At that time, he was able to say (using the old system of genderizing a person by birth sex):
“My observation of transsexual patients dates back more than sixteen years. Their total number now stands at 439: 387 males, 52 females”.
On the issue of etiology, he said:
“I am in full agreement with those who believe in a multiplicity of determinants for cross-gender identity, be it in the field of psychology or biology. To my clinical sense, however, a prenatal, neuro-endocrine disorder appeals most for the majority of cases. It offers to me the most likely explanation why psychotherapy cannot cure the transsexual, why the emotional distress goes to such depths as to demand surgery, and why endocrine therapy often brings such dramatic relief. This relief, however, is palliative only. None of our present therapeutic efforts are curative in a sense that the psychological sex will be brought to conform with the anatomical. Until the future can provide new psychiatric or chemical weapons, symptomatic treatment with more or less effective alleviation is all we can offer at present to these often tormented people.
“In spite of poor prognosis, I feel that an attempt should always be made, with the help of psychotherapy in whatever form, to induce the patient to accept himself (or herself) in the role of his anatomical sex. Usually the patient will resist all such attempts because they ‘go against the grain of the inner self’.”
He then mentions use of the anti-epilepsy drug Dilantin based on findings by Swedish sexologist Jan Wälinder who had found an abnormal EEG in “28% of a group of transvestites and transsexuals”. Wälinder gave an anti-convulsant drug to in a patient who had developed “transvestitic and transsexual tendencies” together with epileptic seizures after a brain injury, with the result that the obsessive desire to dress was abolished. Benjamin tried Dilantin with a few transvestites who wanted to be cured, and to two transsexuals who were willing to experiment. This apparently worked for some of the transvestites who desisted [for a while at least] but it had no effect on the transsexuals.
Benjamin does not mention this, but Lyn Raskin, who published a rather racy Diary of a Transsexual a few years later, was given a prescription of Dilantin by a deceitful doctor – and it had no effect at all on her yearning to be a woman.
Benjamin continued by noting that there are three types of relief for a ‘male transsexual’: dressing, endocrine therapy and surgery.
“But neither dressing nor hormone therapy can be depended upon to accomplish enough for the true transsexual. It can allay but rarely replace the demand for the third alternative, which is sex-reassignment surgery. It is hardly necessary to emphasize its radical, irrevocable and controversial nature. Its pros and cons can tax the physician's conscience to the utmost.”
He admits to two nightmares: 1) self-mutilation or suicide when transgender surgery is denied or otherwise unavailable 2) post operative regret. Both had occurred. On regret:
“Actually, there was hardly ever admission to that effect, but that means little. It would be difficult to admit to such a mistake. In possibly 4 to 5% of the operated male transsexuals (and in one female), I have a lingering suspicion that there is a degree of remorse and they would undo what was done, if it were possible.”
He suggests that psychiatric evaluation with a “prolonged period of observation, up to a year”. He continues:
“Alas, such is more often a pious wish than a clinical reality. Too often, transsexuals make their own decisions, find their surgeon and, under the driving and blinding force of their sex and gender confusion, act without anyone's consent or recommendation.”
He criticizes the lack of support by doctors:
“Among them are puritanical and other prejudices, politics, a too dogmatic adherence to psychoanalytic theories”.
He also criticizes:
“The selfishness, unreliability and questionable ethical concepts of some male and female transsexuals have undoubtedly deprived many of them of the otherwise fully deserved interest and sympathy on the part of the medical profession. Fortunately, there are also those whose touching gratitude and loyalty make up for the deplorable defects of the others.”
He mentions a scare in 1968 when the British Medical Journal reported the cases of two transsexuals who had conversion operations, had also received breast implants and unknown but probably large doses of estrogen by various methods of administration. Both died of breast cancer. This was publicized by the New York Times. However Benjamin was able to report from his own files:
“Among more than 300 patients under estrogen medication, not a single case of malignancy was observed in sixteen years. Common sense must tell us that, since a small number of the male population does develop breast cancer, a male transsexual, treated or not, may well be among them.”
He regrets to inform us that although the number of post-operative transsexuals in New York State had significantly increased, applications for legal change of status continued to be denied on the grounds that “the ‘chromosomal male’ is more important than an ‘ostensible female’."
In conclusion he says:
“Transsexuals can be diagnosed by their life's history, showing cross-gender identity from earliest childhood on, by their pronounced emotional rejection of their genitalia and their secondary sex characters, and also by their insistence upon a surgical transformation.
Transsexuals, as a rule, are definitely not psychotic, but often show mental peculiarities aside from their sex and gender role disharmony, peculiarities that can contain neurotic, depressive, paranoid, schizoid, or merely sociopathic and eccentric features. Asexuality is by no means rare. There can also be an unfortunate character defect which I have come to think of as the "transsexual character."
Gender role disorientation has been observed in several schizophrenics.
Transsexuals are deeply disturbed, unhappy people who deserve more sympathy and attention than they have so far received.
Psychotherapy in presently available forms is without value.
Endocrine therapy is usually of sufficiently great benefit as to be indispensable. Oral medication is adequate for the majority of patients, although injections are more effective.
Liver function tests are advisable from time to time under estrogen therapy, especially if there is a history of hepatitis. Thrombophlebitis is a contraindication for large doses.
Sex reassignment surgery is requested by almost all true transsexuals. It is fully indicated in some, and not indicated in others (as too much of a gamble). Patients' families have to be earnestly considered. It is just as wrong to reject the operation as a matter of principle as it is to grant surgery for everyone who wants it and can pay for it. Sometimes, however, the question arises what may be the lesser evil.
The results of the operation are favorable, to a greater or lesser degree, in more than 75% of the patients that I have observed. Their lives have been made more contented, although by no means free from emotional and social problems and complaints. After all, they are still the same individuals, yet sufficiently improved in their ad-justment to life and less troubled so that they have a better chance to be productive and to pursue happiness.”
Benjamin’s paper was printed in The Journal of Sex Research, 5,2, May 1969.
- Jan Wälinder. Transsexualism: a study of forty-three cases. Goteborg Akademiforlaget, 1967.
- W St C Symmers. “Carcinoma of Breast in Trans-sexual Individuals after Surgical and Hormonal Interference with the Primary and Secondary Sex Characteristics”. British Medical Journal, 2, 1968: 83-85.
- New York Times, April 11, 1968.
- Lyn Raskin. Diary of a Transsexual. The Olympia Press, 1971: 38.