this meet. Sex change in social aspect is a

so yes, it's the three. Yes, this

Listen yeah, X, they set me up.

They have known each other. I take it through

referring patients from one to another because it's clear that

a patient with the problem of the time we're going

to discuss could first of all turn up to an

endocrinologist or could first turn up to a surgeon or

could first turn up to a psychiatrist. And I

understand that the three of you have have referred patients

from one to another, but I think this is

the first time there's been an opportunity for on open

exchange of off ideas about the about the underlying causation

and the and the proper treatment of these cases.

So now, although they are experts, I'm quite

sure at least I hope that we do not arrive

at any solutions. In quotes to this problem,

the whole aim of this Medicine and Society forum is

to explore into some difficult areas on. Hopefully we

will raise more questions than we will provide answers on

This is why we always provide a protocol for the

meeting with a list of references This is why we

videotape record thes sessions so that they will be available

for further study and will encourage you to pursue articles

and books and whatever in the literature. Now,

in order to limit to some extent and focus in

on the area, which we think is the one

of major concern here. We decided that there were

one or two aspects of problems of off sexual identity

conflict which we did not want to go into today

on day. One of them that we don't want

to go into is the obvious case off a baby

at birth, for instance who is a clear inter

sexual where it's very difficult to say whether or not

this is a boy or a girl eyes an embryologist

. It's very interesting for me that of all the

systems of the body which develop in the embryo,

it is the genital system which is the last one

to become clearly defined in the course of development for

a long time. In every well, relatively long

time in m. Biological development is very ambiguous as

to whether this is going to be physically male or

female, and sometimes babies are born still with this

ambiguity and uncertainty. Now, we don't really want

to go into those cases because what would happen then

will be there. Be a surgical consult, be

a genetic consult. It will be decided, which

either boy or girl, it would be better for

this baby to be on. Then appropriate surgery will

be done. And then, hopefully the gender identity

instill by the parents into the baby. It would

be of the appropriate kind. We don't want to

go into that question, nor do we want to

go into the question off. Gender identity conflict in

a Children where sometimes the parents will come and ask

for medical advice that the child who is ostensibly a

boy is behaving in a very effeminate way or vice

versa that the girl is a tomboy on the parents

may want the child's behavior more nearly to conform with

the physical sex identity off the child may ask for

psychiatric help in behavior modification or whatever. Now,

this is not the area that we want to discuss

today. What we want to discuss today are the

cases, and they would have to be of older

Children or adolescents or adults who come for a consultation

, saying that although their primary and sex characteristics are

those let us say of a male. They have

felt always that they are really a female trapped in

a male body, and they want some help in

sorting out this problem all vice versa that a woman

will consult and say that although she is physically feminine

, she feels trapped in that feminine body. Wants

to be a male on wants whatever help the medical

profession can provide for her on under these circumstances,

it may well be and a chronological help or surgical

help or psychiatric help, or all three. Or

it may be that the decision is made to try

and persuade the patient that really their desires, which

is what they're coming to express, are not properly

based in reality. So let me, now just

very briefly read through the short protocol, which we

devise for today's meeting. Increase public and medical interest

on the problem of sex change has caused more and

more patients now in the thousands in the United States

to request that they be given hormones to shift their

secondary sex characteristics toward the appearance of the opposite sex

on that they be granted the surgery necessary to convert

their genitals to the appearance of those of the opposite

sex. Should such massive physical changes be the treatment

off a psychological condition, which patients, if any

, among those requesting such treatment will benefit? Since

extensive, adequate follow ups have not yet been reported

? Should restrictions be placed on the numbers of such

patients operated on? If such restrictions are enforced?

What will happen to the many patients who request treatment

and are not accommodated? Are there endocrine a logical

surgical and psychiatric risks to the procedures and, if

so, how severe end of what frequency? In

other words, what are the consequences of doing these

procedures and of not doing these procedures to the patients

, to the medical profession, onto society at large

? On our last Dr Lev? If he would

first make some opening comments on this topic, Thank

you. An endocrinologist who enters into a professional relationship

with the transsexual patient must agree that he begins and

ends the full circle of his treatment with humanity.

