Primary and Secondary Transsexualism–Myths and Facts

Notes on Gender Role Transition

By Anne Vitale Ph.D.

Primary and Secondary Transsexualism–Myths and Facts

January 22, 2000

It is with dismay that I continue to encounter individuals with gender identity issues using the terms Primary and Secondary Transsexualism as diagnostic indicators. The terms show up repeatedly in Internet chat rooms, in the Internet news groups, in my email, and by individuals presenting to me in my private practice. The individuals who self-identify as Primary Transsexuals are usually using the term to mean that they are “Benjamin Type VI, true transsexuals.” Those who self-identify as Secondary Transsexuals are usually trying to diminish their condition and to find some way to deal with their gender dysphoria without having to face the possibility of transitioning. As we shall soon see, neither term has ever had anything to do with severity or prognosis. There is no hierarchy of transsexualism. There are no Primary Transsexuals or Secondary Transsexuals. There are only gender dysphoric individuals who need help.

Never-the-less, important information about the variations of behavior within transsexualism has come to light from the efforts of those authors who thought the severity of gender dysphoria was quantifiable. But before we get to that, here is a short history of these classification attempts.

Sex researchers have been trying to classify people who display gender-variant behavior since the early part of the Twentieth Century. They started by naming the more obvious subgroups such as male cross-dressers and effeminate homosexuals. Later as more individuals came forward seeking help regarding gender rather than sexual orientation issues, a host of authors tried to come up with umbrella terms to distinguish those male individuals seeking sex reassignment who display, what is referred to as “innate” or “core” feminine behavior from those who display behavior that is indistinguishable from non-gender-dysphoric males. As a result, we are left with an array of awkward terms ranging from automonosexualism (Rohleder 1901), homosexual and non-homosexual transvestism (Money and Gaskin,1970-1971 ), primary and secondary transsexualism (Person and Ovesey 1974a and 1074b; Stoller, 1980; Levine and Lothstein, 1981) and now androphilic transsexualism and autogynephilic transsexualism (Blanchard, 1989a).

The terms Primary and Secondary transsexualism came to be the most commonly used. Meanings for those terms were those described by Ethel Person M.D. and Lionel Ovesey M.D. in two papers published in the 1970s (1974a, 1974b).

What has interested clinicians most about Person and Ovesey’s study was that they clearly showed that, along with what everyone considered to be the “classic” effeminate homosexual transsexual model, there existed an even more prominent group of non-homosexual genetic males seeking sex reassignment. Although for some it seems counter-intuitive, Person and Ovesey designated the non-homosexual group Primary Transsexuals and the homosexual transsexuals, Secondary Transsexuals. Looking beyond the terminology, here is what they came up with.

Essentially, Person and Ovesey define a Primary Transsexual as one who is functionally asexual and who progresses resolutely toward a surgical resolution without significant deviation toward either homosexuality or heterosexuality. They define a Secondary Transsexual as one who is a homosexual and effeminate from early childhood into adulthood. Within the Secondary classification they identified two sub-classes: Homosexual transsexualism and Transvestitic transsexualism

In discussing Primary transsexualism, Person and Ovesey note that of the 10 non-homosexual transsexuals in their study sample, 9 showed no evidence of effeminacy in childhood. Each member of the sample was clearly identified by both male and female peers as a boy and was never referred to as being a sissy. They participated in rough-and-tumble behavior as required and did not engage in girls’ activities any more than the other boys in their peer group. All 10 of the sample were socially withdrawn in childhood, loners who read a great deal, watched television or occupied themselves with private hobbies. Each of the sample admitted to being envious of girls and fantasized being a girl, but the authors note that none of the sample actually believed he was a girl.

