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INTRODUCTION TO GENDER DYSPHORIA SYNDROME
By Sr. Mary Elizabeth, SSE
Also see the Transsexualism FAQ

Descriptions from classical mythology, classical history, Renaissance and nineteenth-century history plus cultural anthropology point to the long-standing and widespread pervasiveness of the transsexual phenomenon.[EN1] These descriptions were generally hidden away in historical or scientific documents, unavailable and of little interest to the general public.

This situation changed in late-1952, however, when transsexual (sex reassignment) surgery burst publicly upon the world. On December 1, 1952, the New York Daily News carried the banner headline, "Ex-GI Becomes Blonde Beauty." [EN2] For the next few months transsexualism became a household topic as story after story was published. Eventually interest in the subject dwindled and one-time front page stories were lost within the inner pages of the tabloids.

Few articles appeared during the period 1954 to 1976. Those that did seldom rated front-page space. During the summer of 1976, however, the world of professional tennis was disrupted by the controversy surrounding a player who had undergone sex reassignment and subsequently desired to play professional tennis as a woman. [EN3] The controversy once again sparked the nation's curiosity concerning transsexualism and, during the following months, numerous magazine articles, newspaper reports, and television programs dealt with the scientific phenomenon of a "female mind trapped in a male body" or vice versa. [EN4]

Interest in transsexualism would have dwindled once again, had it not been for a seemingly endless series of newsworthy stories involving transsexuals, such as "Transsexual Wars With The Army" and "Sex Changed Teacher Seeks Job Back." [EN5] Further, the courts were suddenly alive with transsexual litigation; the common denominator in each being a persistent pattern of severe discrimination.

Systematic medical treatment of transsexualism was initiated in the early-fifties by Harry Benjamin, a prominent New York endocrinologist. [EN6] The first gender clinics opened during the 1965-67 period at Johns Hopkins Medical Institutions, the University of Minnesota, and UCLA (University of California Los Angeles).

Professionals involved with these clinics realized early in their research that differential diagnosis would be difficult and controversial. Consequently, international symposiums were established to resolve many of the issues surrounding the treatment of transsexualism. International symposiums have since been conducted in London (1969), Denmark (1971), Yugoslavia (1973), Stanford (1975), Norfolk (1977), San Diego (1979), Tahoe (1981), Bordeaux, France (1983), Minneapolis (1985), and Amsterdam (1987). [EN7]

By 1976 it was clear that transsexualism was no longer seriously questioned as an accepted medical entity. And, in 1979, a professional subspecialty group (The Harry Benjamin International Gender Dysphoria Association) was formed during the Sixth International Interdisciplinary Symposium on Gender Dysphoria, with minimum standards subsequently being established for the treatment and care of gender dysphoria patients.

Today, some 30-plus years since becoming front-page news, gender dysphoria syndrome [EN8] is described thoroughly in the literature. [EN9] The literature suggests that: (1) The causes remain unknown; [EN10] (2) pre-surgical transsexuals as a group are among the most miserable of people, [EN11] often exhibiting extreme unhappiness which frequently brings them to the verge of suicide [EN12] or self-mutilation, [EN13] and (3) a satisfactory outcome to sex reassignment surgery, in terms of improved social and emotional adjustment, is at least 10 times more likely than an unsatisfactory outcome in properly selected patients. [EN14]

The literature describes the problem of transsexualism as a disturbance of gender identity, where individuals experience a sense of incongruency between their psychological sex and their anatomic sex. [EN15] Other disturbances described, but frequently confused with transsexualism, include homosexuality and transvestism.[EN16] They are, however, actually distinct from it.

