Gender Confirmation Surgery: Principles and Techniques for an Emerging Field

Gender confirming surgery represents one of many therapies for individuals with gender dysphoria and can be pivotal in allowing individuals to become their true selves. An emerging field, this text represents a continuing evolution of surgical techniques, as well as a framework around which surgical therapies are based. Providing a fundamental understanding of the surgical principles while also recognizing the fast-paced nature of the advances in technique, Gender Confirmation Surgery touches upon the challenges and complexities in the surgical care of transgender individuals, featuring detailed sections for transwomen and transmen surgeries, non-surgical options, and establishing educational programs.
Written as a guide primarily for surgeons in plastics, urology, and gynecology, this book can also appeal to primary care practitioners, mental health professionals, and endocrinologists. By representing an evolution of technique and advances in the field, Gender Confirmation Surgery offers a framework around which practitioners can familiarize themselves with gender surgery.

• Language: English
• Publisher: Springer
• Release date: Jan 31, 2020
• ISBN: 9783030290931

Book preview

© Springer Nature Switzerland AG 2020

L. S. Schechter (ed.)Gender Confirmation Surgeryhttps://doi.org/10.1007/978-3-030-29093-1_1

1. History, Societal Attitudes, and Contexts

Jamison Green¹  

(1)

Independent Scholar, Vancouver, WA, USA

Jamison Green

Keywords

SexualityTranssexualGenderHomosexualityAndrogynyGender role

The Concept of Transsexualism

The modern concept of transsexualism is rooted firmly in the nineteenth century when the applied science of sexology was emerging and the fields of science and medicine were intoxicated with their relatively new systems of classification and examination [1].

In 1886, Richard von Krafft-Ebing (1840–1902) published Psychopathia Sexualis, a collection of recountings by patients, as documented by Krafft-Ebing, of their sexual fantasies, desires, or feelings and acts [1]. His text was reissued 11 times before he died; each new edition expanded to include an ever-increasing number of cases divided into detailed categories of perversions, dementia, and degeneration. The project was intended to guide the legal profession in the application of jurisprudence and to present to physicians and jurists facts from an important sphere of life: sexuality (emphasis added) (Krafft-Ebing 1886) . It became a surprise bestseller, even though Krafft-Ebing had obscured what he felt were its most obscene passages by rendering them in Latin rather than German. At that time, of course, the sections in Latin could be read by any educated person, including members of the clergy. As one might expect, the text sparked a controversial debate in the public sphere over sexuality – tinged with fascination and revulsion and stimulated by prurient lust and moral indignation – that has continued into the twenty-first century.

Transsexualism per se was not mentioned in Krafft-Ebing’s text (the term had not yet been coined), but several of the case studies he documents under his categories of antipathic sexuality – homosexuality, viraginity, psychic hermaphroditism, gynandry, androgyny, effemination, eviration, defemination, etc. – describe people whose appearance, mannerisms, feelings, experience, or self-understanding might today be understood as typical of what, since the 1950s, has become the classic transsexual narrative.¹ Psychopathia Sexualis set the stage for subsequent discussions of the topic of gender variance (or deviance, or diversity), from Krafft-Ebing’s contemporary sexologists such as Magnus Hirschfeld (1868–1935), Albert Moll (1862–1939), Havelock Ellis (1859–1939), and Max Marcuse (1877–1963) to later professionals who took an interest in sexology, most notably David O. Cauldwell (1897–1959) whose article Psychopathia Transexualis [4] invoked an extremely pathological view of female gender variance, unsurprising for post-World War II society, and introduced the concept of transsexualism (with a single s) in North America [4] and John Money (1921–2006), who, with colleagues Hamsun and Hamsun, first promoted the concept of gender [5].

Karl Ulrichs (1825–1895), a German writer who studied law, theology, and history, first worked to create a taxonomy to enable discussion of sex and gender variance from the simple binary concepts that most people believed in and thought they understood. He described homosexual men as having a female psyche in a male body, giving us language that was adopted in the early twentieth century to describe transsexual people.

