters already should be fairly well acquainted with the (transsexual) man who wants not only to appear as a woman by dressing as one, but who actually wants to be a woman in appearance as well as function and wants medical science to make him such as far as that is possible. In other words, it is the man who suffers from a reversed gender role and false gender orientation. He wants to change sex. As we have seen, these persons, in a strictly scientific sense, fool themselves. No actual change of sex is ever possible. … If a chromosomal study should be made, however, the true (chromosomal) sex would be discovered and this remains true no matter how long the person may have lived as a member of the opposite sex or what operations or hormone treatments may have been applied.” p65-6/30

A trans woman is a “man who suffers from a reversed gender role and false gender orientation ... these persons ... fool themselves. No actual change of sex is ever possible”.

Remember that this is our premier advocate. It is also the same doctor who wrote Chapter 1, wherein he explained that chromosomes alone do not constitute sex. It is also in contradiction with the subtitle on the cover of the Warner paperback: “All the facts about changing of sex through hormones and surgery.” If Benjamin actually thinks that “No actual change of sex is ever possible” Then what is this book?

In the dedication, Benjamin thanked Brooking Tatum for editing the book. Perhaps Tatum should have pointed out these contradictions.

The transsexual in life and love. “There is hardly a person so constantly unhappy (before sex change) as the transsexual. Only for short periods of his (or her) life, such as those rare moments of hope when a conversion operation seems attainable or when, successfully assuming the identity of a woman in name, dress, and social acceptance, is he able to forget his misery. It is not always the frustrated, passionate sexuality, but more so the heart-breaking anguish of the transsexual's gender disharmony that makes him forever a candidate for self-mutilation, suicide, or its attempt. The false relief obtained from alcohol and drugs is not an infrequent complication.” p66/30

There is actually much in this chapter that would be of use to anyone writing a rant against transsexuals. It is noteworthy that Janice Raymond did not actually use this material.

Benjamin then discusses a small number of his patients who resorted to self-mutilation, and then a patient, Juana, who committed suicide at age 30 in 1963.

Psychological state and sex life in transsexuals. Benjamin discusses the rationalizations of transsexuals who still have sex with their wives. He then discusses those who have a boyfriend/husband. “The ‘husband’ in such a union offers an interesting psychological study. Are there actual or latent homosexual inclinations in him so that he can be attracted to a transsexual man? Naturally, the attraction is to the ‘woman’ in this man, but could completely normal, heterosexual men be able to forget the presence of male sex organs, or, if an operation has been performed, even their former existence?” p70/32 More recent studies have established quite well that the husbands (no quotes) of trans women are in fact mainly heterosexual. They may appreciate some extra aspect of their wife, but they are not interested in men. However this was not understood in 1966.

He then discusses those transsexuals, before and after the ‘conversion operation’ who make a living as a prostitute – the topic of his 1964 book – although only briefly, and with no mention of those like Patricia Morgan who did so successfully.

And then, this paragraph, which many would read as a gratuitous calumny against his clientele:

“It has happened in a few cases that all of a sudden, money became available to go abroad (and come back a broad, as somebody quipped) without any evident source. Being aware of the overwhelming, desperate urge of the transsexual to be made ‘female,’ doubts have sometimes crept into my mind whether funds were not acquired illegally, other than by prostitution. A parallel to the crimes committed by equally desperate drug addicts readily comes to one's mind.” p71/32

If one is to make comments like this about a group of people, it is a reasonable rejoinder that one should either put up or shut up. How about some examples where this has actually happened. A short paragraph like this without details is gossip at best and should not be in a serious book. This is not to deny that a small percentage of trans women are criminals – about the same percentage as the general population.

And then a quote from Dr Ira Pauly: “"Because of his isolation, the transsexual has not developed interpersonal skills, and frequently presents the picture of a schizoid or inadequate personality.” p71-2/33

Bemjamin then finishes the section by reassuring us: “Improvement of the mental condition occurred under estrogen treatment as well as after the corrective surgery, but by no means in all cases. Much is yet to be observed and studied along these lines. As a general rule, however, transsexuals are nonpsychotic.” p72/33 Just as well that he says that, for I was beginning to worry about transsexuals.

The physical state of male transsexuals. “The physical examination of transsexual patients usually reveals nothing remarkable. …. Among my patients I discovered no so-called Klinefelter syndrome ..., although such combination of transsexualism and Klinefelter syndrome has been observed and reported in the medical literature. Otherwise the transsexual male and female are genetically normal.” p72/33

This is still so. Every now and then a biological marker of transsexualism is claimed – H-Y antigen, BSTc size, etc – but in the longer run, replication tests fail, and the claim is dropped.