In the second part of the study (1974b) the authors report that the homosexual transsexuals they studied resembled the clinical and then-perceived stereotypical transsexuals. These genetic males were effeminate from earliest childhood. As children they preferred girls as playmates, avoided boyish pursuits and were “mother’s helpers.” Crossdressing began in childhood, initially for narcissistic satisfaction, but later at puberty to attract male sexual partners. Cross-gender fantasies were frequently tied to identification with movie actresses and drag queens. The authors note that the homosexual cross-dresser wants to be noticed and to this end often wears flamboyant and colorful clothing and engages in theatrical endeavors.

Also included in the Secondary classification, were those cross-dressing transsexuals who were characterized as never being effeminate in childhood but instead were appropriately masculine, and occasionally exceedingly hyper-aggressive and hyper-competitive. They neither played with girls nor engaged in female pursuits. They fantasized about being girls when cross-dressed, but valued their assertiveness and maleness.

Given the number of later authors who attempted to classify transsexuals as either primary or secondary, it is obvious that they also believed that one form of gender dysphoria was more significant than the other. However, these authors differ radically from Person and Ovesey over which sub-type should qualify for which classification. For example, Stoller’s primary transsexuals fit the description of Person and Ovesey’s secondary transsexuals. Stoller further asserted that Person and Ovesey’s primary transsexual should be referred to as secondary transsexuals. The following year, Levine and Lothstein (1981) described a condition they called “primary gender dysphoria” in genetic females. Neither Person, Ovesey nor Stoller agreed with Levine and Lothstein.

Given these important differences of opinion, Primary/Secondary terminology has largely been dropped from the literature. It has instead been replaced with sex researcher Ray Blanchard’s more descriptive and non-hierarchical Autogynephilic and Androphilic transsexualism. (More on these classifications in a future work.)


Despite efforts to classify transsexualism hierarchically, neither sexual preference nor a history of feminine behavior have been shown to have any bearing on whether or not an individual will or will not profit from treatment. The work of Person and Ovesey was helpful in describing the range of behaviors and orientations to life that transsexuals may experience. From this we have learned that transsexuals can be widely different from one another, yet show a common need for their condition to be understood and helped. There are no primary transsexuals or secondary transsexuals. There are no true transsexuals or “wannabe” transsexuals. Being gender dysphoric in a society that barely acknowledges the existence of such a condition requires the development of coping mechanisms. Some coping mechanisms are more overt and obvious than others. But no matter what the individual does to survive, one thing is certain, everyone who suffers from gender dysphoria must eventually come to terms with his or her situation.

Blanchard, R. (1989a). The classification and labeling of nonhomosexual gender dysphorias. Arch. Sex. Behav. 18: 315-334.

Levine. S. B., and Lothstein, L. (1981). Transsexualism or the gender dysphoria syndromes. J. Sex Marital Ther. 7: 85-113.

Money, J., and Gaskin, R. J.(1970-1971) Sex Reassignment. Int. J Psychiat. 9: 249-269.

Person, E., and Ovesey, L. (1974a). The transsexual syndrome in males. I. Primary transsexualism. Am. J. Psychotherapy 28; 174-193.

Person, E., and Ovesey, L. (1974b). The transsexual syndrome in males. II. Secondary transsexualism. Am. J. Psychotherpy 28; 4-20

Stoller, R. J. (1968), Sex and Gender, London, Hogarth.

Stoller, R. J. (1980), Gender identity disorders. In Kaplan, H. I., Freedman, A. M. and Sadock, B. J. (eds.), Comprehensive Textbook of Psychiatry, 3rd ed., Vol. 2, Baltimore, Williams & Wilkins.

Rohleder, H. (1901) Vorlesungen uber Geschlechtstrieb und Geschlechtsleben des Menschen [ Lectures on the Sexual Drive and Sexual Life of Man], Fischers medizinische Buchhandlung, Berlin.

Copyright, 2000 by Anne Vitale, PhD
Dr. Vitale is a Licensed Psychologist specializing in gender related issues. Dr. Vitale’s office is located at 610 D Street, San Rafael CA 94901, (415) 456-4452, Email: Contact Dr. Vitale. This note may be reprinted in any non-profit organization’s newsletter if Dr. Vitale’s name and address appear with it. Other publications must obtain written permission from Dr. Vitale. A copy of any reprints must be sent to Dr. Vitale.