Magnus Hirschfeld believed science and scientific understanding of sexuality would lead to justice and social acceptance for sexual minorities. He contended that each human being is neither a man nor a woman but is both, at the same time, in unique and unrepeatable proportions, thus theorising his doctrine of sexual intermediaries, a refinement of a concept which can be traced back to Charles Darwin (see [6]: 22–23) and even to the ancient Greek physician Galen (see [7]: 4–7). Hirschfeld first invoked the term transsexual by way of the phrase seelischen Transsexualismus (spiritual transsexualism) in a 1923 essay Die Intersexuelle Konstitution. Surgical sex reassignment began experimentally, using animals, in Vienna in 1912, and attempts were made to surgically transform people from one sex to the other throughout Europe in the 1920s. Hirschfeld’s Institute for Sexual Science in Berlin was a site of some of the earliest sex change or sex reversal surgical procedures, later referred to by English speakers as sex reassignment surgery (SRS), transsexual surgery, gender (or sex) confirmation surgery, and (most recently) gender affirmation (or affirming) surgery.

The term phalloplasty was first used by Jos. Sprengler in 1858 to mean a repair to external tissues of the penis ([7]: 311), and the first reconstruction of an entire penis was reported by Nikolaj A. Bogoras [8, 9], while the first application of the procedure in a transsexual patient was reported by Harold Gillies and R.J. Harrison in 1948 [10]. The first reported vaginoplasty performed on a trans woman was done by Felix Abraham in 1931 [11] (for greater detail, see [12] and [13]). Surgical normalising of intersex children enabled a practice forum for the fashioning of both male and female genitalia. Gillies and others created new techniques to create normal-appearing genitals in adults. Because of the drive toward normalising, transsexual people could only access services if they subscribed to (or at least could convincingly claim acceptance of) the medical definition of who they were and they shared the medical objective of conformance to the binary view, then the only moral justification for such procedures.

By the late 1950s, the medical community had firmly assumed captaincy of the ship of sex and gender, which were thought to be essentially the same thing. An uncomfortable debate on the fringes of the medical and psychological communities persisted, with some asserting trans people were helped by finding congruence between their body and mind (see [14, 15]), and others arguing that people who requested sex reassignment were exhibiting neurosis, which does not respond to surgical intervention (see [16]). For transsexual people, to look for information about themselves in the psycho/medical scientific literature of the second half of the twentieth century (almost the only literature available) was, in most cases, to see themselves objectified and ridiculed – often an intimidating experience. But it didn’t stop them from seeking relief.

The taxonomy of binary sex and gender which posits only male and female as essential and valid physical categories, with specific social roles, has been reinforced by social inequality between women and men and by an assumption of heterosexuality as a behavioural norm. Hirschfeld’s idea of sexual intermediaries found desexualised (idealised) psychological expression in Carl Jung’s concept of animus and anima, the internal male or female that lives within each woman or man, respectively, and sexualised physical expression in human beings born with ambiguous genitals or other problems of sexual differentiation, often called hermaphrodites or intersex people (see [17]). Another German sexologist, Max Marcuse (1877–1963), published about the drive for sex transformation (geschlechsumwandlungstrieb) in 1916, distinguishing the desire for sex-change surgery from the more generalised sexual inversion (conceived of as homosexuality, exemplified by extremely feminine males or masculine females who were attracted to same-sex intimate partners) or cross-gender identification, which was frequently associated with cross-dressing behaviour ([6]: 19), though over a century later, its legitimacy is still being questioned.

German endocrinologist and American émigré Dr. Harry Benjamin (1885–1986), who later was to popularise the term transsexual [14], encouraged effective medical treatment and legal recognition in the new sex. He would become a champion of transsexual people in medical and legal arenas through the latter half of the twentieth century, until a new, less-medicalised self-advocacy emerged in the 1990s [18, 19], heralded by the term transgender.

Transgender quickly became an umbrella term, intended to be inclusive of a wide variety of behaviours and identities that did not conform to the stereotypes reinforced by the binary. To complicate matters further, many people objected to the term transgender because they felt their gender never changed, but it was their sex characteristics that wrongly circumscribed their identity. Others felt the stigma of having their label associated with sex, and they were more comfortable with the euphemism gender. Eventually, and partly to avoid the sex/gender debate, many people simply shortened the label to trans. More recent terms coming into wider acceptance are nonbinary, GNC which means gender-nonconforming, TGNC for trans and gender-nonconforming, and TGNB for transgender and non-binary. This article will continue to use the terms transsexual, transsexualism, and trans" because these are the most commonly understood terms intra-culturally at present. Readers should not take this to mean that all transgender or nonbinary or TGNC-identified people will desire or eschew surgical intervention. The boundaries between these categories are highly permeable, and new vocabulary arises continuously, so medical professionals must be flexible and listen to and respect the terms their patients employ.

