E XT RE ME FE MININIT Y IN BO YS 58

Sex and Gender

VOLUME II
THE TRANSSEXUAL EXPERIMENT

Robert J. Stoller, M.D.

Professor of Psychiatry
DEPARTMENT OF PSYCHIATRY,
SCHOOL OF MEDICINE
UNIVERSITY OF CALIFORNIA AT LOS ANGELES

JASON ARONSON
New York
 CONTENTS

Acknowledgements page vii

Introduction
1
Part I
THE HYPOTHESIS

1. Bisexuality: The ‘Bedrock’ of Masculinity and Femininity 7

2. Extreme Femininity in boys: The Creation of Illusion 19
3. The Transsexual Boy: Mother’s Feminized Phallus 38
4. Parental Influences in Male Transsexualism: Data 56
5. The Bisexual Identity of Transsexuals 74
6. The Oedipal Situation in Male Transsexualism 94
7. The Psychopath Quality in Male Transsexuals 109

Part II
TESTS
8. The Male Transsexual as ‘Experiment’ 117
9. Tests 126
10. The Pre-Natal Hormone Theory of Transsexualism 134
11. The Term‘Transvestism’ 142
12. Transsexualism and Homosexuality 159
13. Transsexualism and Transvestism 170
14. Identical Twins 182
15. Two Male Transsexuals in One Family 187
16. The Thirteenth Case 193
17. Shaping 203
18. Etiological Factors in Female Transsexualism: A First Approximation 223

Part III
PROBLEMS
19 * Male Transsexualism: Uneasiness 247
20 Follow-Up 257
21 Problems in Treatment 272
22 Conclusions: Masculinity in Males 281
References 298
Index 313
 Part III
PROBLEMS
 19

MALE TRANSSEXUALISM:
UNEASINESS

The carnival atmosphere that prevails in the management of male

transsexualism may have been unavoidable, considering what a
spectacular aberration this condition is; at any rate it is too late to turn
back. By now probably a thousand or so males have been ‘sexually
transformed’. (We shall never know how many, because of the clandestine
arrangements used by some surgeons.) Should time show us that the rate of
untoward results is acceptable in terms of the severity of the condition,
then we shall rest comfortably, and such procedures will become an
unremarkable part of medical practice. But while we await these follow-up
studies, there is reason for uneasiness.
First let me express the opinion, in disagreement with those who feel
that ‘sex transformation’ is never indicated, that there are extremely
feminine males who can effortlessly pass undetected in society as females,
for whom there is no known treatment that would render them masculine
in behavior and appearance. In the absence of any such treatment, we have
three choices: (1) insist nonetheless that they be treated by some method
that does not work (e.g. psychoanalysis); (2) do nothing, with or without
moral exhortation; (3) provide them with ‘sex transformation’. I have been
in favor of the third for these patients.
But the issue is complicated, more so than is usually acknowledged.
Some years ago, positions were polarized: a small number of physicians
favored helping patients to change sex roles while a majority of people,
particularly in the medical profession, including psychiatrists, were
opposed (1). Now, publicity and showmanship have reversed opinion, with
much of the public and the medical profession comfortably—and
unthinkingly—accepting the treatment. Here is the first complication: the
patients themselves announce the diagnosis of