Benjmain’s hope of a future (post 1966) development was with hypogonadism: “Such more or less distinct underdevelopment, known as hypogonadism, but rarely to the point of eunuchoidism, was found in 61 cases out of a total of 152 male transsexuals, approximately 40 per cent. These findings may eventually prove to have significance as far as the underlying causes of transsexualism are concerned.” p73/33

The transsexual’s plight. This section is mainly about the lack of access to transgender surgery in the US. I took this to refer to the period between 1962 when Elmer Belt ceased operating, and 1966 when operations started at John Hopkins Hospital in Baltimore. In this period, and also before, most US transsexuals who did obtain surgery had to go to Europe or Africa to get it. In particular, many went to Dr Burou in Casablanca.

“The greatest plight of any true male transsexual is the problem of where to turn to have the conversion operation performed. Even if they find a surgeon who is willing and competent to do the operation (and there are undoubtedly many urological surgeons in this category in the United States), the problem is by no means solved. A hospital is needed for this operation and hospitals have their boards. These boards are partly composed of laymen; among them may be priests, ministers, and rabbis. Without the board's permission, the operation could not be performed in that particular hospital.” p74/34

Six pages are then devoted to a reprint from Sex & Censorship Magazine, 1, 2, apparently 1958, but Benjamin does not say. So this is actually referring to the late 1950s. The article, “The Unfree’ is by William J O’Connell, apparently the previous male name of a trans woman: “The happiness I chose to pursue - had to pursue, more precisely - was simply and shockingly, an operation to change my ostensible sex; for I am a person, physically male, whose mind and heart are feminine. … My decision was made in the clear perception that my life was quite intolerable in its falseness. After some hard, realistic thinking, I went to a sexologist, a man wise in the ways of glands and their secretions. He received me with kindness and understanding, and sent me to a psychiatrist who confirmed his judgment that I was of sound mind and quite competent to decide where my happiness lay. Then he carefully began the process of feminization by the administration of estrogen and other female hormones.” A surgeon was found in the US. “The surgeon, skilled and courteous, was not to be rushed; it was necessary that he be certain in his own conscience that what he was doing was best for me. I could not doubt that this great gentleman, like the sexologist, truly intended, in the words of Hippocrates, to govern his treatment by the needs of the sufferer. To make assurance doubly sure, he sent me to another psychiatrist who, in turn, convened a panel of his brethren. After many hours of discussion and questioning and study, these three psychiatrists unanimously recommended the operation, adding that they were powerless to alter my feminine psyche and that the surgeon would be doing me a great service by operating. Even then the surgeon was not wholly convinced and there were further discussions with him before he at length consented.” O’Connell was admitted to the hospital, but days go by. “Finally a member of the all-important Tissue Committee appeared: the Committee, because of protest from the ‘religious elements’ of the hospital, were to review my case. But my visitor, although he was perhaps to present my side of the matter to his colleagues, seemed much more interested in talking than in listening; I think his mind was made up, and I think that neither justice nor ‘the needs of the sufferer’ found any room there. The Tissue Committee refused to permit the operation. They did not ask me to present my case; indeed, it was quite obvious (as I was told by one of the doctors) that they did not consider me at all but only considered placating the ‘religious elements’." p74-80/34-6

However: “For all that, they did not hesitate to charge me two hundred of the dollars I had so laboriously saved for the operation - two hundred dollars for discomfort and profound disrespect. No other hospital, now, would accept me after this one had turned me out; in any case, my short vacation was gone for another year.”  According to this Inflation Calculator, $200 in 1964 would be $1,540 in 2016.

Benjamin adds a note that “this patient, after another year or so, did find a skillful surgeon abroad. The operation was successful as I was able to convince myself. This is a more contented person now.” p81/37  However he never gives us a female name by which to refer to her.


Three different types of transsexuals.

Type IV Nonsurgical. Benjamin’s associate Virginia Prince would declare herself in 1968 to be living full-time as female, in effect a non-surgical transsexual, but apparently never accepted this label. However this was after Benjamin’s book came out and thus is not mentioned. The androphilic non-surgical trans women whom I mentioned in Part I of this rereading such as Holly Woodlawn were not yet famous in 1966. However Benjamin’s associate Louise Lawrence who educated Benjamin about much of the trans scene is an obvious person to mention here. That is what I assumed Type IV Nonsurgical to be.

