Jan Wålinder (1931-2014) psychiatrist, chief physician, sex change doctor

Jan Wålinder, the son of a civil engineer, was raised in Eskilstuna, 100 km west of Stockholm. He studied medicine at Uppsala University from 1952, and was licensed as a doctor in 1958. He spent a year at the Maudsley Hospital in London, 1961-2. In 1964, his boss, Hans Forssman, became a professor at the University of Gothenburg and chief physician at Sankt Jörgen Hospital in Gothenburg; Wålinder transferred with him.

From 1962–1974, 92 patients were referred to the University clinic, Sankt Jörgens hospital, for evaluation as transsexuals. Wålinder became the doctor leading the program. Fifty-two of these were considered transsexual and accepted for a sex reassignment program.

Wålinder published a first paper on occasional derivation of transvestism/transsexualism from cerebral dysfunction in 1965. 

He wrote his dissertation in 1967, based on the patients in the program and a review of the then published literature. 

He adhered to the then convention of using birth sex rather than gender identity – thus trans women are ‘male’ and ‘he’, and trans men are ‘female’ and ‘she’. Like many others, he incorrectly claimed that Hirschfeld had coined the term ‘transvestism’.

He analysed 207 cases that he found in the existing literature – 185 ‘males’ and 22 ‘females’. He found 70% had cross-gender behavior before the age of 10; that intelligence was distributed along the normal curve for the population; that 10 of the 207 had a family member who also cross-dressed; that 33% had adnormal EEG readings, and five of those also had epilepsy.

In February 1965 Wålinder sent a letter to every psychiatrist (child psychiatrists excluded) in Sweden asking about any trans patients that they had treated:

“Seventy-six per cent, or 361 out of the 474 psychiatrists answered the letter, and together reported 91 cases. Most of them gave detailed descriptions of their cases by letter or on the telephone. A few were unwilling to disclose any details about their patients, and these had to be excluded. Two of the patients were not known for sure to be alive on the census date, and these were also excluded. All patients under 15 were also excluded.

Sixty-seven of the remainder reported were transsexuals, judging by the safest criterion to use when one cannot interview the patient personally -- they wanted a surgical change in sex. It was checked that none were registered more than once. Including my own 43 cases, this gave 110 transsexuals in Sweden on December 31, 1965. Sweden having a population of ca. 5.96 million over 15 years of age, this meant a prevalence of ca. 1 per 54,000. Eighty-one of the 110 were men and 29 women, giving a male/female ratio of about 2.8:1, and a prevalence of ca. 1 per 37,000 for men and ca. 1 per 103,000 for women.

Transsexualism is naturally more common than indicated by these figures, which only stand for transsexuals under so much strain because of their anomaly that they had to consult a psychiatrist. Six of the 110 were foreigners, but only 3 of them appear to have come to Sweden expressly for a "change in sex". As I know of some Swedish transsexuals who have gone to other countries to have plastic surgery done, the admixture of these 3 persons to the series should not distort the figures for prevalence.”

Of the patients who came to the program at Sankt Jörgens hospital: 

“Personal examination of the subjects, including: their personal accounts of their history, with the interviews conducted on informal lines in each case; physical and neurologic examination; body measurements; EEG-examinations; hormone analysis; examination of sex chromatin, occasionally supplemented with determination of the karyotype; analysis of personality by means of a questionnaire; psychologic tests of intellectual capacity and masculinity-femininity; examination for psychiatric disorders. In each case I first had an informal conversation with the patient, when he or she gave me a brief account of their troubles. The next time we met they were asked to describe their particular problems in detail. After these two interviews, the patients gave an account of their history along the lines of a questionnaire used routinely at our institute. Most of the patients stayed at the hospital for a week or so while the examinations were being made.” 

Information was also gathered on the patients from their families and/or spouse, hospital records and social agencies.

Treatment:

“Ten men got no specific treatment, 11 only got estrogen treatment, 5 got estrogen treatment and afterwards a conversion operation. Eight got their name changed legally, all 8 after estrogen medication and 4 in combination with a conversion operation.

Two women got no specific treatment, 1 woman got only androgen treatment, 8 got their breasts amputated after androgen treatment, and 9 had their name changed legally, all after treatment with androgens and 7 in combination with a removal of their breasts.

In all except 3 cases of operation or change of name too little time has elapsed to be able to say anything definite about the results. The length of follow-up for the men who had an operation or their name changed now amounts to 20.7 months on the average (median 24.5 months) and for the women to 42.3 months (median 26.2 months). The patients themselves all said, however, that these measures had made it easier for them to adjust, made them more stable mentally, and improved their sex life. None regretted what had been done. None showed any signs of the treatment having an adverse mental effect.

On the whole, the women seemed to have profited more from their treatment than the men.

All patients were given supportive psychotherapy in order to help them cope with their problems, and various measures were taken to provide a better social adjustment.”