247
248 THE TRANSSEXUAL EXPERIMENT

transsexualism and expect us simply to perform the mechanics necessary

for altering their bodies. This is odd, but more distressing are the referrals
from medical colleagues who fail their responsibility to make their own
diagnosis and accept the patient as a transsexual simply because the
patient has requested ‘sex transformation’. These physicians then wish us
to arrange for the treatment. Imagine: a diagnosis based on the treatment
the patient recommends. This is terrible medical practice, mitigated for me
only by the hope that it makes no difference who is ‘transformed’ if all
have happier lives. But we do not know that yet; we can suspect that some
patients are not doing well post-operatively. Here is a hypothesis that can
be tested if proper follow-up studies are done: the more masculine a
patient’s appearance and behavior as an adult and the more he has passed
through masculine episodes from earliest childhood on, the more likely
there will be psychic disorder after ‘sex change’.
A second complication also results from issues of diagnosis: some
believe that transsexualism is a fiction invented to permit homosexuals to
escape their responsibility for being homosexual (2), or that prevents the
unmasking of the psychosis hiding behind a clever delusion (3, 4). These
positions grow from the inadequate criterion used for defining
transsexualism. There must be a better way to diagose the condition than to
say a person is a transsexual because he requests sex transformation. I
would rather attempt to diagnose by assessing the degree of femininity and
how long and how completely it has existed. To put it differently, how firm
is the patient’s conviction he really is a woman trapped in a male body?*
Since it has been done earlier, I shall not describe once more the clinical,
pschodynamic, and etiological features that help me make the diagnosis.
To summarize my position regarding male transsexualism: If there is a
group of people who have (more or less) the same clinical picture, the
same dynamics, and the same etiology, one can properly consider the
subjects to belong to a clear-cut diagnostic category. Issues in treatment
and in the

* Of course, those of us faced with the task of diagnosing transsexualism have an

additional burden these days, for most patients requesting ‘sex change’ are in
complete command of the literature and know the answers before the questions are
asked.
 MALE TRANSSEXUALISM: UNEASINESS 249

search for etiology are only confused, however, if one throws many
different clinical types into the same pot simply because all share in
common one striking feature—the request for ‘sex change’—when they
fail to share other features.
This may come through in the following examples.
C ASE O NE
The patient is a divorced father of two, in his 30s, in a profession
practiced only by men, in which signs of femininity would lead to
professional disaster. His appearance is masculine, not only because he is 6
feet 5 inches and weighs 250 pounds but because he is unable to carry
himself in a feminine way. Nonetheless, since early adolescence, he has
dressed secretly, for an hour or so at a time, in women’s clothes, becoming
sexually excited and then masturbating. Despite his masculinity, he has
also recognized a wish to be a girl since mid-childhood, and beginning in
adolescence when he first dressed in his sisters’ or mother’s clothes, he has
told himself he has two aspects, a girl’s and a boy’s. The greater part of his
life, spent as a masculine appearing man, is experienced by him as himself,
a man, inhabiting his male body, but when in women’s clothes, he feels he
is a woman (though not a female) and has a woman’s name. He does not
believe ‘sex change’ will remove the part of his identity that is a man.
Nonetheless, he demands such treatment, since he feels his feminine
aspect is enslaved inside the male body. For years, he could manage with
intermittent cross-dressing, but while this was sexually gratifying, he
began to yearn to reveal his femininity. Frustration of this desire brought
him severe anxiety, and at times he slipped into a paranoid state with
persecutory delusions. His next attempt at ‘cure’ was to find a masculine
homosexual woman who would want to be transformed into a man, marry
her, and then each would trade roles. When he could not arrange this, he
began thinking of ‘sex change’. Not yet motivated to do so, he married,
hoping either for a ‘cure’ via heterosexuality or by spending more time in
feminine activities, as by taking over his wife’s household chores.
Although he could get erections and fathered children by fantasying he had
a vagina, this attempt—marriage—failed also.
250 THE TRANSSEXUAL EXPERIMENT