However Benjamin’s actual description is: “’Dresses’ as often as possible with insufficient relief of his gender discomfort. May live as a man or a woman; sometimes alternating.” Let us look again at Benjamin’s description of Type III True Transvestite: “’Dresses’ constantly or as often as possible. May live and be accepted as woman. May ‘dress’ underneath male clothes, if no other chance.” This difference is subtle rather than definite. Surely Type IIIs are sometimes taken to be Type IVs, and vice versa. And the difference of Type IV from Type V and Type VI is not simply surgical, despite the name.

The only example that Benjamin gives is
 “Peter A. (who, however, much prefers to be called Irene). He is a rather well-known musician from Oregon, married for twenty-five years, with a grown-up daughter who knows nothing of her father's hobby. The wife knows and makes the best of it, but does not want to see him ‘dressed,’ except perhaps on occasion of a masquerade ball.” p81/37 Benjamin estimates Irene to be a Kinsey 2 or 3. She has not gone full-time nor committed to surgery “But as things are, he would harm too many people, could not continue in his profession, or preserve his present standard of living.” Apparently, Irene never did transition, or we would be celebrating her as one of the very first trans musicians, earlier than Wendy Carlos or Canary Conn.

Given that Peter/Irene matches Benjamin’s Type IV, where do the full time non-op trans women go?  Benjamin later (see below p115/53) does tell us that he knows a dozen who are living, illegally,as women, although unable to obtain the operation.

Like gay and female transvestites and gynephilic Type VI s they have been erased from Benjamin’s schema.

Type V Moderate Intensity. Ricky V, late fifties, had lived and worked as a woman in a business office for seven years. Ricky had previous married and had two children, by then grown up. Ricky was anxious to have TS surgery but was unable to afford it. Benjamin estimates her to have been a Kinsey 3, but she currently had no sex life. [Remember that Benjamin’s scale decrees that Type V are Kinsey 4-6.]

Type VI High Intensity. Harriet [called Ava in the biographical appendix to the book] was 28 in 1964. Raised in foster homes, he married at 19. “With the help of fantasies, he succeeded in fathering three children”. He twice attempted suicide. Benjamin put Harriet on estrogen, and she stayed in her male job until she had enough money for the operation. Attempts to have the operation in the US failed, and in 1965 she had the operation in Europe. Later she found an older man and became his wife. Benjamin regards Harriet as a Kinsey 4, when a father, and later a 6. [Remember that Benjamin’s scale decrees that Type VI are Kinsey 6 – and some would say that a true Kinsey 6 would never actually be able to father children, no matter what fantasies he invoked.] p83-5/38-9

In the biographical appendix is the story of Betty, a Kinsey 6 from childhood, a female impersonator who was in the US Navy, and had corrective surgery at age 24. I don’t know why she is not mentioned here.

Further handicaps of transsexuals. Benjamin discusses unsympathetic doctors. “But, alas, the failure of psychotherapy to achieve any change in the patient's attitude is fully acknowledged by those who have had any pertinent experience. With a rather unprofessional antagonism, some physicians are known to have hurt these patients psychologically.” And then: “Cross-dressing is a help, but not always and not enough. The law forbids them to ‘dress’ and hold a job as a woman. Yet this would be the most effective form of therapy (together with estrogen) until an operation can be had, provided the demand for it persists.” p86/39   The antagonism to his patients expressed at the beginning of the chapter seems to have been forgotten.

Benjamin tells how he started providing his patients with a letter that could be produced if the patient were arrested – as Hirschfeld had arranged in Berlin in the 1920s. It was rarely required. However one policeman tore it up and threw it in the patient’s face. In other cases it had the hoped-for result. However in one case the patient was convicted for ‘impersonating’ by a District Attorney who then complained to the County Medical Society, who passed it to the Division of Professional Conduct, and Benjamin was politely but firmly asked not to write any such certificates again. p87-8/40 Benjamin does not say what year this happened, but it was probably shorty afterwards that the Johns Hopkins Gender Clinic started issuing identity cards with the Johns Hopkins phone number.