He throws in on Lee, a few steroid nuclei

. An endocrinologist treating transsexual patients has little opportunity and

should really require that for razzle dazzle intellectual, broken

field running. But if the endocrinologist allows himself to

be less of a train technologist and more of a

physician and as a physician, if he permits himself

to touch bases in a manner of compassion and humanity

, then there is no more grateful and thankful return

than from the transsexual patient. The initial responsibilities of

the endocrinologist involved assuring himself that both from a psychiatric

and biological consideration, his ultimate treatment strategy is appropriately

applied. He makes careful use of knowledgeable psychiatrist as

an initial step to be assured that the patient he

will treat is the patient who should be treated hormonally

. He makes reasonable and accurate attempts to identify a

disorder of sexual differentiation whose diagnosis would promptly alter the

pace, therapy or order of therapy. Now,

basically, what is the aim off hormone therapy in

treating the transsexual? It really is a multiple strategy

. Really. What you desire to do is to

suppress the undesired sexual characteristics and assume the desired characteristics

the patient wishes. The basis of this is as

follows. Imagine if you would a part of the

brain that produces a trophy hormone. This trophic hormone

is responsible for coursing through the body and causing sex

glands to produce an elaborate their sex hormones in the

normal course of events. The elaboration of these sexual

hormones produces what we consider to be the secondary sexual

characteristics. But if you have an individual who perhaps

should have this concept changed, if you administer exogenous

hormones in amounts greater than are physiologically present in the

body, these hormones act on both hypothalamic and pituitary

centers to decrease the elaboration of the trophic hormone with

a decreased elaboration of the trophic hormone. Then the

hormone normally made by the sex gland is not elaborated

. If that hormone is not elaborated, then the

purpose it's observed does not occur. That is the

maintenance of secondary sex characteristics, or if it were

to begin before puberty, it would deny the expression

of what we consider to be pew brittle secondary sex

characteristics. Not only that, but the presence of

a hormone considered to be paradoxical, that is a

female hormone in a male or a male hormone in

a female might very well produce characteristics that would be

normally not considered associate ID with that particular genetic sex

. Another very important consideration from the endocrinologist point of

view in the treatment of a transsexual patient is time

. Please understand, while from the patient's point of

view, there is a rush. If he confined

a discipline or she confined a discipline, which seeks

to offer them the change they wish. From the

point of view of the endocrinologist, psychiatrist and the

surgeon, time is a critical and essential thing to

buy Time allows the psychiatrist to evaluate, consider support

and examine the patient. Time also allows the patient

on opportunity to very carefully and thoroughly evaluate his or

her own motivations because with the use of hormonal therapy

, assuming that the psychiatrist would agree that it is

not psychologically contra indicated and maybe psychiatrically indicated, we

have an opportunity to produce changes which in males are

reversible and which in females are mostly reversible except for

certain changes. So time really is an important attributes

in the consideration of hormonal therapy. It is surgery

without a scalpel because it is surgery that allows for

change. If there should be a change of idea

. From the point of view of both the male

and the female, there is an enormous psychiatric benefit

. Once hormonal therapy begins. The male patient describes

a quietness, a solitude, a piece. The

female patient describes a feeling continent with the concept that

patient has about her own body. As she visualizes

it in her mind. The details off the hormonal

treatment are basically as follows. What do we aim

for in the mail? We aim, as I

described before, for the psychic effect in the mail

. It is very important for him to have those

secondary sex characteristics that he imagined his body was entitled

to. Breast development. Nipple developed Arriola development.

Many of the males desire decreased erection, and if

hormones or given long enough and carefully enough, there

will be a female distribution of fat in the female

. One of the prime considerations is a cessation of

menses. There is also the desire for hair growth

, and many of the females strongly indicate not all

of the females a desire for the breast to be

taken away. Hormonally, we really can't do that

because when you give male hormones to a female,

the breast do not. In veloute, they may

end veloute slightly or moderately, but of course they

do not do so totally time. There is an

increase in libido drop invoice federal hyperplasia in summary,

then the aim is the suppression off what appears to

be those characteristics consistent with the genetics of the patient

and the desire to accumulate characteristics according to what the

patient desires. Thank you very much. J.

Now you're implying that this is a slower and possibly

reversible treatment. You have more time atyour disposal.

Is it? Well, when you're doing into chronological

treatment from the surgeon's point of view? Well,

is whatever you do irreversible? Or will you now

comment as a surgeon on appropriate therapist? Well,

once the decision has been made to to establish an

anatomical change, uh, it is irreversible once it's

done on. That's one of the important points about

time. Um, the surgeon looks upon. This

is a technical problem which needs a good understanding of

anatomy and also some understanding of a person. And

without going too far into this, I could say

that the technical problems they're pretty well solved, uh

, but that the important point, as far as

the surgeon is concerned, is toe have Cem some

psychiatric and endocrine support. I don't think there's any

surgeon who would want to make an irreversible move of

this nature, either male or female, without having

all the support he could get. It's like going

into a major operation without the capability of blood transfusion

. No surgeon wants to do that, and so

I think that that's our position. The risk is

probably the same with any major operation, probably not

very great, except for the things that can happen

in any operation. I only know of one death

, although I do know that, and either in

Belgium or Holland patient died. And I know of

a number of complications of surgery in both sexes,

which are formidable. And I think the surgeon is

aware of this, Uh, so much for the

just the technical part of it. Uh, and

I think most surgeons who had experience with these patients

, both male and female, uh, feel that

they would like to have them screened completely by the

psychiatrists and the endocrinologists before they ever become involved with

, um, I'd like to see them after the

decision has been made and clearly made. Um,

and there is an ethical side to this which I

think ought to be mentioned and not very many places

in surgery where, UH, we're willing to remove

a normal Oregon. There are some exceptions to this

, but they do bring up an ethical question.