With his marriage, he had stopped seeing me. Then, a few years later, he
wrote to request an interview. A few minutes before the appointed time, he
appeared, ashen, looking in shock. He had just incised the base of his penis
in the bathroom across the hall. When the emergency was resolved, he told
of planning this exploit for weeks, having studied the anatomy of the
genitals so as not to bleed to death inadvertently. He had hoped to force me
—and thus our Medical Center—to provide him with an operation,
although we do not have a program for such surgery.
Since he and I had always had a good relationship, I felt comfortable
telling him I would not be blackmailed in this matter. He apologized for
having done so but added that without the operation he would, regretfully,
either blow up an airplane or poison the water supply of Los Angeles, both
of which he may have been technically equipped to do. He also could
barely resist running girls down in the street with his car as they crossed to
school. Not forgetting his paranoid propensities I told him that on further
consideration I could be blackmailed. This consisted in my condoning his
dressing more in women’s clothes, prescribing a progesterone derivative
(with minimal feminizing effects), and standing aside benignly as he
worked to save the money and then, recently, arranged with a private
surgeon for genital surgery. He calmed down, and the two years he has so
spent have been the happiest of his life. For the first time, he bought a wig
and women’s clothes and began appearing publicly in the daytime. He
looks grotesque, but he is thrilled. He acts convinced, despite his mass, the
blonde wig that does not fit, the bizarre makeup, the bulky walk, and his
inability to carry himself in a feminine manner, that people think he is a
normal female. He never appears thus at work and has raised no suspicions
there. In fact, the happy calmness that has overtaken him has led to this
being the first professionally successful period in his life.
He says that after the operation he will continue to work as a man and
spend his days as a masculine person but that he can survive only if he has
occasions to live as his womanly self. Let us hope he is right; that will be a
better solution than another overt paranoid psychosis.
Why call him a transsexual ?
 MALE TRANSSEXUALISM: UNEASINESS 251

C ASE T WO
This patient, in ‘her’ 30s’, divorced and the father of two children, lived
exclusively as a man until a few years ago. Having sensed a feminine
quality in himself since mid-childhood, he began dressing intermittently in
women’s clothes throughout his teens, always getting sexually excited. He
lived for a few years with another man in an avowedly homosexual
relationship, in which he played both the masculine and feminine roles but
preferring the feminine. During his years of military service, he had
several homosexual affairs. In addition, he created and kept hidden in an
apartment an artificial, full-sized man that he built. He would make love
with this man whenever he could, placing the artificial man’s arms around
him in an embrace and putting the artificial man’s penis in his anus. He
also got pleasure from heterosexual affairs and eventually married.
Then in his late 20’s, he spent several years as an armed robber whose
spectacular feats were headline stories. This avowed attempt to be manly
ended when he was finally arrested; he spent many years in prison, during
which time he decided he would live as a woman when freed. I first saw
him shortly after release.
In time, on his own, he arranged for ‘sex change’, returning thrilled with
the anatomical and psychological results. Although over six feet tall,
because he was sufficiently graceful, he did pass successfully as a woman,
has been employed steadily, and has had boy friends.
Should he be called a transsexual? Socarides reports a similar case
represented as being the prototypical transsexual (2).
C ASE T HREE
The patient is a married man, the father of three children, in his late 30’s,
successfully employed in a masculine profession. He has never cross-
dressed in his life. He has never become sexually excited handling
women’s clothes. He has never had homosexual relations. However, in
recent years, he has decided he must have his genitals removed. During
this time, he has occasionally taken estrogens, but whenever his breasts
enlarge and his potency decreases, he becomes depressed as he thinks
252 THE TRANSSEXUAL EXPERIMENT

of how he is hurting his wife. He has decided to get the operation, divorce
his wife, but still support his family. He says he has no intention of living
as a woman.
Is he also a transsexual?
C ASE F OUR
This married man has never held a steady job because he has suffered
from a schizophrenic thinking disorder since his teens. In his 20’s, he
decided he was a female but nonetheless married a woman he met because
she, older than he, felt she needed a husband, and he acquiesed. They had
intercourse for a few months, but both ended this by mutual consent.
For 10 years he wished for sex change, insisting he was a female. Unable
to arrange this, he moved from Los Angeles, and so I have not seen him
again. However I received a letter one day in which he described the
meticulous surgical skill he employed (he had had practical nurse’s
training) when he removed both his testes in his bathroom.
This list is endless. Anyone doing research on the subject sees numbers
of such people, with the most varied personalities, having in common only
the feeling that a part of themselves is feminine enough to be assuaged
only with sex change. Some are primarily fetishistic cross-dressers, some
primarily effeminate homosexuals, some primarily psychotic—The
possibilities are endless. But if by some inexorable logic they are all called
transsexuals, and if that label now is the only permit needed to grant ‘sex
change’, we shall have failed those patients for whom the operation is
dangerous. Until careful follow-up studies give us more adequate answers
as to who can safely be subjected to this massive surgical and
psychological procedure, I believe the most conservative—and humane—
way to proceed would be to restrict ‘sex change’* to the most feminine of
males. I believe other workers can confirm my experience that all these
patients pass silently, completely, and permanently into society as women.
Perhaps that would be the proper rule, even if my proposi-