Then Benjamin returns, as at the beginning of the chapter, to negative aspects of transsexuals: “Another handicap for many transsexuals is their character and their behavior. From a so-called ‘character neurosis’ to outspoken hostile, paranoic demands for help from the doctor, all kinds of objectionable traits may exist. Unreliability, deceitfulness, ingratitude, together with an annoying but understandable impatience, have probably ruined their chances for help in more than a few instances. Many transsexuals are utterly self-centered, concerned with their own problems only and unable to consider those of anyone else. A surgeon wrote once to me: ‘Our experience is growing in regard to the fact that most of them (transsexual patients) are willing to do anything on earth before operation, but nothing at all afterwards’." p89/40

But balances this with: “On the other hand, there are also those patients who are touchingly appreciative, grateful, and eager to cooperate. They compensate the doctor for many of his disappointments. Alas, they seem to be in the minority.” p89/40

He gives the tragic case history of Joan. “She was twenty-six when I met her and that was just after she had her conversion operation as well as plastic breast surgery. She was then a strikingly attractive redhead, vivacious, possibly somewhat reckless, making her living as a call girl and cocktail waitress. I lost sight of her for several years. When I saw her again, I was hardly able to recognize her. Her attractiveness was all but gone. She had lost much weight, had aged considerably, and looked sick. She had become a ‘goof ball’ addict and was still in the 'racket.’ One day, she was found dead in her furnished room. There was a vague rumor of suicide but no evidence. The medical examiner's office listed her death as ‘narcotic.’ In all probability, she died from an overdose accidentally administered when she experimented for the first time with an injection.” p90/41

“The great majority of transsexuals, let it not be forgotten, are merely utterly unhappy individuals. Some of them have become misfits through their gender disorientation that neither society, nor the law, nor the medical profession at present understands and acknowledges as an undeserved misfortune.” p90/41

5. The Etiology of Transsexualism

Benjamin considers various explanations: genetic, endocrine, imprinting and childhood conditioning, but finds none of them convincing. He concludes:

"Our genetic and endocrine equipment constitutes either an unresponsive, sterile, or a more or less responsive, that is to say, fertile soil on which the wrong conditioning and a psychic trauma can grow and develop into such a basic conflict that subsequently a deviation like transsexualism can result." p108/50

6. Nonsurgical Management of Transsexualism

The chapter opens with “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.” p110/51

How can he say that after spending two full chapters on transvestism? Possibly this was written before it was decided to include the transvestism chapters. It would seem that Brooking Tatum in his role as editor has failed again.

Therapy in transvestism. “The true transvestite as a rule does not want any treatment. … 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.“ p110/51 On the next page Benjamin describes [remember that this is 1966] a “new and rather outlandish form of therapy”, that is behavior or aversion therapy whereby a subject is given emetics or electric shocks.

(Anticipation of 21^st century trans politics)
The next section. which is easily missed as it is the conclusion to Therapy in Transvestism is quite interesting in that it anticipates how trans politics will evolve in the next half-century. While Benjamin’s scale presents TV-TS as a continuum, this section contains the roots of opinions expressed by Kay Brown or Charlotte Goiar, that there is difference between the ‘addicted’ transvestite who needs bigger fixes, and a true transsexual who is indifferent to the clothes.

“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 ... (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). 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.” p113-4/52-3

Psychological guidance in transsexualism. This section is Benjamin’s classic call for tolerance.

Two years running I posted this quote on IDAHOT. RadicalBitch/Cathryn Platine criticized me for doing so.

“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.” p114-5/53.

Benjamin quotes journalist Walter Alvarez (who did put trans persons in contact with Benjamin, and wrote the introduction to Benjamin & Masters Prostitution and Morality, 1964) in the New York Herald-Tribune, July 1, 1957 as writing in sympathy, although times have so changed that many now would see his words as both patronizing and casually racist: “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. “ p115/53

Benjamin continues: “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.” p115/53

See my comments above on who is or is not a Type IV Nonsurgical Transsexual.

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. … 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.” p116/53

There are still psychotherapists who do not accept this. However 50 years later they have still not divised a better psychotherapy that actually does 'cure’ trans persons. The quote that I have just given still stands as the classic rational for transition.

Estrogen therapy. Benjamin discusses in detail the how and why of estrogen therapy. I assume that most readers of this encyclopedia are well acquainted with this topic, and there is no need for a summary.

7. Conversion Operation

Benjamin discusses in detail the conversion operation. I assume that most readers of this encyclopedia are well acquainted with this topic, and there is no need for a summary.

Bemjamin includes the text of an article he wrote for Sexology Magazine, December 1963, wherein he advises: “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?” p134/ 62 Again he defies the subtitle of the book!

He lists four motives for the conversion operation (p140-2/65-6):

1. Sexual. “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.”
   
2. Gender. “Especially for the older transsexuals, the urgent need to relieve their gender unhappiness can be powerful and impressive”.
   