Is, are you justified in removing a normal Oregon

surgically? And to give you an example of some

of the places where it has been justified is a

living donor, and kidney transplantation may give up a

normal kidney, but in the beginning, that had

to be very carefully worked out. And there's still

people who argue that that shouldn't be done. Uh

, the other places where normal organs are removed,

our, uh, when when either the testes or

the ovaries are removed in cases of cancer, where

it's thought in case of a male that the cancer

of the prostate will be stimulated by the testes.

And Dr Huggins, Nobel Prize winner who is responsible

for that form of treatment. When he first got

to it, um wondered about the morality of this

, the ethics of it, and he went to

the local leader of the Catholic Church in Chicago and

asked him about it. And there was a long

silence, and finally the answer came back. Yes

, it was all right. If it was for

the patients benefit for saving his life that if you're

, uh if you're a runner and you want to

run faster and you cut off both your arms so

you could run, be lighter and run faster,

this would be immoral. But if you're chained to

a railroad track and the only way you could get

off to save your life is to cut off your

arm, then that Zatz legitimate in the eyes of

the the Catholic Church, I don't know how exactly

to apply that to the present situation, but But

I thought it would be worth mentioning. Thank you

. Thank you very much. Well, now,

Dr Stolar has had a lot of experience in this

area. And in fact, some of the references

, as you will see on the on the protocol

, are two papers written by Dr Stolen. And

I know that he has some doubts. And hesitance

is about the topic we're discussing today. And I'd

like him to elaborate on I trust Aiken, be

Azaz, calm and medical is my colleagues on this

subject. But I may get a little frantic at

times as I talk. Uh, at this point

in our discussion. I wanna make Onley three points

out of many things that could be discussed in this

. The first one is that we need a differential

diagnosis in order to get started. In this discussion

, that is, we have to say what is

transsexualism and what are the conditions that are not transsexual

is, um, this is not just a pedantic

exercise. It really should be the basis on which

any treatment is undertaken. And also any research about

the outcome of treatment. Let me say a few

words, since I'm especially interested in this subject of

the differential diagnosis of the major categories that I find

among those people who request sex transformation and who diagnose

themselves as being transsexual, that being another at least

medical as, and perhaps ethical issue, that is

, who should make the diagnosis in this condition.