For many trans people, though, transsexualism is a term fraught with social disapprobation, fear, shame, and negative judgement. One important resource publication targeted toward the transsexual reader seeking legal information in the 1990s stated that

...gender dysphoria syndrome is described thoroughly in the literature. The literature suggests that: (1) the causes remain unknown; (2) presurgical transsexuals as a group are among the most miserable of people, often exhibiting extreme unhappiness which frequently brings them to the verge of suicide or self-mutilation... [and] [t]he literature indicates a consistent trend towards [sic] rejection by both family and friends, harassment and/or discrimination in varying degrees by most of society, and more often than not a refusal by many in the legal and medical professions to render services, either by reason of questioning the validity of such a diagnosis, or perhaps fear of potential peer and/or community sanctions. [20]

Incidence and Prevalence of Transsexualism

At the turn of the twenty-first century, thousands of transsexual people are living ordinary and extraordinary lives around the world. However, there are no reliable numbers that specify either the incidence² or the prevalence³ of transsexualism. What little is known has been derived from studies in a few clinics in several European countries, notably Sweden [21, 22], the UK [23], the Netherlands [24–26], Germany [27], and Belgium [28], and one study in Singapore [29]. The numbers yielded by these studies cannot be cross-compared because they rely on different data collection methods and different criteria for eligibility of subjects to be counted as a transsexual person (e.g. whether or not a person has undergone genital reconstruction, versus whether a person has initiated hormone treatment, versus whether a person has come to the clinic for assistance in accessing medically supervised transition services). They also do not consider the fact that the available treatments offered in the clinic setting might not be perceived as affordable, useful, or acceptable by all self-identified transsexual people in a given area; therefore, by counting only those people who enter the clinic, some number of transsexual people will be overlooked. That these and other culturally specific factors have been unaccounted for in studies indicates that results are likely to underestimate significantly the actual occurrence of transsexualism in nearly every cultural setting.

In 2007, two professors of electrical engineering, Femke Olyslager of Ghent University in Belgium and Lynn Conway of the University of Michigan, presented a paper at the World Professional Association for Transgender Health (WPATH) Symposium in Chicago, describing their efforts to arrive at a reasonable prevalence rate [30]. Analysing the data from the studies cited above in new ways and extracting further results from them, they arrived at a prevalence rate between 1:1000 and 1:2000. This figure is more than an order of magnitude greater prevalence than the accepted figure of 1:17100, which is derived from the clinical records in the Netherlands (1996), where it has been reported that roughly 1:11,900 adult male-bodied people medically changes their sex to female and 1:30,400 adult female-bodied people medically changes their sex to male [26]. Applying the Dutch ratio to the US population yields ~13,500 adult transsexual people who have had genital reconstruction in the US (US Census Bureau estimated the adult population = ~230,000,000 in 2008: 115 million natal males and 115 million natal) females. Credible researchers looking at the same data can arrive at widely varying estimates of the adult transsexual population of the USA. It is reasonable to conclude that there are probably between 13,500 (Dutch ratio) and 230,000 [30] transsexual adults in the USA and that this range, though broad, is relatively consistent across populations worldwide.

Cultural Extent of Transsexualism

Evidence of transsexualism exists in virtually every known culture, race, and class, and while the frequency and sex ratio might vary among different cultures,⁴ it is most likely, as shown above, that there are far more transsexual people than have been estimated. For the most part, transsexual people are invisible to mainstream society, and many function successfully as unremarkable men or women; if this were not the case, society would already be more aware of transsexual people.

Many others live on the social fringe, unable to find legitimate employment, struggling with drug addiction, mental health issues, or other disabilities that may or may not be related to their transsexualism or the reaction of people around them to their transsexualism. This type of existence has long been common in India; in Brazil, Peru, and Mexico; and in Malaysia (migrations through Europe and the Americas are common), although some transsexual people in these countries are rapidly becoming politicised and undertaking efforts toward social change.⁵ Also, the global effort to prevent the transmission of HIV and other sexually transmitted diseases has created a literature and a sociology that includes transsexual people, mostly trans women, even if only marginally.⁶

For the most part, although their bodies and medical histories are unusual, after a few years of treatment and living permanently in the preferred gender role, only a transsexual person’s physicians, those with whom they are intimate, and/or those to whom they choose to reveal their history are likely to know that they have changed their sex, especially in the case of trans people living as men [34]. Generally, trans lives are made easier or more complicated in correlation with the agreements operating within their culture: if their existence is culturally acknowledged, especially with validation of their expressed gender identity, and if they have access to jobs and basic health care, transsexual people are much more likely to lead healthy and successful lives [35].