* Quote marks used at times but not at others indicate that although a patient would
like a sex change (no quotes), the procedure only simulates sex change (thus: ‘sex
change’).
 MALE TRANSSEXUALISM: UNEASINESS 253

tion regarding etiology is wrong. For instance, should it be proven that

there is a specific biological cause to transsexualism, it might still be
wisest at present to restrict the operation to the most feminine of males.
They certainly give one the feeling that their femininity is the most firmly
fixed and that their maleness can have no value to them.
On whom, then, among those requesting help should we not operate? I
think for the present (though clinical judgment may force rare exceptions,
such as Case One), we should exclude those who are now psychotic, those
who have had psychotic episodes in the past, those sorely depressed or
who have had severe depressions in the past, those who are presently
married and have families, those who have been married in the past and
were able to function in intercourse with erections and orgasm, those of
presently masculine appearance (by this is not meant body build so much
as way of dressing and behaving), those who for extended periods in their
lives have appeared unremarkably masculine, and that large group of those
who—despite an ability intermittently to appear feminine—have
throughout maturity revealed that their genitals give them pleasure
(fetishistic cross-dressers and effeminate homosexuals). The factor
underlying the above group of subjects—who make up by far the largest
number of people requesting ‘sex change’—is that these men have
significant, demonstrated masculinity and sense the value of their genitals
(however much they also have abhorrence as well). In other words, they
have a history of having valued what they now propose to give up. One
need not be a psychoanalyst to have experienced people with ambivalence,
one part of which is hidden from sight until the other is removed. Since it
can be very difficult to determine how highly a person prizes an aspect of
himself at a time when he is strenuously denying it, we run risks in
presuming that there is nothing of value to be lost. Until we can replace an
amputated penis, we must be careful. A patient can convince a surgeon that
‘sex change’ is indicated, indeed crucial; yet the patient discovers post-
operatively that he has made a mistake from which he cannot retreat. It is
under these circumstances that we may see the onset of psychosis,
depression, suicidal intent, hopelessness, male homosexual prostitution,
and even medico-legal complications.
254 THE TRANSSEXUAL EXPERIMENT

Yet, undoubtedly, there are many men like those sketched in my case
examples, who will do better if granted ‘sex change’. The problem is that
we do not yet know how many will improve and how many be harmed. We
ought not to be indiscriminate but rather should establish criteria for
accurate prognosis, not relying on anecdotes of good results and not
minimizing the stories of bad.
I have rigorously restricted the diagnosis of transsexualism and then
suggested we only operate on these people. If so, how will we ever know
what happens to the rest? We probably can get our answers, with a bit of
effort, from among the thousand or more such already in society. Or we
might knowingly set up an experiment, restricted to those medical centers
in various countries that would be medically and scientifically responsible.
In this experiment, we would match patients requesting ‘sex change’, in
each category placing those with a different clinical picture, e.g. the
transsexual, the transvestite, the effeminate homosexual, the mixed type. If
only those are treated who seem the most highly motivated, we can then
determine, with proper follow-up, whether those in one category do better
than another, or whether these concerns with diagnosis are not significant
in the end results.
Could one argue that even without follow-up studies, we can proceed
without hesitation ? That is how the medical profession has acted, despite
the example of such scrupulous teams as that at Johns Hopkins. At the very
least, this is no minor, benign surgical procedure but rather one with
significant surgical risks, with frequent post-operative complications. Any
other new and potentially dangerous surgical procedure would have been
better tested. But there is something about this subject that attracts a lower
level of medical performance in all areas of evaluation and treatment. ‘Sex
change’ has profound implications that touch on everyone’s vulnerability
to magic, and in the management of would-be transsexuals the magic and
mystery of the condition seem to act as an excuse for relaxing normal
medical prudence. Worse, the treatment attracts some who are not
medically prudent to start with. We all know of surgeons willing to operate
as long as the price is right; they seem scarcely concerned even when
inexperienced. We know of psychiatrists, as well as
 MALE TRANSSEXUALISM: UNEASINESS 255