I know that in my experience on the telephone,

and I average five or six calls a week and

two or three or four letters a week, from

mostly from the United States, but sometimes from other

places. Most of the time, the way it

comes to me is I am a transsexual. Do

you treat transsexual is Um, so with that being

a practical issue for me, let me share with

you what I think very briefly are the different conditions

that can be found When a person says I am

a transsexual. First there is something that could be

called transsexualism and very oversimplified. I would consider that

to be those people who are the most feminine in

the males and who have been so all their lives

with no episodes of masculinity and, uh, for

the females, those who have been very masculine all

their lives, with no episodes of femininity. This

, in fact, is a very small group of

the total number of people who requests exchange the second

group. Some of us call transvestites. That word

is so widely used and so poorly defined that perhaps

I have no right toe to use it as if

it were a diagnosis. But transvestite is not a

person who feels himself or herself to be a member

of the opposite sex, but in the case of

males, and in fact, it is practically non

existent in females. These are people who feel themselves

to be males. Do not deny that they're males

. Enjoy the fact that they're males, but at

times put on clothes of the opposite sex, namely

women's clothes, for the pleasure that the springs,

the third group, which could be differentiated, are

effeminate homosexuals. They're not transvestites, that is,

They do not put on the clothes because this bring

sexual pleasure or a sense of relief or comfort in

femininity. They're not transsexuals, uh, in that

they do not wish to change their sex. They

feel themselves to be homosexuals. In most cases,

they're comfortably homosexual. I underlying what I said just

before in the diagnosis. I'm talking about effeminate homosexuals

. I'm not talking about all homosexuals. They like

occasionally to put on women's clothes. They like to

appear that is put on a show. It's fun

for them, but they're not driven to be females

. The fourth group are paranoid schizophrenics. Uh,

this is a ubiquitous finding in paranoid schizophrenia that is

the feeling that one sex is changing. It's almost

a universal finding in the males. In most schizophrenics

. It is a very unpleasant condition, that is

, they complain that they are having their sex changed

at night while they're asleep by unknown forces sending raise

into their bodies and so forth, and only rarely

do they actually request sex change. But they do

occasionally show up. The fifth group are the intersects

patients who way won't be talking about. There are

a small number of those, especially people with a

congenital hypogonadism like Klinefelter syndrome, who feel that they

are members of the opposite sex from earliest age on

. Still another different conditions, uh, another aspect

of the differential diagnosis that I know we won't have

time to talk about. But it is quite important

. And that is, the differences between male transsexuals

and female transsexuals is transsexual is, um, a

condition or a disease or an illness and analogous lee

to appendicitis. It's something that can occur in either

sex or is female transsexualism quite different from male transsexualism

? I personally think that that is the case anyway

, this is These are the issues of differential diagnosis

. That's my first point. My second point thistles

. The place at which I try not to get

too frantic is that this whole damn subject is a

circus. It has been treated as such by the

public, who are not to be blamed to a

lesser extent by the medical profession. I don't quite

agree with Will. I think there are people out

in the community who would operate without a psychiatric evaluation

if they could get away with it. And they

can, that there is one essential factor necessary for

sex change in the United States, and it's the

only one that is, is just about essential.

And that is money mhm, and money attracts rotten

medical practice. And one of the reasons that we

all want to talk about this is can something be

done in this community so that rotten medical practice is

decreased against the terrible force that money has to permit

it? Thio continue in this particular area, I

think, is as bad a situation as faras,

this issue of ethics and morality and and money as

there is anywhere at present in medicine. Perhaps in

the past we would have talked about abortion, I

don't know, but right now here's where the money

is. So I am very concerned about the fact

that that there is this unhappy atmosphere first attempting to

the public and to those manipulators of the public,

the media who love to put on lots of programs

about this. Sometimes I think that the definition of

a transsexual or male transsexual is any person who would

like to get onto a television program and say that

he wants his sex changed. So there is the

public that contributes to this. There are aspects of

the medical profession that contribute to this. Now let

me talk about another part of this unpleasant environment,

which is in part, our responsibility. Uh,

and this is what the protocol points to especially give

you an example. The last patient that I saw

. So I'll make it as's fresh as I possibly

can patient called me yesterday patient that I have seen

for some time a male transsexual. She was operated

a month ago. Up it Stanford, which has

a good program. The things that I'm complaining about

do not exist at Stanford at all. She called

me up. She wanted could I, as soon

as possible get her a point with someone who can

take the pro thrombin times that she has to take

because she had a pulmonary infarct about eight days after

surgery. And, as will says, that can

happen in any major surgery, my question would be

, How often does it happen? Uh, some

days after she was put on heparin, she began

bleeding profusely from the suit shirt area of the new

vagina. And had she not been fortunate, she

would have bled to death. She was fortunate.

I don't wanna go into the details. She had

three episodes of severe bleeding because of the heparin.

And the question is, do you keep your honor

, do you take her out? What I'm illustrating

in this is the following. Uh, how many

of these operations have been done? How many of

these operations have been done in the United States?

How many of these operations have resulted in death?

How many in morbidity, ease and complications of various

sorts? What sorts? How many of these patients

became psychologically disturbed, how Maney were improved? The

question I'm asking isn't those questions. The question I'm

asking is, why don't we have any data to

answer any of those questions? Is there any other

program of treatment where there are major effects in which

we have no data, no follow ups that are

worth anything? I won't take the time now to

review the literature. God knows I know it.

I can tell you there are no follow ups.

There are this report and this report and this one

. For some reason, he published Onley in a

German journal and never was published in English. Though

I heard him presented in Copenhagen. Why doesn't he

presented here one of the best people working with one

of the followers? What are we into? How

many of the schizophrenics who are operated on become more

schizophrenic? What's the suicide rate? Is it any

or not? What are we gonna do about the

patients who go around calling themselves amputees? How many

of them are there? I've only heard of a

few. It's a joke in town, the ones

who are unhappy. How many? We had a

patient over in the N. P. I a

month ago. Somebody in the community has got a

problem. Patient developed a on bliss to the brain

, now has permanent organic brain disease. How often

does that? What are the consequences of the surgery

? So my third point is this, since I

do believe that for certain selected patients, this is

the only treatment at present that we have that brings

any sense of relief, since it is the only

treatment that you could give these patients. When should

we do it, and when should we not?

And who is going to do the work ups that

are necessary? It takes many hours to do these

evaluations. Who's going to do it? Who's gonna

pay for the staff that's going to do it?

There are perhaps 3000. That's a minimum estimate of

the number of people roaming around the United States today

asking for sex change surgery. We don't know how

many have had it done, but there are about

3000 minimum that are already known. They've put their

hand up and said to some clinic or another that

they want the operation. Maybe there are 100 done

in reputable places in the United States. Who's gonna

do the workups on these people? Who is going

to tell the 2947 at U. C. L

. A. That they can't have this and who's

going to deal with them after they've been disappointed?