The willingness, or not, of governmental bodies to acknowledge a trans person’s affirmed identity can influence their ability to find and retain employment, a key factor in normalising life experience in the USA [36]. In some cases, where there is no other social place for them, trans people are forced into sex work [37]. Some seek sex work as a way of self-validation in their new gender role [12]. When trans people are engaged in criminal behaviour, whether for survival or self-gratification, they are more likely to come to harm and to the attention of the public; this form of visibility lies at the root of many stereotypes about trans people.⁷ The fact that more trans women (aka transfeminine people, those born with male bodies who transition to female) than trans men are active in the entertainment industry, too, increases their visibility.

The public is often ignorant of transsexual men (those born with female bodies who transition to male, also called transmasculine people or trans men); being much less visible, they are assumed not to exist. The image of a man in a dress, made up to look ultrafeminine, seeking attention, or especially soliciting sex on the street in a run-down neighbourhood or urban park, is, thanks to the media, a prototypical notion of transsexualism in the USA.⁸ Such images contribute to the sense of guilt, shame, and low self-esteem that many trans people experience, feelings that warn against engaging in any activity that brings public attention [39]. Trans men generally are not glamorous or flamboyant, so they largely escape notice. They, and the majority of trans women, too, are generally law-abiding and prefer to avoid courts and jails, knowing that trans people do not always fare well in prison [40].

The human body historically has been conferred certain rights in law. For centuries, rights, privilege, and status could accrue only to male bodies (in some cases in British, European, and American societies, only to Caucasian, light-skinned, male bodies⁹), while women and other non-white men were chattel, servants, or little more than beasts of burden and were frequently regarded as lacking the capacity to reason, even lacking souls [7]. Particular qualities: autonomy, authenticity, authority, dignity – and rights: privacy, freedom, and equality – attach to, or conversely are denied, a corporeal presence. Yet the ways in which difference, particularly gender variance, has been both objectified and exploited have presented trans people with immense barriers against achieving equality under the law as the men, women, and human beings they know themselves to be.

Opinions about transsexualism found a wide audience in popular literature of the 1940s and 1950s. Transsexualism was apparently attractive to mass-market publishers who were willing to exploit freakish subjects, and there were successful business models in Krafft-Ebing’s publishing history and Barnum and Bailey’s sensational displays. Legitimate scientists and medical practitioners concerned with the health and well-being of transsexual people had difficulty finding acceptance in peer-reviewed journals for topics that many physicians considered bizarre or deviant.¹⁰ American sexologist David O. Cauldwell, M.D., Sc.D., found an expressive niche as an author with the general distribution publication Sexology: Sex Science Magazine from 1946 until his death in 1959 [43]. This publication sought to provide for the layman ‘true sex information of a scientific nature’ (Editorial, 1958: 751) [43]. Cauldwell wrote over 3000 articles for the magazine, which carried essays about such topics as Homosexual Chickens, Extra Breasts in Women, "Can Humans and Animals Crossbreed?, Sex and Satan, and Types of French Prostitutes [44]. These are titles from the contents of Yoe’s anthology; Cauldwell was the author of Can Humans and Animals Crossbreed? and many others. He used his medical credentials to establish an authoritative tone that captured his readers’ attention and respect. Yet, according to Ekins and King, there is no trace of Cauldwell publishing in the academic literature".