A Short History of the Victimization of Transsexuals by Medical Incompetents and Quackery

In 1967 after the October anti-war demonstration at the Pentagon I made my way to San Francisco’s Haight Ashbury and eventually moved with a cadre of radicals to Berkeley.

When I came out in 1969, the first places I went to seeking help were the Welfare Department and a pair of gay rights organizations, SIR (Society for Individual Rights) and the Mattachine Society.

From them I got three names: The Center for Special Problems on Van Ness Avenue.  Dr. Fong in Oakland and a Dr. whose name escapes me.

I was poor.  The Center was free.  Dr. Fong was cheap and did a couple of tests for hormone base levels and a sperm count. Plus he gave a hormone shot.

The other Dr. ran a number on me.  He hypnotized me and asked me my “real name”, a trick question considering the only identification I had at the time had the name given me by my parents.  Because I gave him my legal name, which coincidentally I was still using as I was just starting hormones and had not yet started living as a woman full time.  He told me I wasn’t really transsexual.  I told him to go fuck himself.

Easy for me to do as I had two other Doctors who said I was and soon Dr. Benjamin would concur.

Suppose I didn’t have other Doctors contradicting this semi-quack’s evaluation.  How many sisters did he sucker into not looking for treatment at that point by running his hypnosis game?  For what it is worth I went about as far under as I would behind a joint of Thai stick weed and nowhere as deep as I had on even 200 mikes of acid.  I was a veteran of a few 1000 mike trips where I had gone deep into the memory files.  His question was a trick question aimed at furthering his own agenda.

We were lucky in the Bay Area we had our own Transsexual Counseling Service, run by us and for us.  We had the Center and Stanford University Medical Center’s Gender Clinic.  We also had several reputable Doctors and an alternative to the Center named Fort Help.

The only problem was that one had to be sane enough to work one’s way through the programs.  The myth is that one had to be pretty to be accepted by these programs and get surgery at Stanford.  The reality was that one had to look enough like a member of the sex one was changing to to be able to hold down a job, even if that job was sex work.

Los Angeles had a Dr. Gaunt who had an office operating room in the Max Factor Building across Hollywood Blvd from Grauman’s Chinese Theater.  He did castrations and breast implants on the transsexual and transgender sex workers of Hollywood.  He had a reputation of asking only one question, “Do you have the money we agreed upon, in cash.”

He operated in his office.  In 1972 he started doing SRS, something completely over his head.  Cash up front, no questions asked.  We had a person with MPD (DID) who came to our office.  Molly was transsexual, Johnny was not.  Molly got SRS from Dr. Gaunt, Johnny jumped off a building and died.  Dr. Gaunt’s surgery techniques were crude at best and it is to his credit that he stopped performing SRS after several attempts although he continued doing castrations and boob implants for sometime after that.

In the summer of 1973 a new player rolled into San Francisco, Dr. John Brown and his sidekicks the Spences.  They were full of promises, one of which was that Dr. Brown had developed a technique of constructing sensate clitorises.  No waiting in line like at Stanford, no pesky psychiatric evaluation.  You paid your money and took your chances.

I questioned the legitimacy of Brown almost immediately based on having seen the same pattern with Gaunt.  I wanted to know what his medical credentials were.  I was bothered by his sudden appearance from nowhere claiming a skill that seemed to require a fairly high degree of training.  I was  bothered by  not only his operating in an office lacking the equipment to care for someone who might experience a medical emergency during surgery, but also by stories I heard of his operating, in at least one instance, in a kitchen and  another instance in a garage.

When I raised questions regarding his qualifications and methodology some sisters accused me of not wanting them to get their surgery because they couldn’t afford Stanford.  I never particularly enjoyed having my motivations questioned particularly when I wasn’t being paid for my opinions.

Besides I was off learning photography and in the process of becoming a lot of sisters’ “Lesbian Experience”.

