Appendix D Biographical Profiles H: Male transsexual. Age thirty-eight. Operated upon at age twenty-seven. When last seen was living successfully as a woman.

H's father was an intelligent but passive man who repeatedly failed in various business ventures and was dominated by his wife, an aggressive, domineering, and somewhat masculine woman. The family's considerable standing in their small New England community was a legacy from H's paternal grandparents, who also left them sufficient funds to withstand the father's business failures.

At the age of two, according to both H and his parents, H refused to wear boys' clothing and would resort to temper tantrums whenever an attempt was made to force him to do so. The parents submitted to his demands and he was allowed to dress as a girl. His mother, if she did not encourage H's taking a feminine role, certainly raised no strong objections to it. Moreover, the family physician recommended that H be permitted to dress as a girl until such time as he would grow out of the desire - probably, this doctor surmised, at puberty.

In his neighborhood, H dressed as a girl outside the home as well as inside. His playmates knew that he was a boy, but did not harass or ostracize him. At school, his grades were excellent and he maintained good relationships with his classmates. Despite his effeminacy, all his relationships outside his family were remarkably free of conflict.

When the time came for him to enter high school, H demanded that he be given permission to attend classes dressed as a girl. The school authorities refused to grant this permission and H then discontinued his education and stayed at home, doing housework. He read a good deal, including various works dealing with transvestism, operations to feminize men, etc. In his teens, he demanded castration. He journeyed to an Eastern city to see a surgeon who, he had heard, would perform this operation. When he was unable to locate the surgeon (who had left the city), H returned home and became increasingly violent. His feeling of frustration and despair caused him to fly into rages, swear, break dishes and furniture, and throw things. Finally, he made physical attacks on his father and mother. He was then turned over to juvenile authorities and, shortly thereafter, was transferred to a hospital where his case was studied by many staff members. The result of this exhaustive study was a recommendation that castration and penotomy be performed and an artificial vagina constructed. However, no surgeon could be found to carry out the recommended operations. He was then sent to another hospital where, although his psychological femininity was conceded, surgery was refused.

Although he had never heard or read about such activity, H began spontaneously to masturbate toward the end of his thirteenth year. He masturbated about four times a week. His masturbatory fantasies were of males, often of soldiers carrying guns. He also fantasied being whipped (as a small child) and being made to wear male clothing.

H is the fourth of five siblings. With his oldest sister, seventeen years older than H, there was mutual dislike and constant conflict. She refused emphatically to accept him as a girl and objected to his wearing girls' clothing regarding this as a threat to her own social status. Since the parents sided with H, this sister left the home. She has since refused to have anything to do with him.

With a sister eleven years his senior, H had an affectionate relationship. He slept in the same bed with her until he was well up into his teens. Upon graduation from college, this sister continued to live at home, refusing to seek employment. One day when H and his sister were alone in the house, she suffered an "acute schizophrenic breakdown." Sex play between the two was suspected by psychiatrists. The sister believed herself to be the bride of Christ and to have been impregnated by Him. She was placed in a state institution and some years later was still confined there.

H was sexually attracted to a brother six years his senior. He says that this brother would embrace him and reassure him that his condition did not affect their relationship. On such occasions, H would experience an erection.

His fourth sibling, a brother three years younger than H, rejected him completely, apparently regarding him as a threat to the social standing of the family.

H expresses feelings of affection for both his parents. He admires his mother's "courage, independence and initiative." He reports that his father was always very affectionate toward him - the father tucking him into bed and kissing him goodnight even after H was past twenty.

H's case is of particular interest because, in addition to examinations by urologists, sexologists, and gynecologists, he has been studied by a large number of psychologists and psychiatrists. At no time does it seem to have been disputed that H is psychologically much more feminine than masculine.

At Hospital A, where he was sent after his disappointment over failure to achieve Surgery and the resulting violence, H aroused the interest of almost the entire staff and was repeatedly interviewed and tested. A number of staff meetings were devoted to discussion of his case, and at the final such meeting, attended by more than thirty persons, the majority voted for the sex conversion surgery. This hospital's report on the patient includes the following:

After being carried to the level of corneal anesthesia during narco-synthesis with sodium amytal, his first reaction upon slow recovery was feminine. His feminine affectations including voice, defensive gestures were even more prominent than on a waking level. He repeated his story (details of his life up to that time) as before, adding only that at the age of three, he felt that his older sisters were getting more toys and prettier clothes and were loved more by his parents because they were girls. He denied hallucinations, delusions, ideas of control, blocking or ideas of reference ... .