And who's gonna do the psychiatric treatment on the ones

who need the psychiatric treatment? So my last point

is this your damned if you do and you're damned

if you don't Thank you very much, Bob.

Well, now you've raised a great many questions here

. Why is it that we don't know the answers

to some of these questions that you've put? Is

it a fundamental Puritan streak running through American society and

the medical profession in general that we won't allow ourselves

openly to consider these topics and to have an open

forum debate like this? Is it a area of

inquiry which has been rather kept, uh, in

the dark over all these years? Is this why

there are no statistics available? Uh, from all

over the world, from Europe? Certainly. There

should be quite a lot of statistics available are than

none. Yeah. Are you asked Jerry in your

in your practice to fill in any questionnaires or send

in any information to any data collecting resource anywhere in

the country? No, I'm not in partial answer

to your question. And I can't answer for the

Europeans because I don't know what their malpractice problems are

there. But can you imagine if some doctor was

heroic enough to say I operated on 24 transsexual patients

and I had 12 complications and two people die because

of my surgery when he would do his next surgery

and when his malpractice insurance carrier would cancel him.

Now, I know that sounds terribly practical, and

it sounds terribly earthy. But while all the other

things that Bob has mentioned and all the other things

that we will consider are valid, that must play

a part in coming honestly and intellectually to announce the

kind of follow ups that occur. You're you're exposing

yourself mhm. Does it worry you? Well,

the question when you go into the operating room,

you perform. So every time there's a risk in

any surgery, of course, anything something could go

wrong at any time. A really skilled good surgeon

hopes that his mobility rate will be very, very

low. But there's always the possibility of an anesthetic

death or whatever. Does it worry you if you

are operating on an organ, which ostensibly is a

normal organ and you are modifying it in the way

you in the way you spoke of? Is that

the underlying concern of most people, or is it

a malpractice question? I think I don't think that

malpractice had so much to do with the feeling people

had their after all this subject is just now surfacing

. But it's something that's after Ah, Christine Jorgensen

is more than 20 years ago. Um and she

wasn't the first. I don't think just may be

the first to get in the newspaper. Uh,

but the subject is just surfacing now, and I've

watched watched it over the years, and a lot

of my colleagues took the approach that this was absolutely

immoral and unthinkable and a Zilong as there was that

kind of feeling in society. Why, uh,

nobody wanted to talk very much about it as the

times have changed. And I think everybody would agree

that our society is much more permissive than it was

20 years ago. Why it has surfaced. And

I've just shown you a thing here from from the

American College of Surgeons, which is going to meet

in the middle of May in San Francisco. And

their topic is just what we're talking about today,

whole whole morning spent on it eso surgery of the

transsexual patient is the title of But a few years

ago you could never seen that on a program.

And so I think the that this subject is surfacing

. I don't know why there aren't good figures except

that people just haven't really wanted to talk about it

. Um, as far most surgeons could tell you

about their own individual patients, but maybe not about

a Siri's. And I've always felt that these patients

were primarily belonged not to me, except for the

time that they were in the hospital for the surgery

and that all the rest of it belonged to the

psychiatrists and the Yeah and the endocrinologist. Hmm.

Of course, it is the case now. It's

a great deal. More surgery is performed on what

in the past would have been regarded as normal organs

or normal aspects of physical anatomy. I mean,

the plastic surgeons air into it in a big way

. You could go and have your nose authors or

your wrinkles taken out, or all kinds of things

can be done, which I would suspect 50 years

ago would have been regarded as very doubtful ethically as

to whether it but they won't cut your nose off

even if you had, uh, even for money

. But this question what? What you raised was

the question of the of the of the ethics of

mutilation is what it's called. I think in in

moral theory, isn't it mutilation of the body or

mutilation oven organ on when and under what circumstances are

you entitled to? Mayhem, mayhem, mayhem is

how it would have been regarded in the past.

