Clowns to the left of me… ♫♫

♫jokers to the right♫  ♫Here I am stuck in the middle with you.♫

Also in 1978, at the Harry Benjamin Gender Dysphoria Symposium, Richard Green, M.D., expounded on the problem of the age:

“The name of the game is follow-up. The controversial question of the early 1960’s: “Should transsexual surgery be performed?” has metamorphosed into the compelling question of the 1970’s: “On whom should it be performed? ‘~ Various viewpoints exist regarding the appropriate candidate for sex-reassignment surgery. It has become increasingly clear that candidates cluster into three major groups: i) individuals who report a lifelong core-morphologic sexual identity contradictory to anatomy, an absence of effective socialization in the role expected by virtue of their anatomy, an absence of genital arousal accompanying the wearing of clothes of the other sex, and an absence of genital pleasuring with partners of the other anatomic sex (“true transsexuals”); 2) males who have vacillated in their sexual identity or have been ambivalent in their identity from childhood, who have experienced genital arousal accompanying cross-dressing and who have had sexual relationships with persons of the other sex (“transvestic transsexuals”); and 3) individuals whose core-morphologic identity has been primarily consistent with anatomy, who have manifested gender-role behavior that is culturally atypical~ who have not experienced sexually arousing cross-dressing, and who have had extensive sexual relationships with same sex partners (“feminine male and masculine female homosexual transsexuals”). Some eventually receive surgery; others do not.”

Green wanted to answer this burning question, just who would and would not be helped by transition and SRS.  Transfolk were notorious for dissappearing after they got what they wanted out of the surgeons, so follow-up studies tended to be skewed to those segments of the population who would be inclined to cooperate.  Green proposed that transfolk be required to post a substantial bond to get service.  That bond would only be returned in tranches as they came back for follow-up.

“I propose the following: Each individual who is accepted into an evaluation program for sex reassignment surgery must deposit an appropriate amount of funds for the anticipated professional services into a followup, interest-bearing, escrow account. In the case of medically indigent patients, the State or some third party should deposit a comparable amount on the patient’s behalf. This money is to be returned to the patient at bi-annual visits over a ten year period, one-fifth of the total amount at each visit.”

This would in effect raise the hurdle that less affluent, younger transkids would have to clear.  I can tell you from personal experience that this would have had the effect of driving yet more transkids onto the streets, into sordid means, or to using the services of underground butchers like the infamous Dr. Brown in California.  I could well imagine that for well-to-do older transitioning folk, the bond would represent an affront, and may even backfire, causing less cooperation rather than more.  Fortunately, this proposal went nowhere.

But the question still remained… and in his opening statement, Green shows us a murky problem for the clinicians.  Just who was a “transsexual”?  On one side, they could clearly recognize transvestites, men who clearly were or had been sexually aroused by cross-dressing.  On the other side, they could clearly recognize homosexual men who occasionally put on drag to go to clubs, or homosexual women, who presented as butch as our culture allows.  And they believed that they saw a group in the middle, who requested somatic feminization or masculinization, to allow them to live as members of the opposite sex.  So far, pretty straight forward.  But what to make of those folks who requested such somatic changes, but could be recognized to have very strong resemblance to transvestites or homosexuals?  What of those who, in their presentation and narratives, downplayed such resemblance, but hints were there anyways?

The problem some thought was to find those bright shining lines that served as a demarcator for being a “true transsexual”, to separate those who were actually either homosexual or transvestite, calling them “pseudo-transsexuals”.  Some researchers already thought that they had found these bright shining lines.

Person and Oversey had simple, bright shiney lines for MTF types.  If you were attracted to men, you were homosexual, period.  If you were having, or ever had, sex with women and cross-dressed, you were a transvestite, period.  Their “primary transsexual” was completely asexual, but had vacillated on their gender identity growing up, usually having made “one last effort to be a man” before succumbing to their disorder.  They readily admitted this was a very tiny minority.  (Blanchard later demonstrated that Oversey&Person’s “primary transsexual” was autogynephilic.)

Green’s description of the three types is recognizably based on Stoller’s typology of “true” or “primary” transsexual.  For MTF, his bright shining lines were drawn very tightly.  If you were attracted to men, but used your penis, you were a homosexual, period.  If you were attracted to women, and/or experienced arousal when cross-dressed, you were a transvestite, period.

Notice that Stoller’s and Person&Oversey’s “primary transsexual” were mutually exclusive, they didn’t even overlap!

Even Fisk at Stanford, which had the most liberal policy for acceptance for SRS, used a tripartite model: homosexual, transsexual, transvestite.

Using these indicia, various clinics made decisions as to who they would deign to allow SRS.  Different clinics had different criteria, ranging from strictly “true transsexuals only” to very liberal, everyone welcome, so long as you pass the “Real Life Test”.  Of course, you could always go overseas or Mexico, where if you had the money, they had the knife!

Given these models in use by various programs, there was a powerful incentive to lie, to craft one’s personal narrative and history to fit the acceptance criteria, as stated by Berger, as reported by Green,

“It certainly seems that we are all agreed that one of the problems that we are trying to deal with in evaluating results is determining what happens to these people postoperatively. I think that it is equally a problem in that we do not know what happens to those who are rejected. I think that these people are consummate actors in many cases, and that when they are rejected, they learn what it was that they said wrong so that they can go to the next place and say it right. Since we do not communicate with each other and have no way of doing so about our results with specific patients, there is no way that we can really followup a specific patient in their travelings from clinic to clinic.”