Cauldwell’s 1949 [4] article Psychopathia Transexualis established several myths about transsexual people in the popular consciousness, even though almost nothing was known at the time about transsexualism as a scientific or medical construct. Cauldwell wrote that there are people who live as members of the opposite sex because of some misfortune, accident, or physical malformation which causes them to become transsexuals by affectation, enabling them to live useful lives; these individuals are, he declared, evidently…all purely autosexual. This claim implies transsexual people are so inverted; they are not a social or sexual threat to others. They do not impose themselves on others, lie, cheat, or seduce, like the specific female-to-male case he describes in his article. He inferred that an obsessive desire for hormones and surgery is indicative of the underlying psychopathology in transsexual people. He blatantly stated it would be a criminal act for a surgeon to mutilate a pair of healthy breasts or to castrate a woman with no disease…and without any condition wherein castration might be beneficial ([4]: 276), never imagining that such treatment might have intrinsic benefit for the patient. Psychopathic transsexual individuals, Cauldwell asserted, have a poor hereditary background and a highly unfavourable childhood environment. This claim recalls eugenic theories about homosexual men. He also claimed that [p]roportionately there are more individuals in this [psychopathic transsexual] category among the well-to-do than among the poor. Poverty and its attendant necessities serve, to an extent, as deterrents ([3]: 274). This implies that children of the rich are spoiled, wilful, selfish, and delusional, while the poor are respectful of others and able to subdue their desires and are, therefore, virtuous and realistic; or it might imply that poor people are simply too busy trying to meet their basic survival needs to indulge in such fantasies. He never considered that there might be any number of reasons that it might not occur to an uneducated, economically disadvantaged gender-variant person to seek professional help, not the least of which would be the expense.

Cauldwell provided few references to any scientific literature to substantiate his opinions. Yet, many of Cauldwell’s assertions were frequently repeated in popular commentary about transsexual people even into the 1990s,¹¹ indicating that his opinions, or inferences made from them, had become foundational to many damaging beliefs about gender-variant people (and possibly about poor people as well). Practitioners of both law and medicine live in society, too, and they are just as easily informed by popular beliefs, especially if they have no reason or opportunity to become otherwise educated; this is particularly true concerning marginalised subjects. Lending historical perspective to the misplaced confidence we have seen in judicial rulings that chromosomes are the definitive element of sex, it was only in 1956 that the world learned humans have 23 pairs of chromosomes instead of the 24 pairs previously believed ([45]: 41). Science never stops seeking, and finding, new facts; society, however, may not be ready to hear them.

The Benjamin View

Endocrinologist Harry Benjamin, M.D., whose 1966 book on transsexualism [14] reached a wide popular audience, had his first contact with a transsexual person in the early 1920s, though he acknowledged he did not think of the patient as transsexual [46]. A male-bodied individual who lived as a woman at home, presented as male outside the home, and wondered whether a newly available estrogenic hormone would enlarge his breasts, which would give him a great emotional satisfaction. The hormone was effective in producing mild gynecomastia (enlargement of breast tissue in the male) to the infinite delight of the patient and with emotional improvement. Benjamin wrote:

This desire for physical changes, I realized later, characterized the transvestite as having a transsexual trend. The true transvestite would not be interested in it, at least not seriously enough to do something about it. He is content with cross-dressing alone. (Benjamin [14]: 2)

Benjamin later encountered two young adult males who exhibited enough feminine characteristics and behaviours that they were repeatedly harassed by their college classmates. One young man sought masculinisation, and his father told Dr. Benjamin that his son had never been a real boy. The other, Benjamin notes, was afraid he was on his way to becoming a homosexual. Benjamin reported:

I was unable to follow either one’s career but, in retrospect, I am reasonably certain that at least the second boy was more likely to develop into a transsexual than a homosexual, because in him there was a disturbance of gender consciousness, which is not the case in homosexuality.

It is difficult to know what Dr. Benjamin meant by a disturbance of gender consciousness. He may have meant a particular awareness on the part of the patient that he was not or could not be male in some way that felt expected of him. Alternatively, Benjamin (and possibly his patient as well) may have conflated homophobia with transsexualism, such that the patient’s expressed fear of being homosexual somehow signalled a desire to align his body with his feminine qualities so that if he were attracted to men, he then would not be homosexual. Nevertheless, it is clear that Dr. Benjamin was cognizant of the different taxonomies between transsexual people, people who cross-dress, and people who are homosexual in their attraction, but secure in their gender identity (as it is aligned with their body). Benjamin represents, and certainly championed, the harmony principle in medicine with respect to the trans body. He recognised the ability of hormones and surgery to relieve the distress and suffering of those individuals who understood themselves as belonging to the opposite sex. He was later joined, directly and indirectly, by many other skilled physicians, surgeons, psychiatrists, psychologists, and theorists of various disciplines,¹² who have agreed with Benjamin that [p]sychotherapy in all its presently available forms had failed utterly to induce these patients to accept themselves in their anatomical and genetic sex (Benjamin [14]: 4).