Homosexuals, who are sexually attracted to members of their own sex, and transvestites, who occasionally dress in clothes of the opposite sex, experience conflicts which are only superficially similar to transsexualism. Unlike the transsexual, they do not desire to alter their anatomy. [EN17] The transsexual, in sharp contrast, feels trapped in a body of the wrong sex and seeks release; either through skilled surgical intervention, or through what ever means--including suicide--available to effectively escape. [EN18]

The literature indicates a consistent trend towards rejection by both family and friends, harassment and/or discrimination [EN19] in varying degrees by most of society, and more often than not, a refusal by many in the legal [EN20] and medical professions [EN21] to render services; either by reason of questioning the validity of such a diagnosis, or perhaps fear of potential peer and/or community sanctions. [EN22]

Additionally, it is clear from the literature that the causes of transsexualism are disputed among professionals; most of the controversy focusing on whether the etiology is psychogenic or organic. [EN23] Money and Ehrhart suggest that a fetal metabolic or hormonal component may predispose a person toward gender confusion. [EN24] Block and Tessler discuss an endocrine theory which assumes that chromosomal sex and endocrine do not always correspond, [EN25] and Seyler and associates have demonstrated that the response of female transsexuals to diethylstilbestrol (DES) and luteinizing-releasing hormone (LRH) was intermediate between the female and male patterns, suggestive that a biological component is present. [EN26]

Virtually countless theories abound, with research failing to wholly support any one position. The result is that most professionals accept the theory that best corresponds with their own personal background, education and clinical experience. [EN27] Adding to the controversy is a lack of standardized criteria to determine the presentation of true transsexualism; the diagnostic process being one of inference and the ruling out of other disorders. Definitive diagnostic tools such as standardized physical or psychological tests are simply non-existent. [EN28] On the other hand, there is considerable indication that experienced practitioners are finding methods to accurately differentiate primary from secondary transsexualism [EN29] and predict outcomes.

Extensive patient histories, psychometric testing and psychiatric evaluations program during intake, mid-transition (following initiation of hormone therapy and full-time living in the gender-role of reassignment), and just prior to surgery are used to monitor patient progress and adjustment/suitability for sex reassignment surgery. Coupled with this evaluative process is the real-life test, extending from one- to two-years, supplemented by private or group therapy to resolve non-gender related emotional problems, etc. and develop realistic patient expectations prior to surgery. [EN30]

Despite the controversy about transsexualism, the literature on the subject does reflect some recurrent themes. First, each individual's gender identity is well established by early childhood. Second, transsexualism usually manifests before puberty, and once the pattern is established, it is highly resistant, if not impossible, to change. [EN31] Third, true transsexuals do not respond to psychotherapy, rejecting this mode of treatment because they see their problem as physical and the solution as surgical, not psychiatric. [EN32] Consequently, therapy aimed at other than sex reassignment has consistently failed, [EN33] rendering self-castration or suicide a real risk. [EN34] Fourth, transsexuals suffer from a distinct gender disorder of unknown etiology that is capable of amelioration, if not cure, [EN35] uniquely through sex reassignment. [EN36] Fifth, as might be expected, surgical complications are more frequent when individual surgeons or surgical teams are making their initial attempts at vaginal construction. As experience of each group develops, the complications may be largely reduced or eliminated. [EN37] Sixth, sex reassignment, while often treated as cosmetic in the literature, has consistently been deemed non-cosmetic and, in the majority of cases, medically necessary by the courts. [EN38]

Despite the generally favorable non-cosmetic and medically necessary judicial decisions, the American judicial system has failed to keep pace with medical and scientific advances, particularly in the area of gender dysphoria syndrome and transsexualism. This failure is aptly demonstrated by a diversity of decisions, rendering the transsexual vulnerable to discrimination in a variety of socio-economic contexts, especially in the areas of civil rights and health care. This vulnerability was clearly de scribed in a recent article by Tim Alger, [EN39] wherein it was stated that "[t]here [are few] provisions for transsexuals under the law. They're kind of left out there, hanging in space. Each time they go into court, depending on the empathy of the judge, it is unknown how they will be treated."

There can be little doubt about the complexity of the socio-legal problems surrounding the transsexual. The newness and limited size of this field makes research difficult. Furthermore, more often than not, the professional may find that once a body of information has been accumulated, it may well fail to provide an answer to the question which motivated the research. On the other hand, few fields of endeavor offer more challenge.

Lawyers, legislators, and judges need to better understand the human condition as it relates to gender dysphoria syndrome, in particular transsexualism. For only through this group of professionals can the advancement of equal rights and equal protection under color of law be attained.

Every member of society, regardless of race, national origin, religious belief, sex, sexual orientation, or sexual status (transsexual, hermaphrodite, etc.) should be entitled to be judged and to live under a government of laws, free of prejudice and the weakness of a government of men or women acting without laws to regulate their treatment.