This case created a great deal of interest on the part of the staff of the _____ State Hospital and the psychiatric institute and the department of psychology at _____ University. Several personal interviews were had with the patient by Dr. _____, professor of psychology, Dr. _____, professor of psychiatry, the entire staff of the department of neuro-psychiatry here at the hospital, and other physicians in the state service who met jointly at two staff meetings to discuss the problem in this case and also the possible inethods of treatment. The following facts were developed as a result of the joint staff discussions and are to be made a part of this record.

That this individual has been conditioned to his present profound emotional conflict for a long period of time. That because of the inability of the family to correct certain tendencies during childhood and adolescence, this individual is now completely conditioned to his present state. That no form of psychotherapy or any other medical approach can convince this individual that he must assume the role of a male and live out his life as one of masculine character. That all the conflicts and overt behavior toward the family is an expression of the unwillingness of the individual to assume masculinity, and the open rebellion as manifest by his behavior in the past year is a warning sign of potential dangers ahead. The patient has indicated that he will commit suicide before he will try to assume the role of a male. It is further pointed out that this individual has lived an odd sexual life to date and if there is any indication of what the future has in store for this individual that it will have to be in the role of a female, to make life compatible for . Although this individual definite] ' y has all the attributes of homosexualism, there has been no overt behavior on his part that would make him run afoul of the law along sexual lines.

Following the liberal discussion at the general staff meeting in which more than thirty people participated, the majority voted for surgical intervention that would make it more possible for this individual to live out his span of life so as to serve his personal interests and without conflict with the law. It is pointed out that the medical profession has as its first responsibility the welfare and well being of the patient. Where the patient is in danger of developing a severe mental disorder or where the dangers of suicide exist unless the patient can be properly treated, it is the responsibility of our profession to institute treatment directed at the correction or prevention of such complications. It is further pointed out that this individual does not fit into the social order in his present status, and that he will never participate in the social life of the community as a male, that society is in no way being affected as a result of any treatment that might be directed to relieve his present condition. There is, therefore, no moral obligation to insist upon his living as a male from the standpoint of the community or society in general.

Conclusion: It is the opinion of the senior staff of this hospital and the collective opinion of the majority of those who sat in the discussion of this case that this individual should be treated surgically so that it will be possible for him to make a better mental and emotional adjustment and thereby prevent the development of any more serious mental difficulty than exists at the present time. The only alternative would be to delay action in this case and if at a later time this individual develops an actual psychosis he could then be institutionalized. The patient refuses to have any brain surgery done that might destroy his present desire to remain a female mentally and it should be pointed out that any such stirgical operation of the brain might also destroy certain personality traits and characteristics and render this individual ineffective and incapable of taking care of himself in the future. If we recognize as our major objective in this case the relief of this individual's distress and the need for making it more possible for him to live in a normal fashion, it then resolves itself into the question of performing surgery (castration) and plastic surgery, which operation in the judgment of this staff would best serve the interests of the patient in meeting his problems in the future.

There then followed, as noted, a search for a surgeon to carry out the above recommendations. When such a surgeon could not be found locally, the patient was referred to Hospital B where, after further psychiatric evaluation, it was hoped that the surgery could be performed. As at Hospital A, the patient was extensively tested and interviewed. Hospital B's report includes the following:

MENTAL STATUS: At the time of the first interview the patient (age twenty-three) was neatly dressed in a blue plaid suit with a dark blue blouse (silk), long silk stockings, black suede angle-strap shoes with low heels, small handbag and gloves, and wore earrings. At other times the patient was dressed in a small, red velveteen hat with veil (very tiny, nose length), full rayon skirt with plaid blouse, and at one time wore high-heel pumps with lacy cut-out. His dress was youthful, like a young college girl sometimes and at others like a "big city sophisticate." The patient wears a wig of light brown, parted on the side, falling in soft waves and a few curls; sometimes a few curls are pinned up in bobby pins. He plucks his eyebrows (sometimes the regrowth is evident), wears heavy foundation makeup and rouge, lipstick, and nail-polish. In the light a beard shadow is evident, nonetheless. At first, patient presents a pleasant, smiling, cooperative façade. He is ingratiating. However, one very quickly comes to feel under a great deal of pressure from patient. If there is any suggestion of not accepting him fully as a woman, or any hint that all of his requests may not be met, he rapidly becomes suspicious and openly hostile. He expects and demands that a great many things be done for him and is extremely threatened by the idea that it might be possible for him to do anything for himself.

The patient is almost obsessed with the idea of obtaining the operation he requests. Although he can verbalize that he does not actually believe that this will make him into a woman, still he has many fantasies and daydreams about achieving the status of a married woman - with husband, children, beautiful home, etc., which he clings to and continues to hope for. He does not have a realistic idea of the results of the operation or what the future holds for him were this operation performed. He is infantile in his reaction to people - if they accept him and agree with him, he likes them; otherwise, he does not. He has a tendency to exaggerate greatly kindnesses shown to him, especially by men, and to fantasy and dramatize those into special attentions over which he ruminates. He is naïve and vulnerable ... .