Confusion between sex, sexuality, and gender, as meaningful terms, has infused debates about transsexualism since Hirschfeld. Even Dr. Benjamin found these terms problematic, and in his 1966 book, he tried to make sense of them for his readers: There is hardly a word in the English language comparable to the word ‘sex’ in its vagueness and in its emotional content. It seems definite (male or female) and yet is indefinite. The more sex is studied in its nature and implications, the more it loses an exact scientific meaning. The anatomical structures, so sacred to so many, come nearer and nearer to being dethroned. Only the social and legal significances of sex emerge and remain (Benjamin [14]: 15), and determinists continue to rely upon the concept of true sex to deny legal recognition to trans people, despite Benjamin’s efforts to inspire professional compassion.

A paper published in 1968 by a surgeon and two psychiatrists, members of the Gender Identity Committee of the Johns Hopkins Hospital [48], discussed the problems of evaluation and selection criteria that were applied to transsexual people at that time. The paper reveals the authors’ belief that the desire for a change of sex operation is an:

illness [involving] a conflict antedating genital sexuality […–] an attempt by the patient to become asexual, and then appear female to fulfil infantile needs, the origins of which derive from this pregenital period ([48]: 520).

This focus on pregenital, infantile needs suspends transsexual people in a state of helplessness and incapacity. No matter how they described themselves, transsexual people’s issues and concerns risked being misinterpreted or negatively judged.

Benjamin noted that [o]pposition came mainly from psychoanalytically oriented physicians (Benjamin [46]: 5). The University of California, Los Angeles, psychiatry professor Robert J. Stoller, M.D., wrote: transsexualism, a term with a scientific, diagnostic ring, bears no such weight (Stoller [49]: 161). Relying on a 1968 article by Kubie and Mackie, Stoller wrote:

Though there can be sex reassignment, there cannot yet be – I believe – sex change or sex transformation. Sex reassignment is a social phenomenon to be accomplished by legal means and by convincing others to accept one’s changed role (new name, clothes, job, voice, and so on). In brief, the term does not imply that one has changed sex, for that would require chromosomal and anatomic reversal, but only that an assignment – and therefore a role – has changed. Guppies can change sex; humans cannot. Cosmetic surgery and manipulating secondary sex characteristics with hormones or electrolysis create biologic facsimiles only. (Stoller [49]: 162–163)

Lawrence S. Kubie (an M.D. psychoanalyst) and James B. Mackie (a Ph.D. editor of The Journal of Nervous and Mental Disease) recommended the term gender transmutation as an alternative to transsexualism to refer to changes of those bodily characteristics associated with gender differences [50]. They also questioned how much was known (in the late 1960s) about the differences between homosexuality, transvestism, and the desire for gender transmutation (transition from one gender role to the other, presuming there are only two gender roles, male and female). They compared gender disturbances (expression of or identification with a gender role that is not the one prescribed by one’s genitals) in humans with gender role behaviour in subhuman primates, and, after citing many of the limitations on such comparative studies, they nevertheless offered the conclusion that artificial environments and atypical patterns of development increased both the amount and variety of sexual behaviour shown by adult chimpanzees. Specifically, they noted:

Under these conditions they also observed peculiarities in gender-role behaviour: adult males appeared to be more interested in the care of infants and juveniles; females became more aggressive; social dominance for both males and females ceased to be related to sexual behaviour; and sex perversions appeared more often among both males and females, though the range and frequency of these perversions were greater among males than females, just as they are greater among human males [50].

No conclusion was offered, and no scientifically logical connection was drawn between the study of primates and human subjects. This information was simply inserted into a superficial discussion of the acquisition of gender identity, and the reader was left to infer whatever implications might be drawn regarding human gender identity and expression and how transsexualism or gender transmutation develops in human beings. Readers were apparently intended to infer that human beings in artificial environments and [encouraged to adopt] atypical patterns of development will exhibit increased, varied sexual behaviour. The underlying message was that to prevent these developments, parents must provide appropriate environments and limitations on behaviour to ensure comportment with assigned/expected gender roles.

The Gender Clinics of the 1960s and 1970s: John Money’s Paradigm

Throughout the twentieth century, discussion of transsexualism has been marginalised by mainstream medicine, while debates about sex, gender, and sexual behaviour have consumed politics, religion, and education; social sciences such as psychology, sociology, and anthropology; and such scientific fields as biology, genetics, and neurophysiology. Some of the debates have roots in feminism and reaction to the changing roles of women in society; and some have had to do with changing sexual mores; the political visibility of gay men and lesbians; the study of sexology, sexually transmitted diseases, and human sexual response; and better medical understanding of sexual development and differentiation. But antipathy from some practitioners and administrators toward transsexualism did not prevent some medical researchers from using it as a point of comparison in attempts to understand gender identity development and behaviour.