[1] Green, R. and Money, J., Transsexualism and Sex Reassignment 13 (1966).
[2] "Ex-GI Becomes Blonde Beauty," New York Daily News, December 1, 1952, at pg. 1.

[3] Kennedy, "She'd Rather Switch--and Fight", Sports Illustrated, September 6, 1976, p.16.

[4] See, e.g., Burstein, "Dr. Money Explains the Why and How of People Who Want to Change Their Sex," People, September 20, 1976, at p.63; Greene, "What Makes A Person Want To Change Sexes," The National Observer, October 16, 1976, at p.1; Liddick, "Most Transsexuals Search for Happiness In Vain," The Pittsburgh Press, October 19, 1976, at p.13.

[5] Duke, "Transsexual Wars With The Army", Los Angeles Times, September 14, 1977, at C-1; "Sex Changed Teacher Seeks Job Back", Los Angeles Times, November 27, 1976.

[6] Benjamin, H. "Transvestism and Transsexualism," 7 International Journal of Sexology 12-14 (1953); The Transsexual Phenomenon, Julian Press (1966).

[7] Source: JANUS Information Facility, San Francisco, CA. JANUS closed in 1986.

[8] "Gender dysphoria syndrome is a descriptive term, encompassing selective clinical situations or a set of psychosocial symptoms and/or behaviors that have been reported by a group of deeply troubled often desperate patients seeking gender reorientation including surgical sex conversion." Fisk, N. "Gender Dysphoria Syndrome: The How, What and Why of a Disease," Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome, at 7 (1972).

[9] A recent keyword search of electronic databases available through DIALOG Information Services, produced in excess of 1,200 journal and news media citations on transsexualism.

[10] "From all available evidence in the field of psychology as well as physiology, I feel that no one is justified at this time in saying categorically that transsexuals are made, not born. The opposite may also be true. More than one cause can bring on--say--convulsions, and more than one cause is probably responsible for the transsexual syndrome: Benjamin, H., "Should Surgery Be Performed On Transsexuals?" 25 Am. J. Psychotherapy 74, 76 (1971).

[11] Dr. Pauly is quoted as saying that "[t]he suffering of the transsexual is beyond belief," Leff, "Genes, Gender and Genital Reversal," Med. World News, April 18, 1977, at p.56; See, also, Baker, H.J. & Green, R. "Treatment of Transsexualism," Current Psychiatric Therapies, 88, 93 (1970); Mason, N. "The Transsexual Dilemma: Being A Transsexual," 6(2) Jn. Medical Ethics 85-9 (Jun. 1980); Money, J., DePriest, M., "Three Cases of Genital Self-Surgery and Their Relationship to Transsexualism," 12(4) Jn. Sex Research 283-94 (Nov. 1976); Money, J. "Genital Self-Surgery," 124(2) Jn. Urology 210 (Aug. 1980); see, also Note 13, infra.

[12] G.B. v. Lackner, (1978, 1st Dist.) 145 Cal. Rptr. 555, 557; Levine, S. B., "Suicide By A Transsexual (letter)," 13(3) Arch. Sex Behavior 287-9 (6/1984); Huxley, P. J., Kenna, J. C., Brandon, S., "Partnership in Transsexualism, Part 1: Paired & Non-Paired Groups," 10(2) Arch. Sex Behavior 133-41 (4/1981); Danto, B. M., "Violent Sex and Suicide," 5(1-2) Mental Health Soc. 1-13 (1978); Herschkowitz, S., Dickes, R., "Suicide Attempts in a Female-to-Male Transsexual," 135 Am. J. Psychiatry 368-9 (3/ 1978).