other physicians who put themselves in the position of psychiatrists, whose

only criterion for recommending surgery is the shrillness of the patient’s
request. They are unconcerned about and unequipped to evaluate properly
the patient’s personality and equally uninterested in doing the follow-ups
we so badly need. And so far, there has been almost no protest about this
state of affairs from those of us who know these patients best.
Conclusions
Since 1953, when ‘sex change’ procedures were first publicized (5), an
unknown number of males has received hormonal and surgical treatment
on request. That we have no notion how many have been treated, when the
procedures are experimental and potentially dangerous, is astonishing.
That we do not know, almost 20 years later, how the patients fared, is
scandalous. So far, only two workers have reported careful follow-up
studies of more than single cases.* Randell published results on 29 males
and 6 females (6), extended in 1971 to 44 male and 8 female patients (7).
So far the Johns Hopkins team, the first to set up a well-planned program
of sex reassignment, has published one report, on 17 male and 7 female
patients, in 1970, in German, which Money later summarized in English
(8). We do not know the frequency of surgical complications, post-
operative complications, morbidity, or mortality. We know little of the
nature and nothing of the frequency of psychiatric complications. We do
not know what percent of patients benefit from the procedures, or even if
anyone has published a competent rating scale to measure benefit. Except
for anecdotes, we do not know yet what the passage of years does to these
patients.
This is too primitive.
Can we not devise ways to control this runaway process? I believe it
ought to be the responsibility of the university medical centers setting up
programs for treatment—and I think these experimental procedures should
be restricted to the universities—not only to practice the finest medicine
and develop proper instruments to measure pre- and post-operative results,

* Benjamin also has reported his impressions, but he did not try to establish precise
criteria for rating the results (9).
256 THE TRANSSEXUAL EXPERIMENT

but also to exert effort to prevent incompetent and uncaring practitioners

from treating these patients.
And, while not the subject of this chapter, a last thought: these
conclusions hold for females as well.

Chapter 19
1. Green, R., Stoller, R. J., and MacAndrew, C. (1966). ‘Attitudes Toward
Sex Transformation Procedures’. Arch. Gen. Psychiat. 15.
2. Socarides, C. W. (1970). ‘A Psychoanalytic Study of the Desire for
Sexual Transformation (“Transsexualism”): The Plaster-of-Paris
Man’. Int. J. Psycho-Anal. 51.
3. Stafford-Clark, D. (1964). ‘Essentials of the Clinical Approach’. In The
Pathology and Treatment of Sexual Deviation, ed. I. Rosen. London:
Oxford.
4. Kubie, L. S. and Mackie, J. B. (1968). ‘Critical Issues Raised by
Operations for Gender Transmutation’. JMND 147.
5. Hamburger, C., Sturup, G. K., and Dahl-Iversen, E. (1953).
‘Transvestism. Hormonal, Psychiatric, and Surgical Treatment’.
JAMA 152.
6. Randell, J. (1969). ‘Preoperative and Postoperative Status of Male and
Female Transsexuals’. In Transsexualism and Sex Reassignment, eds.
R. Green and J. Money, Baltimore: Johns Hopkins.
7. — (1971). ‘Indications for Sex Reassignment Surgery’. Arch. Sex.
Behav. 1.
8. Money, J. (1971). ‘Prefatory Remarks on Outcome of Sex
Reassignment in 24 Cases of Transsexualism’. Arch. Sex. Behav. 1.
9. Benjamin, H. (1966). The Transsexual Phenomenon. New York: Julian
Press.