Well, now today, it's quite meant that you

couldn't serve the king. Mhm. Well, now

it's quite clear that a lot more is permitted today

, and this is probably because we're beginning to see

, isn't it the case bob, That psychological aspect

are a very important part of one's total health of

one's total organization is a human being. And if

somebody is psychologically disturbed, it then becomes ethically as

right to do something to help that psychological disturbance as

if he had a physical disturbance. We're moving much

more into the realm of psychological disturbance and treatment of

those, But can I speak to that for a

minute? Uh, kidney transplantation is one of my

great interests. And when it was new, it

came up for the first time in Boston that,

uh, it was done successfully between twins, and

shortly after that, it came up that there was

two little girls who were underage. One was a

sick twin and needed a kidney, and the other

wanted to give it. But a child can't give

permission. The parents have to give permission. And

the question was, could the parents give permission to

remove this normal organ? And what they did was

take this to the Boston courts. And the judge

in the court said that that he would give permission

for this to be done, because if it weren't

done, the child who didn't who wasn't the donor

would be so upset, psychiatrically that it would be

bad for that child. Yeah, Mhm, Yes

, I wanna carry on a bit with the question

of ethics that you raised, because I think that

at this stage, in our knowledge, it's primarily

a matter of ethics. It becomes less a matter

of ethics if the's follow up studies were carried out

so that we would know, Uh, it is

true that psychological issues are much more in the forefront

of medical awareness, and psychological indications for treatment are

very much considered. But as you run through the

the ethics of the problem we're talking about today,

there isn't just one ethical thread running through it,

and that's what I meant by your damned if you

do and you're damned if you don't. Is it

ethical, not toe have such a program? If

you believe that it helps certain people, is it

ethical to operate when you don't know the morbidity or

mortality? These are opposing ethics. I don't know

the answer to it, but it seems to me

that the beginning of an answer is that somebody establish

a a research program, which would take a long

time because follow ups in this study take a long

time and that the treatment would be restricted to those

places that are willing to do the research and take

a long time. Put that in the psychiatric literature

six or seven years ago. I still believe that

I don't have any reason not to believe it.

I believe it even more now because it's getting that

it's easier and easier now for these operations to occur

, and I think it's unethical at this point for

any surgeon who has a license to operate or for

any endocrinologist. I think it should be as I'm

saying, this kind of discussion should occur and planning

should occur, and not every hospital should have available

in operating room for this to be done. Now

I'm saying this is if nobody else has done this

. In fact, there are places who have done

exactly this. Their reports, their follow ups haven't

come through yet, but I think that it's our

responsibility in the community. I think not. It

is three case. My private opinion is that it's

a responsibility of a major medical center to do what

it can in this community to prevent unlimited surgery or

endocrine, a logical treatment when you don't really know

the outcome when you don't really know the psychiatric diagnoses

of the patients. Now okay, Calling the psychiatrists

, practically none of them can make this differential diagnosis

. That's why my phone rings a lot because everybody

calls me up. I've got a patient. Was

a transsexual know? What the hell do I do

? Well, that could be remedied also, if

this time you could teach this to, there's nothing

tricky about what I have learned in the differential diagnosis

. It's easily taught, though it would take some

time surgery, there's no problems. The endocrinology.

There's no problem. The getting of the follow ups

is no problem if you give yourself time, but

we don't have time anymore, that drums are beating

and the soap is being sold. Bob there.

There's one other problem, and this is where any

kind of program would have to give a lot of

consideration. Many of the patients who have had their

surgery and have been treated under chronologically disappear. You

have to understand that. Not only is it a

question off, perhaps our unwillingness for whatever reason,

to gather information, but somehow or other, there

must be a conscription and participation on the part of

the patient himself or whose self who have had surgery

and one of the things that I've noticed that patients

drift after surgery. And I can understand that if

I have had a way of life and I am

recognized in a certain way, and suddenly there is

a dramatic change, I'm going to go to another

city, and I'm gonna ask to be left alone

, and I'm going to be asked to carry on

my life kind of the way I want to.

And the unfortunate part is is that the Onley time

I begin to ask for help is when I'm in

desperate, desperate trouble so that not only must we

provide the kind of collecting places, but I think

we must also provide a place where patients who have

had surgery understand that we want to know about them

wherever they are and before they get into serious trouble

, be it medical, psychiatric or surgical. Well

, this will be done. Wouldn't be Bob on

your idea. If there were a number of centers

around the country where this kind of off advice on

a deep investigation were underway, it be the same

kind of thing is in the heart centers like Houston

, Texas. You know, patients can be referred

from one center to another for very intricate, very

detailed treatment, which ought not to be available in

every community hospital. Well, I would ask Bob

question. Do you find that even if such centers

existed, that the natural tendency of the patient is

to make themselves use those centers if they existed for

the sake of our follow up? Because they want

some anonymity, they want some privacy. They have

a new life that has begun. Well, let

me let me answer and and in the process,

be putting in a plug for my desire for a

differential diagnosis to be made. Three Answer is that

it depends on the patients. It is true,

in general that males who have had sex change surgery

are very difficult to do. Follow ups are within

the category of males. However. There are some

where there's no problem in doing follow ups. And

somewhere there's a great problem because, in fact,

there psychiatrically different with the females. Everything is different

. They are much more as a large group,

stable of quote, ordinary and fade into the world

. And there's no problem with followers with them.

Uh, but Bernie, what you say female to

male females? Chromosomally female? Uh, but But

it can be done. What you've said Jerry,

is the facts, which are greatly increased. That

is the difficulty because most of the people doing the

, uh, medical aspects of the treatment are not

interested in any follow up. They're perfectly happy to

have the patients go away, I think, because

it was mostly as I said before in my discussed

a monetary situation. But I do think that better

follow ups can be gotten if the people doing the

follow ups want to badly enough but it za lot

of work. I have never seen a patient that

I can think of where I haven't been able tohave

follow ups indefinitely. The longest now is about 16

years, but I don't see a lot of patients

, and I do take a lot of time.