This lying became very extensive, as Deidre (Donald) McCloskey, whose 1999 autobiography Crossing: A Memoir documents numerous episodes of auto-erotic transvestism, writes (using the third person “Dee”):

“The young woman psychiatrist asked Dee the usual questions, mentally running down a checklist of the gender-crossing illness. “When did you first want to be female?” “Were you effeminate as a child?” (…) Dee started to lie. They all do it. Of course gender crossers lie. They can read the DSM just as well as the psychiatrists can. “Oh yes” Dee said to the Free University psychiatrist, “I’ve always had these desires. Oh yes Doctor ever since I can remember. Oh yes it’s just like being a woman in a man’s body. Oh yes Doctor I hate my penis. Oh yes Doctor whatever your dopey list says“.

(McCloskey 1999) (Bolded text is as originally printed)

Note that McCloskey’s interviewer is asking questions based on Stoller’s “true” transsexual profile.  This lying may have distorted research, paradoxically adding weight to what we later learned was a flawed concept.  But as Berger shows above, and Meyer shows below, the fact that SRS candidates lied was very well known.

“It should be borne in mind that there is a degree of uncertainty in the data. This uncertainty derives, among other factors, from having seen the patients intermittently, rather than continuously, the patients’ tendency to dissimulate in order to achieve sex reassignment, and the confidentiality of the evaluations which prevented direct checking of statements. …  However, since most patients are aware from the literature of the “correct” early history, a degree of common falsification, and therefore factitious similarity, must not be discounted.”

In contrast to this concept of the bright shining line, was the continuum of symptomology and gender dysphoria.  Harry Benjamin himself thought this was true.  Meyer at Hopkins held this opinion.  He clearly described a range of autogynephilic and separately homosexual individuals who requested SRS.  Interestingly, he also described a group he called “Eonists”, which I recognize as transkids, both MTF and FtM.  (Ironically, he used the term “Eonist” which was named after a famous historically significant cross-dresser, who by his history, is easily recognizably autogynephilic.)

So, as Meyer and Benjamin described, Freund pointed out, Blanchard powerfully demonstrated & defined, and Nuttbrock recently corroborated (if unwillingly); there are no bright shining lines dividing and creating a middle group.   There is nothing between the classic extremely gender dysphoric AGP transsexual and the classic closeted transvestite.  There is nothing, save possibly deep disgust and shame regarding the penis, between the classic demure “true transsexual” and more flamboyant club crawling street trannies and drag queens.  There is only one line, the one separating homosexual from non-homosexual transsexuals.   But that is not the line that may be used to determine who is and who is not suitable for somatic feminization.

In the end, I think Meyer summed it all up best,

“One is faced, however, with more ambiguity than clarity when the differential diagnosis for applicants requesting sex reassignment is limited to homosexuality, transvestism, and transsexualism. Far too many patients fall into the gray areas between. The selection of an overall classification, with the addition of descriptive subcategories, would seem more workable.

With this in mind, I would propose recognizing the condition of sufficient gender discomfort, skew, or unease to request sex reassignment as the “gender dysphoria syndrome.” This admirable term and its application, to my knowledge, were originally suggested by Norman Fisk (1973). As mentioned previously, factors in assigning the “gender dysphoria syndrome” label would be a sense of inappropriateness or incapacity in the anatomically congruent sex role, a sense that improvement would ensue with role reversal, …  …and an active desire for surgical intervention. Explicit in this definition is that the patient take some active steps to realize the interest in reassignment.  …  The use of “gender dysphoria syndrome” has the added advantage of emphasizing disharmony within the patient’s own gender rather than implying, as in the term “transsexualism,” the successful negotiation of a gender, even though an anatomically incongruent one.

There is still the question of how to deal with the loosely used, generic term “transsexualism.” I find that I can no longer use “transsexual” or “transsexualism” without quotation marks. The use of this term suggests that there is a single diagnostic entity “transsexual,” which in current loose usage is characterized by a request for sex reassignment. All applicants, however, are not the same, and reassignees from the various clinical categories will presumably react quite differently to their surgical modification over time. Kubie and Mackie (1968) have previously emphasized these problems of definition as they relate to follow-up. An appreciation of the presenting clinical varieties emphasizes the need for great specificity in initial patient characterization if one is to speak of improvement or deterioration over long-term follow-up. Without these preliminary distinctions, with all patients lumped together, the truly valuable information will wash out of follow-up series and any opportunity for specificity in future prognosis or selection will be lost.

I would propose that the term “transsexual” be abandoned except for one specific usage. The term should be reserved only for those patients who have actually undergone, and completed, genital reassignment. The term, therefore, would refer to an anatomical fait accompli, and would have no further meaning. It could then be used as a purely descriptive term without implications regarding etiology, psychodynamics, character structure, preoperative adjustment, postoperative course, etc. It could be used much as the term “amputee” to describe a postoperative fact, with no implication as to physiological dynamics (diabetes, arteriosclerosis), character structure (alcoholic, drug addict), or the hazards of the fates (accidental trauma).”

Blanchard thought this definition was too restrictive and that the fact of being post-op was not the key characteristic.  Instead, it was being gender dysphoric and actively seeking social and medical transition that defined a transsexual, of either taxon/type.  I could not agree more!

Further Reading:

Essay on Norman Fisk coining “Gender Dysphoria” and how it allowed autogynephiles to obtain HRT & SRS without lying to clinicians

Essay on Stoller’s description of a “True Transsexual”

Essay on Evelyn Person and the creation of the “Primary” and “Secondary” Transsexual

References:

Richard Green, “Transsexualism: A research note”
http://www.springerlink.com/content/x32756q117717817/

Jean M. Dixen, Heather Maddever, Judy Van Maasdam and Patrick W. Edwards, “Psychosocial characteristics of applicants evaluated for surgical gender reassignment”
http://www.springerlink.com/content/j3478u3647875058/

Jon K. Meyer, “Clinical variants among applicants for sex reassignment”
http://www.springerlink.com/content/qx35288724j54862/