3. Legal. “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.”
   
4. Social. “applies only if the transsexual patient happens to have a conspicuous feminine physique, appearance, and manners” [while still presenting as male]

8.   51 Male Transsexuals and the Results of Their Operations

Benjamin summarizes:

"By the end of 1964, a total of 249 male transvestites were observed in my offices, either in New York or in San Francisco. Of these, 152 were diagnosed as transsexuals. This figure, however, may actually be higher as some transvestites do not reveal their true intentions during the first few interviews. In some others, an apparent transvestism may gradually seem to progress into transsexualism with or (more likely) without any treatment and patients originally diagnosed as transvestites (of the II or III type in the S.O.S.) are actually transsexuals (V or VI on the S.O.S.). A few of them are among the 51 cases operated upon.

These patients were, in the earlier years, mostly operated upon in Denmark, Holland, or Sweden, and a few in Mexico. Then, Dr. Elmer Belt in California performed a series of such operations. In approximately half of them I could observe the results. Dr. Belt discontinued this type of surgery a few years ago, largely for personal reasons. During the last three or four years, most conversion operations among patients I know were done in Casablanca, Morocco, by a French surgeon, Dr. Georges Burou. Reports have reached me of operations being done occasionally, rather secretly, in the United States, rather freely in Japan, occasionally in Mexico,and a few in Italy. “ p146/68

“The technique employed by the different surgeons undoubtedly varied from time to time and according to the patient, particularly concerning the formation of the vagina. In the majority of the 51 cases of operation in this country, the vaginal canal was lined with skin taken from the thigh, while in all those operated upon in Casablanca the inverted skin of the penis was utilized. In two patients that I know of, a short piece of gut (ileal loop) was removed and used to form the vagina. This technique naturally constitutes a more extensive operation as it involves the opening of the abdominal cavity. In four of my 51 patients, the technique is unknown.” p147/68

So up to this time, it was mainly those operated on in Casablanca by Dr Burou who had the penile inversion method.   Dr Edgerton at Johns Hopkins then adopted and adapted this method.  When he was contacted by Dr Stanly Biber in 1968, this was the method that was recommended.

“The fees reported to me by patients ranged in the majority from $2,000 to $4,000, usually including a three- to four-week stay in the hospital. It was disheartening to some patients to be prepared to pay the reported fee of $2,000 or even $3,000 to a particular surgeon, only to find out when they tried to make a definite appointment that the price had gone up $5oo to $1,ooo in only a few months' time. The surgeon, however, is said to have operated anyhow, allowing the patient credit for the balance of the fee.” p148/69 According to this Inflation Calculator, $2000 in 1964 would be $15,400 in 2016.

Here is the age distribution:
23 in their 20's
14 in their 30's
11 in their 40's
3 in their 50's
p148/69

and occupations:
Office work 10
Salesperson 3
Musician 1
Store proprietor 3
Hairdresser 6
Housewife 5
Stockbroker 1
Show business (acting) 10
Domestic 1
Office manager 1
Prostitute 3
Teaching 2
Practical nurse or companion 2
Photography 1
Retired 1
Unknown 1
p148-9/69

So show business/acting and office work are the most common. Show business would include female impersonation. The later trans stereotype of computer work was of course very rare in 1964. But where are the military? Study after study has shown that trans women are over-represented there, usually as an attempt to deny their destiny. The reprint of Benjamin’s 1953 paper "Transsexualism and transvestism as psychosomatic and somatopsychic syndromes" had been in particular demand by army doctors.

Post-operative follow-ups, at an average of 5-6 years, rated the conversion as follows:
Good 17
Satisfactory 27
Doubtful 5
Unsatisfactory 1
Unknown 1

“Considered unsatisfactory was the case of a "woman" now sixty-four years old, of Latin extraction, operated upon in Europe in 1955 without my consent. She was the only one who expressed regret over the decision to be sex changed. The operation, incidentally, did not include the formation of a vagina. This patient, in his former male role, was reasonably prosperous, having always held a well-paying position in the business world. As a woman, he was never able to make a satisfactory living and was always in financial difficulties, although fully acceptable as a women in appearance and manner. She had insisted on conducting her own mail-order business in which she had no experience. Her command of the Spanish language was hoped to be a great asset. Alas, it did not prove to be so. Her general health had also failed, perhaps owing to psychosomatic influences (lack of a sex life?) and a return to the male status is now being considered and most likely advisable. In this case, the sex motive had probably played an equal part with the gender and legal motives when the operation was decided upon at the age of fifty-six. Emotional frustration, however, compounded by economic failure and the aging process, probably led to the present unsatisfactory state which, as may be hoped, can be improved under a new life pattern. Here, the outcome of his venture into the female world was considered unsatisfactory by the patient himself. Such self assessment, I feel, is necessary to justify an unfavorable diagnosis. I found no other similar example among the 51 patients.“ p151-2/71

Three of the 51 had already died by 1964.