New Zealand native John Money, Ph.D., professor of medical psychology and paediatrics, enjoyed a long career as a teacher and researcher at Johns Hopkins University in Maryland. In 1955, Money published an influential paper with department colleagues Joan G. Hampson and her husband John L. Hampson (Money et al. [51], in which they introduced the concept of gender role :

to signify all those things that a person says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively. It includes, but is not restricted to, sexuality in the sense of eroticism. (Money [52]: 119)

Money was trying to describe the psychology and sexology of hermaphroditism, looking for a term that would allow him to discuss the situation of a person, for example, without male genitalia, but living and functioning as a man in every way except genital, copulatory sex. For Money, this meant that the man could not fulfil the male sex role; hence, without the creation of the term gender role, Money and his colleagues had no way to discuss the subject’s behaviour. Money reflected that, by the mid-1960s, the concept of gender role merged with the concept of gender identity , which had developed at UCLA with Stoller, the originator of the concept of core gender identity , and psychologist Evelyn Hooker, who became known for depathologising homosexuality ([52]: 120).

In what was thought of as a logical outgrowth of his work in gender-role development and sex differentiation, Money directed the first North American university-based gender clinic, established at Johns Hopkins in 1963, first publicised in 1966 ([52]: 121). John Randell established the first clinic in Britain at Charing Cross Hospital in 1967. The Johns Hopkins clinic was made possible following a Maryland court decision ruling that a transsexual could be operated, and thereby protect[ing] the physicians and hospitals involved against legal consequences ([47]: 468). Money’s work in this area received financial support from the National Institutes of Health, the US Public Health Service, and grants from the Stiles E. Tuttle Trust and the Erickson Educational Foundation¹³ [54].

Money and his colleague and co-author, Anke A. Ehrhardt, were, for decades, two of the most influential writers in the USA on gender, sexuality, and sexual dimorphism. They collaborated on one book and numerous articles concerning human sexuality and gender variance. Their theories about ‘tomboyish’ girls, some of whom had an intersex condition called adrenogenital syndrome , were criticised heavily by feminist scholars Barbara Fried [55] and Lesley Rogers and Joan Walsh, for attempting to reinforce outdated gender stereotypes about women and for supporting biological determinism as an explanation for groups in society who behave differently, the so-called sexually deviant groups – homosexuals, transvestites, and transsexuals [56]. The conflation of biological sex, physical intersex characteristics, and deviant sexual behaviour categories was common because so little was known, and so much presumed about what was normal and what was not.

John Money and Clay Primrose published a paper in 1968 entitled Sexual Dimorphism and Dissociation in the Psychology of Male Transsexuals in which they discussed theories of gender variance driven by hormonal imbalances in the womb (and corroborating animal experiments) and compared 14 transsexual women’s self-described sexual histories and behaviours against generalised sexual histories (mostly stereotypes) of homosexual men and heterosexual trans women (then called male transsexuals). This article postulated that a psychosexual ambiguity of differentiation analogous to hermaphroditism might result in sexual deviations such as homosexuality, transvestism or, more rarely, transsexualism. It also declared that [t]he male transsexual [is] the extreme form of homosexual […] completely dissociated from male identity ([53]: 483–484). Psychological aberrations such as multiple personality disorder in one patient and reports in the literature to indicate that, occasionally, a change of personality toward transvestism may occur in conjunction with the development of temporal lobe seizures are offered as evidence that [i]t is […] in neurophysiology as well as neuropsychology that the answer will one day be found to lie ([53]: 483).

John Money’s research of this period helped reinforce the idea of the primacy of the body, and the belief that sexual expression (even when expressed by gender signals rather than erotic intention) that did not conform to heterosexual norms was, at best, the manifestation of deformity.