A notable difference between Wålinder’s study and that of Benjamin, published the year before, is the factor of organic causes which apply in some cases.

“Several authors have suggested that transsexualism is of organic origin, that it is due to genetic, hormonal or cerebrolesional mechanisms. Data pointing to an organic factor in my series were: (1) The large number of abnormal EEG's. Epilepsy was over-represented in the cases I collected from the literature, and 1 of the 43 transsexuals in my own series was epileptic and another got a grand mal attack during photostimulation. I have already reported (Wålinder, 1965) that cerebrolesional factors have been noted in cases of different kinds of sexual aberration. (2) In 1 of the present cases the transsexualism started some years after a severe head injury, no signs of deviation being observed before; in this case the transsexualism disappeared on anticonvulsant medication (given because of an abnormal EEG) and reappeared when the medication was stopped. (3) The familial occurrence in 4 cases of mental retardation, cerebrolesional signs and abnormal EEG's, pointing to the possibility of a hereditary disorder in cerebral functioning. (4) Definite evidence of an early cerebral lesion in 1 case (case 1) and the possibility of such in case 16. Adding together these cases gives 15, or about 35 per cent, with evidence of an organic disorder (cases 1, 4, 7, 12, 13, 15, 16, 19, 23, 25, 29, 31, 33, 38, 42).

It is unlikely that the same mechanism lies back of every case of transsexualism. On the other hand, disorders in cerebral functioning may cause a wide variety of mental disorders, the kind probably depending on the site of the injury, and the age at which it occurs. In view of NS, and the usually early onset of transsexualism, the injury must occur early in life if transsexualism is of organic origin. One can influence the sexual behavior of animals by giving hormones prenatally … My study of prenatal and perinatal factors, however, did not reveal any circumstances of note.

Of particular interest when discussing the possibility of an organic factor are the cases in which treatment of a hormonal disorder … or treatment of cerebrolesional disorders … eliminated or lessened the intensity of the transsexualism" transvestism. My case 15 is another example. In all these 3 cases the symptoms were reversible and, in my case at least, they began later than in most cases. In the majority of cases, however, the transsexualism begins early in life and does not respond to treatment. The consistency from case to case is compatible with some form of organic disposition.

My investigation has shown that it is hardly possible to attribute transsexualism to only psychologic or only organic causes. Circumstances pointing to organic origin were present in some cases, and circumstances pointing to environmental origin were present in others. It is reasonable to assume that the two kinds of factors interact, that environmental factors in the wide sense shape and determine how the transsexualism develops, and that some unfavorable external factors precipitate the transsexualism, or turn what was only a disposition to transsexualism into a permanent, fixed form of the anomaly. It is also possible that psychologic factors affect the fixity of the transsexualism, and help to make it irreversible after puberty.”

The dissertation, published 1967, led to his becoming an associate professor in psychiatry. 

Harry Benjamin in New York read Wålinder’s study and tested the claim re an anti-convulsant drug and tried Dilantin with a few transvestites who wanted to be cured, and 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. Leo Wollman, in a lapse of ethics, prescribed Dilantin instead of estrogen to Lyn Raskin - and it had no effect at all on her yearning to be a woman.

In 1968 Wålinder published a summary in Acta Psychiatrica Scandinavica. He repeated his definition:

“The line between transvestism and transsexualism drawn by many authors has been and still is all too obscure. As long as no definite criteria are employed to differentiate these two groups, progress in understanding of the conditions will be limited,

In an investigation of 48 cases of transsexualism primarily segregated according to Benjamin’s (1966) criteria, the following variables were noted in 100% of the subjects:

1. A sense of belonging to the opposite sex, of having been born into the wrong sex, of being one of nature’s extant errors.
2. A sense of estrangement with one’s own body; all indications of sex differentiation are considered as afflictions and repugnant.
3. A strong desire to resemble physically the opposite sex via therapy including surgery.
4. A desire to be accepted by the community as belonging to the opposite sex.

The fundamental, primary disturbance appears to be a feeling of contrary sex-orientation, i.e. inverted core gender identity in Stolleu’s (1964, a, b, c ) meaning. All of the other symptoms seem to cluster around this erroneous sex identity.”

In 1969 he contributed two papers to the Richard Green & John Money anthology, Transsexualism and Sex Reassignment: one on parental age and birth order of transsexuals, and one on the situation in Sweden.

He gave a paper at the Reed Erickson sponsored September 1971, Second International Symposium on Gender Identity in Elsinore, Denmark re legal changes for trans persons in Sweden.

In 1974 he became the chief physician at Sankt Jörgen Hospital

From 1992-1996 he was professor of psychiatry and chief physician at Linköping University and Linköping Regional Hospital, where he stayed for 18 years, 

In 1996 Wålinder responded to a paper ‘Men as women’ by Stig-Eric Olsson, Inge Jansson, and Anders Möller in the Nordic Journal of Psychiatry:

“The authors of the previous article state that ‘the phenomenon of transsexualism is still controversial from a medical standpoint’. On the contrary, transsexualism is a well-recognized disorder and identified in DSM IV under the heading ‘Gender identity disorder’. The authors’ statement that ‘reports in the medical literature on psychologic adjustment after sex change treatment are rare’ indicates that they are unfamiliar with current research in the field.

