XVI Harry Benjamin International Gender Dysphoria Association Symposium
17 - 21 August 1999, London

Reflections on "Transsexualism and Sex Reassignment" 1969 -1999

Reflections on "Transsexualism and Sex Reassignment" 1969-1999: Presidential Address, August 1999

Richard Green, M.D., J.D., President, Harry Benjamin International Gender Dysphoria Association

Abstract:

Thirty years after co-editing Transsexualism and Sex-Reassignment, this speciality’s first multi-disciplinary text, the author reflects on changes over the past three decades. Transsexualism, then esoteric, is now familiar to school children. Previously solid medical opposition to endocrine and surgical treatment has melted. Origin(s) of transsexualism remain enigmatic but more evidence is in place for a substantial biological contribution. More is also known about the variability of sexual orientation of transsexuals, with extensive experience with males becoming lesbian women and limited experience with females becoming gay men. Post-reassignment follow-up data are overwhelmingly positive when pre-operative patients fulfil the Real Life test.
Newer areas of controversial treatment options include surgery on demand for self-diagnosed transsexuals, gender-neutering procedures for the "third sex", and hormonal and surgical intervention for gender dysphoric adolescents. Legal obstacles in the path of transsexuals remain in the terrain of employment, health care, marriage and parenting.
A noteworthy change is the integration of transsexual men and women into its leadership and the biannual meeting presentations of the Harry Benjamin International Gender Dysphoria Association.

I co-edited the textbook Transsexualism and Sex Reassignment, with John Money, in 1969. It was published by The Johns Hopkins Press.
In retrospect, it was a groundbreaking work. Published only three years after Harry Benjamin’s pioneering The Transsexual Phenomenon, it was the first interdisciplinary professional text. In it, transsexualism was promoted as "consistent with the tradition of scientific inquiry and medicine", examining "deviations from the norm in the hope of better understanding normal processes." To justify serious professional attention, transsexualism was packaged in time-honoured wrapping.
Many changes have evolved in these 30 years.
In 1969 the subject of transsexualism was exotic and esoteric. In the 1960s and 1970s, my professional papers on transsexualism needed to define the term at the outset. Now children know it. They have seen lots of transsexuals on television talk shows.
Does transsexualism still pose the most controversial subject in medicine at it did then? Although it is still contentious, other topics such as abortion and euthanasia also exercise emotions. But they do not challenge psychodynamic theories of psychosexual development or anxieties about the genitalia in the same measure as transsexualism.
Transsexualism was characterized in Transsexualism and Sex Reassignment as the most atypical pattern of psychosexual development, with all three components of gender identity being atypical. The transsexual was atypical on basic identity as male or female, for behaviors as masculine or feminine and for sexual orientation as homosexual or heterosexual. Today the relation between components one and two versus three is being refined. We have considerable experience with lesbian women male transsexuals and limited experience with gay men female transsexuals. But it remains true as in 1969 that "the variables on which transsexualism, transvestism, and homosexuality overlap and on which they are separate are not entirely clear".
The prevalence of transsexualism appears higher than previously thought, perhaps double. Probably this is not a true increase. Rather it is an expression of patient optimism that coming forward for help will be respected by the healing professionals.
In the intervening 30 years, surgeons have harnessed the transsexual’s request as technological challenge. Vaginoplasty is excellent. As we have seen at this meeting, phalloplasty is evolving. But the surgical quip of the 1960s remains: "It’s easier to build a hole than a pole".

There has been something of a "help-hurt" role reversal in these thirty years between physician and patient. In 1969, with rare exceptions, such as Harry Benjamin, physicians were the worst enemies of transsexual patients. As I documented in my research during that period, most doctors, even psychiatrists, would rather let transsexual patients die than treat them with sex reassignment. By contrast, today some patients have become their own worst enemies in the face of physicians attempting to be of help.
One reason there are relatively few professionals who commit their time to trying to help gender dysphoric persons is that many find the experience very frustrating, far more so than with other types of patients. They conclude that it is just not worth the effort.
It is difficult to identify another psychiatric or medical condition in which the patient makes the diagnosis and prescribes the treatment. Anything short of fulfilling those judgements is objected to, perhaps vigorously. The administration overseeing the Gender Identity Clinic at Charing Cross Hospital is besieged by patient complaints. This is mostly because the clinic professionals have not acquiesced quickly enough to the patient’s demands for sex reassignment. The expense of handling these complaints has made the Gender Identity Clinic unpopular with administration and has at times threatened its existence. Unhappily, not only are such patients self-defeating but they make it difficult for the great majority of patients who are in genuine collaboration with professionals.