While physical intersex conditions compelled both curiosity and compassion in the late 1960s, homosexuality remained a strong focus of social concern, even among many of the people who came forward to request medical assistance for transsexualism at the university-based interdisciplinary clinics in North America. These clinics were extremely selective about the patients they chose to treat. Screening out homosexual men intent on avoiding the stigma of same-sex erotic attraction was a time-consuming activity for clinicians. According to Vern and Bonnie Bullough, a husband-and-wife team of educators/researchers who were both registered nurses, sociologists, and historians, who wrote many books and articles on sexuality and sexual history, this is a commentary on our society that some people feel less of a stigma about being transsexual than they do about being homosexual [57]. It may be argued that this was supported by the intersex connection to transsexualism and the idea that those afflicted did not choose to feel the way they did about their gender, while homosexual behaviour was cast as a choice and a perversion.

In part because it was the first sex change clinic in the USA but also because of John Money’s confidently expressed and frequently published theories, Money’s Johns Hopkins gender clinic became the training ground for most American psychiatric gender practitioners through the 1980s. However, the clinic experience was less rewarding for patients. Most applicants to the university-based clinics were rejected as transvestites or homosexual men and were offered therapy to help them adjust to life as a member of their natal sex [58]. Patients with physical abnormalities or hermaphroditism were not classified as transsexual and therefore were not treated in these clinics, even though they might have had surgical sex reassignment in another wing of the same hospital. The mental illness model of transsexualism gained precedence in this clinical environment, where stringent requirements were imposed on those who met acceptance criteria that included adoption of a sex-stereotyped manner of dress and appearance (literally along John Wayne/Marilyn Monroe lines) [59]. Candidates became like performing animals, following prescriptive behavioural instructions in order to achieve the withheld prize of hormones, surgery, and legal status in their new sex, and were then criticised by their trainers for their efforts. This professional attitude enabled the sociological critique of what were presumed to be delusional fabrications that transsexual people employed to achieve their aims. It can be argued that objectification from both the hard sciences and the social sciences, combined with prescriptive, rigid, and gender-stereotypical (if not sexist) requirements for treatment, and a general inability to imagine that a person could actually feel that they had the wrong body led to the easily accepted conclusion that trans people are liars.

Psychiatrist Ira B. Pauly, M.D. summarised the clinical experience accumulated by the late 1960s as follows:

Psychotherapy has not proved helpful in allowing the transsexual to accept that gender identity which is consistent with his genital anatomy. [emphasis in original] […] Transsexual patients have been pushed into psychosis, at the point where their well-meaning therapists felt that they were beginning to ‘cure’ the patient of his gender misidentification. There is considerable evidence from studies on hermaphrodites and intersexed patients that gender identity is established early, and once established firmly, is difficult, if not impossible to change. […] It would appear that 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. […] This is particularly true of those operated transsexuals who are successful in obtaining a legal change of status and thus are free to subsequently marry […]. (Pauly [47]: 465–466)

Dr. Pauly wrote that [e]nough experience has now been accumulated so that certain criteria for sex reassignment surgery can be suggested ([47]: 469). This was over 10 years before the development of the first version of Standards of Care for hormonal and surgical sex reassignment of gender dysphoric persons.¹⁴ Pauly’s comment that legal status is particularly important to a successful outcome for transsexual patients is notable, since even now, two decades into the new millennium, recognition in the law remains a significant goal for trans people and a barrier to their full participation in society in most countries.¹⁵

Ultimately, much of Money’s work was discredited by his support of behaviourist theories and his refusal to admit to the failure of the John/Joan experiment ([61]; see also [62]) in which one identical twin boy’s penis was damaged in a hospital accident in Canada, offering the renowned Dr. Money an opportunity to prove his theory that children were blank slates with respect to gender and that making the genitals resemble female physiology and raising the child as a girl would result in a socially well-adjusted female adult. Sexologist Professor Milton Diamond, who had long been challenging Money’s theories of sexual identity formation [63], and the psychiatrist who had treated John/Joan, Keith Sigmundson, M.D., collaborated on an exposé of the case that Money had claimed was lost to follow-up, and therefore a success when it clearly was no such thing. Joan had experienced a very difficult childhood as a girl whom other children perceived as excessively masculine and was relieved when, at age 14, she was told she had been born a boy: she renamed herself David and began living as a male [62]. It seems illogical that Money’s experience with transsexual people would not have already informed him that no matter what their genitals look like and how their parents try to raise them, some people’s gender role/identity is different from that which their body might attempt to dictate. However, in the 1970s and 1980s, John Money remained very much at the epicentre of gender role developmental theory.

Hegemony of the Mental Health Model and Demise of the Clinics

Within the structured environment of the