[13] Block, N. L. and Tessler, A. N., "Transsexualism and Surgical Procedures," 131 Jn. of Surgery, Obstetrics and Gynecology 517 (2/1971); Kriger, M. J., McAninch, J. W., Weimer, S. R., "Self-Performed Bilateral Orchiectomy in Transsexuals," 43(7) Jn. Clin. Psychiatry 292-3 (1982); Lowy, F. H., Kolivakis, T. L., "Auto-Castration By A Male Transsexual," 16(5) Can. Psychiatric Assoc. Jn. 399-405 (10/1971). See, also, A confidential memorandum dated July 1, 1981, written by the Chief of Surgery at th e Colorado State Hospital, Dr. T. J. Fogel, contains a concise history of plaintiff up to that date: "The patient has made six attempts to emasculate himself over a period of years . . . . On the 29th of June he incised and removed a portion of his scrotum, placed string and rubber bands about the spermatic cords bilaterally and this was found the next day and the constricting bands removed . . . . He stated categorically that he would not allow any treatment if it did not involve the removal of his testicles. He made this very clear. He was quite rational. He was seen by Dr. Huffaker, the Colorado State Hospital psychiatrist, who in a very clear evaluation felt that he was sane in every regard and a true transsexual." Supre v. Ricketts, 596 F. Supp. 1532 (D. Colo. 1984), rev'd. 792 F.2d 958 (10th Cir. 1986)(Appeal was on awarding of attorney's fees and administration of hormones in the correctional environment).

[14] Pauly, I., "Outcome of Sex Reassignment Surgery for Transsexuals," 15(1) Aust. NZ Jn. of Psychiatry 45-51 (1981); Pauly, I., "The Current Status of the Change of Sex Operation," 147 Jn. Nervous & Mental Disease 460 (1968).

[15] Benjamin, H. and Ihlenfeld, C. L., "Transsexualism," 73 American Jn. of Nursing 457-461 (3/1973).

[16] "It has frequently been said here that the term `transsexualism' has come to encompass a variety of conditions that under other circumstances might be labelled extremely effeminate homosexuality, transvestism (particularly conscience-ridden transvestism), schizoid or borderline personality disorder, polymorphous perverse psychopathy, as well as individuals who apparently have manifested cross-gender drives--the classical `transsexual.' Other types of patient occasionally found among applicants for sex reassignment are obsessional neurotics with profound masochistic trends, notoriety seekers, vocationally motivated homosexual prostitutes, borderline patients, and the overtly psychotic." Meyer, J. K. "Some Thoughts On Nosology And Motivation Among `Transsexuals,'" Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome, at 32 (1972).

[17] Frazier, S. H. and Carr, A. C. An Introduction to Psychopathology, New York: Jason Aronson (1974).

[18] Citations, supra, Notes 12-13.

[19] "While there are few people suffering with transsexualism, regular psychotherapy is not effective, and these patients are often hurt by other people . . ." Hynie, J. "Treatment of Transsexualism," Vol. 44, Abstract No. 16739: DIALOG 44-16739; Smith v. Liberty Mutual Insurance Co., 569 F. Supp. 1098 (D.C., Ga. 1975) aff'd Smith v. Liberty Mut. Ins. Co., 569 F.2d 325 (5th Cir. 1978); Grossman v. Bernards Township, 316 A.2d 39 (1974) aff'd. 538 F.2d 319 (1975), cert. denied 429 U.S. 181 (1976); Voyles v. Ralph K. Davies Medical Center, 403 F. Supp. 456 (N.D. Ca. 1975), aff'd. without op. 570 F.2d 354 (9th Cir. 1977); Powell v. Reads, 436 F. Supp. 369 (D.C. Md. 1977); Holloway v. Arthur Anderson & Co., 556 F. 2d 659 (9th Cir. 1977); Kirkpatrick v. Seligman & Latz, Inc., 475 F. Supp. 145 (M.D. Fla. 1979); Sommers v. Budget Marketing, 667 F.2d 748 (8th Cir. 1980); Sommers v. Iowa Civil Rights Commission, 337 N. W.2d. 470 (1983); Ulane v. Eastern Airlines, 581 F. Supp. 821 (N.D . Il. 1983), rev. 742 F .2d 1081 (7th Cir. 1984); cert. denied 53 U.S.L. W. 3730 (4/16/85), 105 S.Ct. 2023 (1985); 105 S.Ct. 2023 (1985); Goerth, C. R., "Ulane Case Highlights Issues of Sex Discrimination Lawsuits," Occup. Health Safety 54-5 (May 1984); Cotton, D. "Ulane v. Eastern Airlines: Title VII and Transsexualism" 80(4) Northwestern Univ. L. Rev. 1037 (1986).