Mysteries of the origins of transsexualism remain. It remains true as in 1969 that "no one now, be he psychoanalyst or neuroendocrinologist or expert in any other science, can claim to have the complete explanation of transsexualism… Much (still) remains to be discovered about how masculinity and femininity develop." And the "eventual availability of measures of circulating gonadal hormones during prenatal development" to help explain the neuroendocrine origins of gender identity remains that – a potential.
There was a flurry of excitement fifteen years ago over the possibility that the HY antigen on the male Y chromosome was absent in male-to-female transsexuals. However, our research at Stony Brook put this provocative theory to rest. More recently there has been some excitement generated over demonstration of a possible variant in congenital adrenal hyperplasia responsible for transsexualism. There has been substantial excitement generated over the finding of a size difference in the brain’s bed nucleus in male-to-female transsexuals.
Of what relevance is it if biological or genetic bases of transsexualism can be demonstrated? Why should it matter? The same issue is raised in discussion of the origins of homosexuality. On the one hand the person with a variant in sexual orientation or in gender identity may be seen as more "legitimate" if the variation is biologically based, not the result of psychological trauma during formative years, or worse yet, sin. But from the perspective of John Stuart Mill, the original civil libertarian, it should be irrelevant whatever the basis of same-sex attraction or wish to be the other sex, providing this is not harmful to another.

An additional concern is that reliance on a "biological" basis of atypical sexual orientation or gender identity may leave such individuals wanting for understanding and legal protection if such a basis is not found. In American law there is a class of individuals who are protected against discrimination when the source of their difference from the majority is innate. The classic example is race, a feature over which few have a say. But acceptance and protection should not be tethered to such an origin.
Research on patients’ post-sex-reassignment has been reassuring. Very early follow-up data in the late 1960s "support(ed) the contention that in the majority of persons in whom cross-gender identity is extensive and of longstanding duration – conflict can be significantly lessened by sex reassignment". This remains true.
The methodologically flawed Johns Hopkins study of 1979 questioning benefits of sex reassignment surgery served as an excuse for discontinuing that hospital’s pioneering program. But it made only a dent in the worldwide professional recognition of the legitimacy of sex change. The methodologically sound study from London’s Charing Cross of 1990 clearly demonstrated the benefits.
Some professionals remain opposed to hormonal or surgical reassignment, retreating into psychodynamic formulations of pathology. They falsely equate providing psychological insight with change of gender identity, reminisce about a poorly adjusted postoperative patient they once saw and indict the sex reassignment follow-up literature as methodologically flawed. But when pressed to recount their personal success rate in modifying gender identity or to cite others’ psychiatrically treated successes, they retreat to their armchairs. There they reign.

30 years after Transsexualism and Sex Reassignment, It remains a truism that "the law must share with medicine responsibility for some of the transsexual’s plight … The problem remains… whether what has been granted medically will be acknowledged legally".
Cross-gender living prior to surgery, the "real-life test," as coined by John Money, has proved to be critical rite de passage. But the real-life test can be obstructed by employment discrimination. In the US, the Ulane case, where I was an unsuccessful expert witness, was the death knell for protecting transsexuals under federal sex discrimination law. Eastern Airlines (now defunct) prevented a previously male pilot, with an impeccable record, from continuing to fly as a woman. However, in the United Kingdom, a lawsuit against employment discrimination reached a more successful outcome in the European Court of Human Rights, the latter court only a dream option of 1969.
The 30 year debate continues on "whether it should be the rightful concern of the law to deny one the right to dress as one wishes, conduct one’s life in a preferred gender role, privately conduct one’s sexual relationship as preferred by oneself and one’s partner, and even to marry in the preferred sexual role." Not only does U.S. employment law neglect the transsexual, the Veteran’s Administration refuses to treat them, and half the states still criminalize same-sex genital contact. In the U.K. post-operative transsexuals cannot marry.

The United Kingdom has been fighting a rear guard action against most of the rest of Europe in its refusal to grant post-sex reassigned transsexuals a revised birth certificate. Andorra and Albania join the UK, with Ireland, in its march out of step. The US is not that far behind where many states still refuse to issue a changed birth certificate.
The UK position on birth certificate change is that the sex designation at birth is an historical event that cannot be undone. This concern should not preclude the issuance of a new certificate with retention of the original on file. Considering that the incidence of transsexualism is 1 in 30,000 females and 1 in 10,000 males it would not appear that the actuarial foundation of the UK would crumble with this rate of "error".
Allocating resources for transsexual treatment is the new discrimination. Government funding agencies and insurance companies marginalizes transsexuals. They are an easy target: a small constituency. But in July 1999, in the United Kingdom, the Court of Appeal ruled that a National Health Service authority couldn’t deny treatment in blanket fashion for transsexual patients. In my position as Head of our Gender Identity Clinic, I authored an 18-page affidavit supporting the transsexual patients in that landmark case.