So my follow ups are pretty close to 100%.

I'm talking about people who are operated regardless of the

diagnostic category, but some of them you gotta see

them when they arrive and they'll say good bye.

I'll see you next week and they show up a

year from next week. But still, if you're

there, the follow can be done. I might

, uh it makes me think of something that's a

little bit off the point, but it is also

important about long term follow up, which nobody has

really done much of. There's a first few reports

beginning, Uh, I have spent a lot of

time on it, but not been able to see

a lot of patients because the more time you take

and the longer you do it, the less patients

you're gonna have time to do it with, uh

, the short term follow up with the patients who

are the best candidates for the treatment. Let's say

in the males, the most feminine. And they

have been feminine all their lives. And they have

no masculinity, which could be threatened by castration or

all the other psychodynamic issues that might arise as the

years pass and also the same for the females as

three years pass. These patients never say they're sorry

they had the operation or the hormones. They never

are unhappy. This small group, they are never

unhappy that they've gone through this, but they get

hopeless now. I don't know whether that happens in

all it on Lee happens in all that I see

they get because it is not possible to change anybody's

sex and they know it, even if the rest

of us don't they? First of all, they

come back, and most people laughed at him and

say, They're crazy. The men wanna have ovaries

and they wanna have a uterus. They won't have

a baby, all right, so they're considered crazy

for that. I don't think that that's crazy.

It's crazy if a man asked for that, but

it's not crazy. If a transsexual does because it's

no more crazy than than the patients that I see

who have had hysterectomies, who are women who are

despairing when they've lost them. It seems to me

that if you feel yourself to be a woman,

it would be nice to have female anatomy isn't quite

that simple. And anyway, they know because they're

not psychotic. The transsexuals, they know that they

are males or they know that they are females.

They know that what was done was cosmetic surgery.

They know that you can't change. And if they're

sophisticated chromosomes and if they're not sophisticated, your past

life, your old memories, your knowledge that you

were born a male, you are assigned to the

male sex. Everybody knew that you were male.

You know that you are a male. You cannot

solve major psychiatric problems just by getting an operation.

And that, incidentally, is something again. If

you give me another moment, I should say those

patients who don't fall into that category of the ones

that I think are the best are trying to do

something terribly streamline. They're trying to solve everything in

one stroke slice and it doesn't work. It works

pretty well for the transsexuals. But for some of

the other patients who think that their difficulty in getting

along with other people are making permanent, loving relationships

or getting into some kind of professional life for some

kind of stable existence or the removal of this psychological

simple, or that they have the hope that everything

will be cured. One pill, one operation doesn't

work. But even in those in whom it really

does work well, the long term result is hopelessness

, which on occasion in my Siris of follow ups

, has led to suicide. But let's call it

existentially. Don't call it depression in that psychiatric connotation

that there's something wrong with the patient. It's a

hopeless situation for these people, even when their lives

have gone well. I don't believe they're all going

to commit suicide. I believe that for those patients

, it's better to have operated than not. Whatever

you do, it was the wrong thing. Now

we are going to finish promptly. At one o'clock

, I'm going to ask if anybody has a question

or wants to make a comment that they should come

up to the microphones here so that the audio recording

will be will be made their two microphones that either

side here, if you would like Thio, stepped

up up to the microphone and just identify yourself,

if you would my name his Ray Smith on.

I think I have a question about the change and

the possibility of of pregnancy and having a child after

birth. I mean after change. Now there is

by word of mouth or some other means that statements

that Christine, let's say I think has had a

child. I don't know. Are these possible?

We can Hank answer your very quickly? It's not

possible yet to do anything more than adopt a child

. How about hermaphroditic? Would that be possible to

change them off limits for this discussion? We said

we wouldn't talk about the intersex, but there have

been no hermaphrodites who have who have managed to do

the opposite sex reproductive task right? One other question

would be about the sexual, the actual sexual act

in itself. Would there be any more satisfaction after

the change? Um, often, yes, fortune

. It's a great reason. Is it a sufficient

reason? There's another question. Thank you. I

had a question regarding timing, especially since in the

case, at least of male transsexual is, um

, the diagnosis can usually be made quite early,

perhaps a surly Aziz, age 2345 in that age

range. And Dr Green and Dr Stoller have worked

with such boys, especially now. I noticed there

is a pediatrician on the panel and I'm wondering,

uh, if indeed these, uh, transsexuals identify

themselves as male and that becomes supposedly fixed between 18

and 24 months, maybe depending on your outlook.

How early can we or should we operate or change

the sex in a normal anatomical male who, by

all history is going to be a transsexual or already

is, as I understand it from my colleagues working

in this area off development? It is, during

those first two years that gender identity becomes established.