[20] "There are very few, if any, other attorneys in this community who would have undertaken this unusual representation . . . " Supre, supra, Note 13; "Few, if any, attorneys will accept transsexual cases . . . ." Letter from Paul Hoffman, Legal Director, ACLU Foundation of Southern California, dated March, 1985.

[21] Green and Stoller, supra, Note 16; "The primary deterrent to physician involvement in the transsexual problem is a self-protective one, hrefly fear of censure and considerations regarding reputation." Hoopes, J. E., Knorr, N. J., and Wolf, S. R. "Transsexualism: Considerations Regarding Sexual Reassignment," 147(5) Jn. of Nerv. & Mental Disease 510, 512 (1968); Baker & Green, supra, Note 11, at 88-90.

[22] " . . . could not the time and effort of such talented researchers be put to better use, to more ligitimate challenges? If a glamorous challenge is insisted upon, we suggest that brain transplanting be preferred to castrating and altering "sick" males." Letter from Nicole J. Michaud and Elliot Bold, G. F. Strong Laboratory for Medical Research, to the Editor, Am Jn. Obstet. & Gynecol., 135(1) Am. Jn. Obstet. & Gynecol. 163 (9/1/1979).

[23] Benjamin, supra, Notes 6, 15.

[24] Money, J. and Erhardt, A., Man and Woman, Boy and Girl, Baltimore: Johns Hopkins University Press (1971); "From animal work it is evident that at least in some species there exists a period of behavioral sexual differentiation in response to male hormone exposure, well as a period of genital differentiation, and that these two critical time periods may be separate." Green, R., Sexual Identity Conflict in Children and Adults (1972) at 36 (Citing Whalen, Peck, and LoPiccolo, 1966).

[25] Block and Tessler, supra, Note 13.

[26] Seyler, E. L., Canalis, E., Spare, S. et al., "Abnormal Gonadotropin Secretory Responses to LRH in Transsexual Women After Diethylstilbestrol Priming," Jn. Clin. Endocrinol. Metab. (In Press) (1978).

[27] Hoenig. J., Kenna, J. C., and Youd, A., "Surgical Treatment for Transsexualism," 47 Acta Psy. Scandinevica, 106 (1971) (Citing five references).

[28] "There are no mental nor psychological tests which successfully differentiate the transsexual from the so-called normal population." Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome, at 16 (1972).

[29] "Primary transsexualism is demonstrated by a life-long fixed and consistent cross-gender identification, whereas secondary transsexualism is generally associated with self-stigmatized, ego-dystonic, homophobic homosexuals or guilt-ridden transvestites, seeing sex reassignment as the only solution to their dilemma. It is estimated that 30-35% of sex reassignment applicants are self-stigmatized, homophobic homosexuals or guilt-ridden transvestites." Pauly, I. "Gender identity disorders." In Farber, M. (ed.). Human Sexuality: Psychosexual Effects of Disease. Macmillian, New York, pp. 295-316 (1985); Pauly, I. and Edgerton, M. T. "The Gender Identity Movement: A Growing Surgical-Psychiatric Liaison," 15(4) Archives of Sexual Behavior 315 (1986); "While it is true that requests for sex reassignment surgery may be made by homosexuals, transvestites, paranoid schizophrenics, and persons suffering from other serious psychological disorders, experienced professionals can distinguish true clinical transsexuals `from so-called pseudo-transsexuals, homosexuals, transvestites, fetishists and psychotics with transsexual symptoms." NOTE, "The Determination of Medical Necessity: Medicaid Funding for Sex Reassignment Surgery," 31 Case W. Res. L. Rev. 194-95 (1980); Pfafflin, "Psychiatric and Legal Implications of the New Law for Transsexuals in the Federal Republic of Germany," 4 Int'l. J. L. & Psychiatry 197 (1981).