I later moved to Los Angeles and in about 1977 I learned that Dr. Brown had killed at least one sister and maimed a few others.  He had his license to practice medicine yanked in California and had gone underground, resurfacing in Tijuana where he was once again doing cut rate SRS of varying quality based on his relationship with his various forms of substance abuse and his state of sobriety on any given day.

There was a new danger on the horizon:  Silicone pumping.  I was an out lesbian feminist, by the time that one hit and had rejected the ultra glamor scene.  I watched silicone injections become the new heroin among transsexuals and transgenders.  People cited positive articles from Vogue and other fashion magazines on the benefits of silicone injections in erasing lines and filling acne scars.  The logic I heard often went like this:  I have silicone breast implants therefore silicone injections must be harmless.

I naturally had a feminine body, developed even more so by hormones.  I was accused by some of not wanting them to have the same rounded hips and ass because I warned them of the dangers of silicone injections to enhance one’s hips and butt.  I told people wanting to get it shot in their cheeks to give them the high cheek boned look that there was a safe way to do that with solid silicone prostheses implanted atop the bone.

Well, Dr. Brown is in jail now.  However not for botched SRS procedures, not even for botched SRS procedures that killed women with transsexualism.  The action that went too far to be ignored was Dr. Brown’s amputation of a healthy leg from an amputation fetishist that resulted in said fetishist dying.

The silicone pumpers are still out there pumping silicone bathroom caulk and floor wax into people who are having their bodies disfigured by the eventual reactions to the silicone and its impurities.

The invention of the psychiatric diagnosis of GID in 1979 brought forth herds of quacks with dubious credentials all eager to exploit people with transsexualism and transgenderism.

Not to mention the religious mind fuckers with their fraudulent cures for homosexuality, transsexualism and transgenderism.  They are all out there trolling the internet, pushing books offering salvation from transsexualism by praying it away.  One can find several books by just such people on Amazon.

I automatically presume someone who emerges from nowhere, who makes strange sounding claims and citing certain people is a fraud.  There is a pattern to their spiel that says to me, “This person is running a con game.”

It really doesn’t matter if it is silicone pumping or the opening of a radical new form of counseling service.  Legitimate people have histories, they do not emerge from the ether or hide behind aliases and credentials that seem shady.

One can trace their credentials.  Too often the silicone pumpers and others claim medical degrees from foreign schools, something that requires them to pass strict licensing requirements to practice medicine within the US.

Counseling service licensing requirements are often much more flexible although not if one bills oneself as a psychiatrist, psychoanalyst, psychologist or clinical social worker.  When looking for services look for the license and the degree.  Ask yourself if you really trust someone who vacillates on producing the same documents and references that one normally sees on the wall of the office of a legitimate licensed professional providing those same services.

Peer to peer counseling is one thing.  You can get that in rap groups at LGBT/T centers.  But if you are being asked to pay then you have the right to know the qualifications of the person or persons asking for that fee.

There are many New Age forms of fraud and medical quackery out there, often hiding behind offers of  validating magical thinking or wish fulfillment.  The old adage of “If it sounds too good to be true then it probably isn’t.” offers the same advice that I took nearly 1500 words to offer.

Dallas Demonstration in Support of ENDA

Yesterday afternoon Tina and I attended a demonstration in support of ENDA.

It was held near the offices of Senator Kay Bailey Hutchison.

In spite of attendance being sparse, fewer than two dozen people taking part for varying periods of time we did have the opportunity to speak with Jim McGee, her North Texas Regional Director.

The exchange was polite on both sides.  A pleasant contrast to the howling mobs of Tea Baggers who greeted Senator Hutchison during her campaign for the Republican candidacy in  the forthcoming election for Governor of Texas .

It felt good to go to this demonstration, a putting of action to words.  Taking small economically reasonable actions in order to politically influence our Senator.

Even if we have little chance in winning her support it was good to have people driving by us see our signs as it means that we too are part of the Texas body politic.

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