It goes without saying that, given the irreversibility of sex reassignment surgery, the need for investigation of prognostic factors is compelling. Such factors have already been identified. In a Swedish sample of more than 200 sex-reassigned persons 3.8% have in some way regretted measures taken. Any one of these cases tells a sad story and is indeed a tragedy. If we consider the years from the early 1950s until now, the figures for repentance cases have steadily decreased, and of those who have been sex-reassigned after 1982 only one person has regretted what was once done. Thus, outcome has improved over the years owing to improved assessment and, consequently, more restricted inclusion criteria, improved surgical techniques, and more attention paid to psychosocial guidance and careful posttreatment follow-up procedures.

At-random-presented cases do not invalidate a worldwide pool of data that speak in favour of a successful outcome in cases that have been carefully selected for sex reassignment. These outcome data comprise in a strict sense both medical and psychologic factors.”

Wålinder was due to retire in 1997, but stayed an extra couple of years to secure the future of research projects. He returned to Gothenburg where his children lived. There he became involved with adult psychiatric reception at a clinic in Mölnlycke just outside Gothenburg.

Jan Wålinder died age 83.

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Wålinder on trans topics:

• “Transvestism, definition and evidence in favor of occasional derivation from cerebral dysfunction”. International Journal of Neuropsychiatry, 1, 1965.
• Transsexualism: a study of forty-three cases. Goteborg Akademiforlaget, 1967.
• “Transsexualism: Definition, Prevalence and Sex Distribution”. Acta Psychiatrica Scandinavica, 43, 1968.
• “Transsexuals: Physical Characteristics, Parental Age, and Birth Order” and “Medicolegal Aspects of Transsexualism in Sweden” in Richard Green & John Money (eds). Transsexualism and Sex Reassignment. The Johns Hopkins Press, 1969.
• with Hans Olof Åkesson. “Transsexualism. Effect on Rate and Density-Pattern of Change of Residence”. The British Journal of Psychiatry, 115, 522, 1969.
• “Incidence and Sex Ratio of Transsexualism in Sweden”. British Journal of Psychiatry, 119, 1971.
• “A Proposal for a New Law Concerning Sex Assignment of Transsexuals in Sweden”. Second International Symposium on Gender Identity, Elsinore, 12-14 September 1971.
• with Inga Thuwe. “A law concerning sex reassignment of transsexuals in Sweden”. Archives of Sexual Behavior, 5, 3, 1976.
• with Inga Thuwe. “A Study of Consanguinity Between the Parents of Transsexuals”. The British Journal of Psychiatry, 131, 1, 1977.
• with M W Ross, B Lundströ & Inga Thuwe. “Cross-cultural approaches to transsexualism”. Acta Psychiatrica Scandinavica, 63,1. 1981.
• with Bengt Lundström. “Evaluation of candidates for sex reassignment”. Nordisk Psykiatrisk Tidsskrift, 39, 3, 1985.
• “Comments on the paper ‘Men as women’ by Stig-Eric Olsson, Inge Jansson, and Anders Möller. Nordic Journal of Psychiatry, 50, 5, 1996.
• Mikael Landén, Jan Wålinder, and Bengt Lundström. “Prevalence, Incidence, and Sex Ratio of Transsexualism”. Acta Psychiatrica Scandinavica, 93, 1996.

Jan Wålinder otherwise specialised in affective diseases: depression, bipolar disorder, schizophrenia. Writings on these and other topics   more.

Other:

• Stoller, R. J . (1964 a ) : “A contribution to the study of gender identity”. Int. J . PsychoAnal., 45, 220.
• Stoller, R. 1. (1964 b ) : The hermaphroditic identity of hermaphrodites. J . new. ment., 139, 453.
• Stoller, R. 1, (1964 c): Gender-role change in intersexed patients. J A M A , 188, 684.
• Harry Benjamin. “Newer Aspects of the Transsexual Phenomenon”. The Journal of Sex Research, 5,2, May 1969.
• Erika Alm. “What constitutes an in/significant organ? The vicissitudes of juridical and medical decision-making regarding genital surgery for intersex and trans people in Sweden”. In Gabriele Griffin & Malin Jordal (eds). Body, Migration, Re/Constructive Surgeries. Routledge, 2019: 225-240.
• Lyn Raskin. Diary of a Transsexual. The Olympia Press, 1971: 38.
• Joanne Proctor writing as P J Schrödinger. “DSM-5: Gender Identity – Creating the Trans epidemic” Trans-friedfluff, December 27, Online.
• Miki Agerberg, “»Jag lär mig något nytt varje dag«”. se, 2013-10-15. Online.

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