[30] The Gender Dysphoria Program of Orange County, Inc. located in San Juan Capistrano, California, has referred less than four per cent of their applicants for sex reassignment surgery; 96 per cent of the applicants making the decision not to have surgery, a clear indication of the value of private and group therapy to the decision making process. Interview with staff of the Gender Dysphoria Program of Orange County; "Surgery does not make a poor patient into a good one. Surgery should come at the end of the rehabilitative process...." Dushoff, I. M. "Economic, Psychologic and Social Rehabilitation of Male and Female Transsexuals Prior to Surgery," Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome, at 199 (1972); Pauly, I., "Outcome of Sex Reassignment Surgery for Transsexuals," 15(1) Aust. & New Zealand Jn. of Psychiatry 45-51 (1981).

[31] Barlow, D. H., Abel, G. G., Blanchard, E. B., "Gender Identity Change in a Transsexual: An Exorcism," 6(5) Arch Sexual Behavior 387-95 (9/1977).

[32] Money, J. and Erhardt, A., supra Note 24.

[33] "Any discussion of the treatment of transsexualism and the current status of the change of sex operation must begin with one simple fact. Psychotherapy has not proved helpful in allowing the transsexual to accept that gender identity which is consistent with his genital anatomy." Pauly, I., "The Current Status of the Change of Sex Operation," 147 Jn. Nervous & Mental Disease 460, 465 (1968) (Citing 19 sources for the statement); This conclusion was recently confirmed by two psychiatrists who suggest, however, that conscientious psychotherapy may benefit the gender dysphoric who is not a true transsexual. Kirkpatrick & Friedmann, "Treatment of Requests for Sex-change Surgery with Psychotherapy," 133 Am. Jn. Psychiatry 1194 (1976).

[34] Wein & Remmers, "Employment Protection and Gender Dysphoria Syndrome," 30/4 Hastings Law Journal 1075, n.8 at 1077 (1977) citing Laub, D. and Fisk, N. "A Rehabilitation Program for Gender Dysphoria Syndrome by Surgical Sex Change," 53 Plast. Reconstru. Surg. 388-403 (1974).

[35] It is doubtful if cure is an appropriate word as few references be found to surgery being a cure. Benjamin's comment "Sex Change Surgery: The Great Debate," 3(11) Sexual Medicine Today 18, 19 (11/1979) is perhaps most descriptive and on point--i.e. ". . . surgery is not a cure for transsexualism. But no one ever claimed that it was, anymore than insulin is a cure for diabetes. What both accomplish is the preservation of the life of the patient. Otherwise, many of the people would commit suicide."

[36]Wein & Remmers, supra, Note 34, at 1078-79 & nn. 10-13.

[37] Edgerton, M. T., "The Surgical Treatment of Male Transsexuals," 1(2) Clinics in Plastic Surgery 285, 315 (4/1974).

[38] ". . . clearly impossible to conclude that transsexual [is] cosmetic surgery, even using the definition relied on by the director . . . .", G. B. v. Lackner, (1978 CA 1st. Dist., Div. 3) 80 Cal. App. 3d 64, 145 Cal. Rptr. 555; "As we stated in G. B. v. Lackner: We do not believe, by the wildest stretch of the imagination, that such surgery can reasonably and logically be characterized as cosmetic." J. D. v. Lackner, (1978, CA 1st Dist., Div. 3) 80 Cal. App. 3d 90, 95, 145 Cal. Rptr. 570, 572; " . . . radical sex conversion surgery is the only medical treatment available to relieve or solve the problems of a true transsexual." Pinneke v. Preisser, 623 F.2d 546, 548 (8th Cir. 1980); "Cosmetic surgery is surgery which is deemed optional or elective . . . . The surgery which is lengthy, requires extensive modifications and realignment of the human body. It is requested rarely, and done even more infrequently. It is performed to correct a psychological defect, and not to improve muscle tone or physical appearance. . . . While many seem appalled at such surgery, it nevertheless has demonstrated proven benefits for its recipients although psychological in nature . . . . From all of the above the court concludes that the treatment and surgery involved in the sex change operation of the plaintiff is of a medical nature and is feasible and required for the health and well-being of the plaintiff, " Victoria L. Davidson v. Aetna Life & Casualty Insurance Co. 101 Misc.2d 1, 420 N.Y.S.2d 450 (Sup. Ct., 1979) .

[39] Tim Alger, "Adoption Case Raises Issue of Transsexuals Legal Rights," Orange County Register, 84 (February 2, 1983).