Risks of medical negligence suits for facilitating sex reassignment have been substantially reduced, in these 30 years, when standards adopted by the professional community are followed. The "Harry Benjamin Guidelines" are in effect, at least for the adult. But with adolescents, similar concerns for medical negligence confront us as previously existed for adults. What is (will be) the standard for accepted practice? Should the physical changes of puberty that handicap later cross-gender passing be interrupted? Will research reveal that benefits to most teenagers outweigh the risks that some will regret the intervention?
Newer ethical concerns in these 30 years have evolved from whether clinicians should grant a request for sex reassignment, to the question, are clinicians necessary? Should sex change be available on demand? That was hardly the issue in 1969, as the nearly insurmountable hurdle then was professionally endorsed reassignment. If gender patients can procure surgeons who do not require psychiatric or psychological referral, research should address outcome for those who are professionally referred versus the self-referred. Then an ethical issue could be, if success is less (or failure greater) among the self-referred, should otherwise competent adults nevertheless have that autonomy of self-determination?

The ramifications of surgery on demand for gender dysphoric persons or persons discontent with some aspect of their anatomy, be it sexual or otherwise, engage legal as well ethical issues. Should there be a limit to a person’s autonomy over body? This question is engaged in debates over pregnancy termination. It is engaged in issues of drug use during pregnancy. It is engaged in refusal of religious groups to sanction life-saving medical treatment.
It is not just in the area of gender identity disorder that requests for surgery that radically alter the body are controversial. There are men and women who demand amputation of limbs to meet their ideal body image. Should surgeons reflexively grant such requests? Should surgeons require psychiatric screening? If screening were deemed appropriate, what criteria would be used for acceptance or rejection of an individual’s request?
Intermediary between these limb amputation requests and what are now considered the "conventional" requests for sex change procedures, are demands of persons who might be termed the emergent "third gender". These include requests of females who want bilateral mastectomy but no other surgery and no virilizing hormone treatment, or males who want castration or penectomy, or both, but no feminizing hormone treatment.
A practical dilemma for the clinician engaged with such persons, whether it is for amputation of a limb or amputation of a sex-typed body part, is that the rite de passage to determine whether the patient has a realistic anticipation of life after surgery is not possible. There is no "Real Life Test" for the would-be limb amputee or the would-be third gender sex-part amputee.
The civil libertarian, John Stuart Mill, argued forcefully that adults should be able to do with their bodies as they wish providing that it did not bring harm to another. Thus if the third gender, the transsexual, or the would-be limb amputee can continue to shoulder social responsibilities post-surgery, then the surgical requests are not society’s business.
But, accepting that philosophical base, a subsequent question asks who will share the financial burden of meeting such requests? Should that be borne by the society? If so, the argument can be that society is affected adversely by needing to meet the expense. However, if the individual is willing to pay for the intervention then it becomes the individual’s responsibility without spreading financial adversity.
Another current political movement argues for removing gender identity disorder or transsexualism, or whatever it may be called next, from the list of disorders of the American Psychiatric Association and the World Health Organisation. But an argument put to insurance companies or a National Health Service for payment is that those persons for whom funding is requested have a medical disorder requiring a specific treatment. Absent that, the procedures are viewed as purely "elective" or "cosmetic", which traditionally have not been gleefully funded by third party payers.
Children of transsexuals continue to engage courts of law and the anxieties of transsexual parents and their former spouses. I am saddened at the number of cases in which I have testified as an expert witness where children and transsexual parent have been denied the opportunity to continue their parent-child relationship. From the many cases that I have seen, a transsexual parent does not have a deleterious effect on the children. There is no objective basis for the non-transsexual spouse’s acrimonious denial of continuing a relationship between the co-parent and child. Yet transsexuals are not popular parties in courts of law. In the United Kingdom implacable opposition by one parent to continuing contact with the other parent often trumps. Emotional blackmail rules the day. Dig in your heels and win the fray.
In closing, I address a remarkable evolution of this field - - the dual role now played by persons with a history of gender identity disorder, or gender dysphoria or transsexualism, as both professional and consumer. This previously marginalised population is increasingly taking its position as respected professional colleague. As President of this Association, I am pleased that our Executive Board contains both transsexual and non-transsexual persons. As Chair of the Program Committee, I am pleased that our program has included both transsexual and non-transsexual professionals.

This would have made Harry Benjamin very proud.
  

References:

Green, R., Money, J. (ed) (1969). Transsexualism and Sex-Reassignment. The Johns Hopkins Press, Baltimore.