• “One was successfully married as a woman for six years, a house wife and clubwoman, a charming, intelligent lady who succumbed to a fatal heart attack at the age of 50.” p152/71
  
• Joan, mentioned above, who died a narcotic death.
  
• “The third died in her 51st year. Her "sex change" dated back to 1954 when she was operated upon in Holland but without the formation of a vagina. This was first attempted later in the same year in the United States, but unsuccessfully. The vagina was reconstructed in the United States in 1958 but a vaginorectal fistula developed. It was repaired successfully the following year. In the meantime, the patient had lived in reasonable comfort as a woman, held a clerical position with a large business concern for ten years, and was fully accepted as a woman. She enjoyed several "sex affairs" after the final operation on her vagina. The patient died late in 1964 of a complication of illnesses requiring repeated operations. Several large liver cysts were removed. (There was a history of hepatitis in the late forties.) Part of a benign pancreatic tumor was excised. Later a "dormant" carcinoma of the pancreas was discovered. She was also operated upon for stomach ulcers, developed diabetes and hypertension, but the immediate cause of death was a pulmonary embolism.” p151-2/71

An example of success.

“Jonathan, usually called Johnny, was twenty-four years old when I saw him first. He was a miserable, unhappy young man of rather short stature, slightly overweight and moderately underdeveloped sexually, a transsexual of the VI type in the S.O.S. He worked in a restaurant as a checker. One of the headwaiters was homosexual and gave our patient a bad time with his unwanted propositions. While Johnny was attracted to men, he disliked homosexuals. ‘They want another man,’ he said, ‘but I feel I am a girl.’ Finally Johnny had saved enough money, his family was understanding, and a psychiatrist to whom I had sent him definitely recommended surgery. One year later, he went to Europe (in 1955) and, in those earlier years, had only a castration and penectomy done. An American surgeon, two years later, fashioned a well-functioning vagina. Then Johnny (now Joanna), met a man a few years older than he (now she) when she was working as a receptionist in a dentist's office. He was and still is a reasonably successful salesman. He fell in love with Joanna and married her. He knows only that Joanna as a child had to undergo an operation which prevented her from ever menstruating or having children. They have had a distinctly happy marriage now for seven years. Joanna no longer works but keeps house and they lead the lives of normal, middleclass people. To compare the Johnny I knew with Joanna of today is like comparing a dreary day of rain and mist with a beautiful spring morning or a funeral march with a victory song. The old life in the original (male) sex is all but forgotten and is actually unpleasant to be recalled.” p153/72

The male transsexual's life after conversion.

“The sex life is less essential or altogether immaterial if the gender motive was the driving force for the operation. Of these 51 patients, twelve married as women. Also, twelve were married previously as men. Five have experienced married life from both sex angles (as a male, unsuccessful, some not even consummated); five were divorced [3] as females and three remarried one or more times. Of the 39 unmarried, twenty-three reported sex relations. Of these, nine are part or full-time prostitutes, at least at this time of writing. The unfortunate fact that a number of patients went into prostitutional activities right after their operations has turned some doctors against its acceptance as a legitimate therapy.” p159/74

The medical literature on the conversion operation.

This section includes two pages by Leo Wollman which we have already quoted. And also quotes from Ira Pauly and Per Anchersen, that support what Benjamin has been saying in this chapter. Anchersen was a Norwegian doctor well known for his work with transsexuals in the 1960s, but now almost completely forgotten. He has no entry in Wikipedia at all, not even in NO.Wikipedia.

Conclusions: “My observations have forced upon me the conclusion that most patients operated upon, no matter how disturbed they still may be, are better off afterward than they were before: some subjectively, some objectively, some both ways. I have become convi nced from what I have seen that a miserable, unhappy male transsexual can, with the help of surgery and endocrinology, attain a happier future as a woman. In this way, the individual as well as society can be served. The rejection of the operation and/or treatment as a matter of principle is therefore not justified.” p164-5/77