Change-of-Sex Surgeries at Johns Hopkins: About 20 Done So Far
November 6, 1969, Vol. XIV, No. 56
Life’s Such a Drag, They’d Rather Switch
by Charles W. Slack
For the past five years or so, the Johns Hopkins Hospital in Baltimore has been offering a change-of-sex service to certain carefully screened patients. This service has its psychotherapeutic and hormone-therapy aspects as well as its surgical procedures and thus demands the participation of a team of specialists representing plastic and reconstructive surgery, gynecological surgery, urology, endocrinology, and neurology, in addition to psychiatry and the press. It is the psychiatrist who, together with the patient, makes the final decision as to whether the rest of the team goes to work or not.
Just how well their work was going became the topic of a symposium last Wednesday evening as the Gender Identity Clinic (this is what the Baltimore physicians and surgeons call themselves) gathered to review progress before colleagues at the New York Academy of Medicine. “Trans-sexuality in the Human Male and the Sex Reassignment Operation” was the title of the meeting and it brought out the biggest crowd the halls had seen since sexual responsters Masters and Johnson did their thing at the Academy a few years back.
Most people who undergo the sex reassignment operation come to the Hopkins clinic with more or less normal male genitalia and leave it with genitals looking and functioning more or less like a normal female, although there are a few who qualify for (and hence get) the approximate female-to-male treatment.
The demand, at least in the U.S. and Sweden, is about 2.7 to one in favor of urogenital men asking to become women. In the Union of South Africa, for some reason, it is reported that there are more urogenital women who want to become men. Data from the remainder of this globe are not yet available.
Wide publicity attended the Identity Clinic’s first sex-changing success in 1965 and, since then, more than 1000 people have written Hopkins requesting the operation (or at least more information about it). The head psychiatrist on the U.S. team, Dr. Jonathan Meyer, mailed a fairly detailed questionnaire to everybody who wrote in and well over half the people filled it out and sent it back. The questionnaire provides good information about U.S. citizens who wish to change sex.
The typical applicant is 25 to 30 years old, in the lower-middle-class income bracket, and is apparently law-abiding in every respect not related to trans-sexualism. More than half have tried psychotherapy but most complain, usually bitterly, that psychological treatment is no help at all with the problem (one or two report that psychotherapy is okay for the side issues although definitely not good for the main trans-sexual hangups).
Hormone treatment is a different matter. Almost all trans-sexuals take hormones before trying to go for surgery. Female hormones taken by males produce female secondary sex characteristics such as breast development. Male hormones taken by females produce an enlarged clitoris. Opposite-sex hormones also produce (or reinforce an already existing) low sex drive. In fact, weak sex drive is one of the surprising characteristics of trans-sexuals as a group. Since so many people who want to change their sex take hormones, it has not been possible, until now, to find out whether they would be different from the rest of us if they didn’t. The Hopkins clinic was able to assemble, from its large volume of applicants, a small group of males who had never had female hormones. Endocrinologically speaking, they turned out to be no different from normal males. Thus, in all probability, the desire to change one’s sex does not ordinarily stem from physiological causes. (There is some hint that damage in the temporal lobes of the brain may be involved but the evidence is not overwhelming.)
Of those who apply for the operations at Hopkins, only a small per cent qualify. The rest, presumably, if they are persistent, must go elsewhere — which, at the moment, means out of the country. To get one’s sex reassigned in Baltimore, one must not be diagnosed paranoid-schizophrenic or otherwise psychotic. One must be living continually (preferably continuously) as a member of the opposite sex. This means more than cross-dressing and changing names: people with conjugal or pseudo-marital relationships are preferred. According to the doctors experienced in interviewing trans-sexuals, those who are really committed to the trans-sexual life represent only about five per cent of those who apply. Really committed trans-sexuals are often well adjusted to their altered role. The very adjustment makes them genuinely frightened of discovery and with some good reason. As trans-sexuals, they pass as the opposite sex. Thus exposure could mean legal, social, and occupational disaster.
The gender-clinic physicians are strong in their agreement that the genuine trans-sexual is not a homosexual. Often enough homosexuals will inquire about or even apply for the operation in the mistaken belief that it might relieve some of the social and sexual pressures now upon them, but during the extensive interviewing given all applicants the homosexuals are disqualified or, more likely, disqualify themselves when they find out what it’s all about.
In the first place, sexual reassignment is not really an operation but a series of procedures. While under observation by the team, and while using hormones, one must first live for a period as a full-time member of the opposite sex. Then those parts of the process which are reversible (breast removal in the female-to-male, breast development in the male-to-female) are undertaken before such irreversible as removal of penises. Before any surgery is undertaken, the team spends a good bit of time talking to the prospect and explaining just what to expect and not to expect. One can understand why this would be necessary. The aim of the operative procedure is basically to satisfy the patient by (1) removing the external genitalia associate with the undesired sex, (2) replacing them with the external appearance of genitalia associate with the desired sex (penises are made from skin grafts from other parts of the body), (3) for male-to-females, providing a functioning simulated vagina. The whole team participates in one way or another during the operations. Reoperations are far from rare and, unfortunately, the whole process is tinged with trial and error. Only about 20 people have been switched so far here in the States, but the clinic is presently going at the rate of one a month. The big-volume sex-changers have so far been the Japanese, Turks, Danes, and Swedes. While admitting that the foreigners might be a bit advanced on the aesthetics of reconstruction (practice makes perfect and they’ve had more change), the U.S. doctors express uniform dismay at foreign lack of attention to urological complications. One gets the impression that as long as the job looks good, the Turks are happy — never mind what develops urogenitally after the patient gets back home.
There can be no doubt that people should have the right to be free of such fears and to pursue such happiness — through hormones or trans-sexual surgery or through any other means medical science can come up with. The pursuit of happiness down one-way streets must not be denied. God Almighty, however, help those psychiatrists to direct this traffic wisely.