POSITIVE PHYSICAL AND NEUROLOGICAL FINDINGS: Patient refused to have the physical examination done by a woman and so it was done by a man. On physical examination the patient was found to have a muscular build with normal male hair distribution except for flat-topped pubic escutcheon. There was slight hypertrophy of the breasts, and inverted nipples, and areola was coral-pink. The heavy growth of hair on the chest was partially shaved, as were the face, arms, and legs. The hair was about six inches long on the back of the head, balding on top. The penis was very large. Bodily characteristics were considered within normal range for male. Mannerisms were very effeminate. The patient wore a wig, brassiére with false breasts, girdle, etc., - entire female attire. He wore heavy facial makeup and his fingernails were painted red.

PSYCHOLOGICAL STUDIES: Extensive personality and vocational testing was done. Considered all together, the evidence suggests that the patient's psychological characteristics, in so far as they have been discovered in this study, are much more like those of the average woman than those of the average man. These attitudes, interests, and other characteristics seem to form a pervasive, internally consistent system - i.e., in none of the factors studied does he seem to be more typically masculine than feminine. . . .

FORMULATION OF PROBLEM: A complex problem involving confused parental identifications, violent sibling rivalry, and a great deal of guilt about sex in an infantile manipulating type of personality who has continued to find victory and rewards in his family life in masquerading as a member of the opposite sex and who now, in the interest and attentions of the medical profession toward him, continues still to find rewards.

There are paranoid trends and the defenses are poor so that the danger of psychosis should not be underestimated if the pressures upon this patient become too great. The effect of the operation he requests should also be considered frorn this point of view as the personality dynamics is not yet clear.

COURSE OF TREATMENT: The patient was accepted at _____ Hospital for evaluation concerning the amputation operation he requested. He was cooperative during this period of study. His case was presented at a group meeting on psychotherapy led by one of the senior staff psychiatrists. The following comments were made:

This patient is not really as convincing as a woman as he could be if he wanted unequivocally to be a woman. This raises the question of the patient's unconscious wishes and conflicts about his sexual status. A patient's message is often different from his verbalizations. This patient has some paranoid trends. The demands of this patient for castration are equivalent in every respect to a patient who says, "I know if you take out my pancreas, I'll be all right." It was also pointed out that one of the problems in this type of case is the doctors with whom the patients become involved, who unconsciously feel challenged in their therapeutic ambitions. The operation should not be performed. The patient should be hospitalized for one year for psychotherapy. Hospitalization would remove the socio-economic stress and place the patient in a position of dependence which would make psychotherapy more feasible.

CASE SUMMARY AND CLOSING NOTE: It was agreed that the patient cannot be cured but that with skillful psychotherapy the symptoms could be shifted so that the patient could adapt better to the real world. The patient should be encouraged to talk about any other problems except this demand for the operation. On the whole, the therapy would follow the lines of treatment used on paranoid patients in general.

One of the consultants in the outpatient department saw the patient for several interviews. He felt that attempts to encourage the patient to wear male clothing were fruitless, for the patient could never pass as a normal male in society. He thought the operation might well be beneficial to the patient.

An informal meeting was held by Dr. _____, Dr. _____ and the therapist evaluating this case. [They] agreed that from the few cases known in the literature it is probable that the operation the patient desires would not be of benefit for the following reasons:

There would probably be no change in secondary sexual characteristics even with complete degenitalization.

Sexual desire would remain, with no possibility for genital outlet if a simple penile amputation were done.

No type of operation would solve the underlying psychological problem.

Patient would not become feminized, as he wishes, but would become a eunuch.

Recommendations were: The operation is not recommended.

Patient should be told the truth, and not "led on" to hope for something which cannot be obtained.

This decision was given to the patient, who became extremely angry and upset, weeping convulsively and rocking back and forth. However, the patient returned after about a month, requesting help for his emotional problems ... . Interviews continued for four months ... .

DIAGNOSIS: Psychopathic personality without psychosis with pathological sexuality. Transvestite; neurotic and paranoid features.

CONDITION AT TIME OF LAST VISIT: Unchanged.

Given the material already presented in this book, little comment is needed concerning the above. Unfortunately, the data now available were not then in existence.

About four years subsequent to his examination and treatment at Hospital B, H had castration and penotomy performed at a clinic in Sweden. The operation was characterized by the surgeons as successful. Following H's return to the United States, the psychological results of the operation were described as "very good."

Several years later, at a hospital in Europe, an artificial vagina was constructed. There has been no contact with H since that time.