But whether or not in an area such as this

one should not wait until the patient, himself or

herself can express a positive desire, a positive wish

. I would have thought that with regard to malpractice

suits, it might be even much worse if you'd

operated on somebody. And then the patient said.

But you did this when I was only two years

old. How was I in a position to express

an opinion on. I think the whole question of

of informed consent for Children before the age of seven

or eight is, Ah, very, very difficult

, ethical one. And I would be very reluctant

, I think, to see any surgery performed on

somebody with A with a gender identity problem that is

excluding. Of course, those with inter sexual or

hermaphroditic carry Stoller. Also answer that for the welfare

of the patient rather than the welfare of malpractice,

etcetera. The The whole issue of civil rights is

involved in this, including Children's rights, not an

easy one, Thio Think about. I'll just tell

you my private opinion and, well, I try

to put my opinion into action by denial, repression

, suppression, avoidance, locked my door and so

forth because it's a typical problem. What would you

dio? My own opinion is that a child should

not be operated on for this unless the child asked

for it and these Children are gonna ask for it

. They're happy the way they are now. Whether

they should be forced later on in life is also

an important question. I don't think they should,

but that you could talk about that. When you

talk about the the consenting adults who knows what he's

signing for. That's a different story. But these

Children to do that because they happen to be different

. Boy Sorry, I personally, I couldn't imagine

such a thing. Nor do I know anybody who

could. But I have. Have you ever Bob

seen a child of 23 or four with such a

compelling request for surgery that you would actually, for

the moment, consider surgery? I've seen them make

the compelling request, but I couldn't imagine taking that

child down to surgery and subjecting it to this,

though the Children big as they get older and learn

the styles of begging that are necessary But starting at

four years old, they are saying they want sex

change and they know what they're talking about. Mhm

. Yes. Um, this question is directed to

Dr Levy and you mentioned that endocrine hormone therapy is

reversible. And my question is, how reversible is

it? And have you found cases where ah patient

comes in? Who desires the hormone therapy, gets

the therapy, then finds out that he really,

truly didn't want to become well, He discovers that

he's not truly a transsexual as a result of having

the hormone therapy, and that it wasn't what he

expected and answer your question for the mail. Hormone

therapy is essentially reversible. The gynecomastia that can occur

is, of course, reversible. Even if the

purpose and we're on long term hormone therapy and obtained

female distribution of fat that is reversible. The changes

of tranquil ization are reversible. I would say this

that in the females it's a different issue. For

example, if you give male hormones long enough to

a female, such that she develops a large larynx

, that lyrics does not shrink because you stop giving

hormones secondarily, once hair growth seems to have begun

and there is here statism. The withdrawal of hormones

does not necessarily mean the disappearance of here statism.

One other point that I would like to make.

And it must be understood that if you had a

patient on large doses of hormones, there is the

possibility of producing permanent sterility in thes patients, and

so that must be given due consideration. But essentially

for most of the patients that I have seen,

who are on periods of 345 and six months and

then wished to withdraw. There are no problems except

for the female. Yeah, gain your section as

a male. Or is that is that having a

female hormones depressed male hormone after having removed on the

repression has not been, uh, What I have

found is that most of the patients who have come

to me and then have requested withdrawal of hormones do

so privately by never returning to my office. And

I must be honest with you, and I do

not know the answer from experience. Although the literature

indicates that they probably will return to the same degree

of potency they had before hormonal treatment was started,

no better, no less. We know that from

treating cancer of the prostate with female hormones that men

still are potent, sexually mhm. It was like

in 1953 where they found it's a lot of histological

damages, which, as far as the report went

, if they found it when there's no remission in

that damage, that's one of the reasons it is

important. And the point that I would make is

that what unfortunately happened sometimes is that massive doses of

hormones are given to avoid this very thing. We

talked about time. There is the desire for sudden

change, and literally it takes unending number of cell

divisions for the kind of changes that air desired to

occur. You could just accelerate nature so fast.

And that's it, so that if you begin to

give massive doses of hormones, then you begin to

get into pharmacologic effects of hormones beyond the pharmacologic effects

of hormones were talking about on that, if doses

air given equivalent. So what say a normal female

would require you avoid many of the problems that you're

discussed? Have time? Just for one more question

. This isn't a question, but my name is

Joe Garth E. And I want to say to

the people in the audience, If there's any other

transvestites or transsexuals and and if you want to go

to a meeting like there is one in Hollywood on

Thursday nights at seven o'clock on Cherokee Avenue, a

half um, Allah ah, half a block north

of Hollywood Boulevard, and there used to be one

in downtown Los Angeles that the Metropolitan Community Church Well

, that's been discontinued. Thank you very much.

Now it seems to me that from the absolute silence

that the audience has maintained throughout the whole of the

discussion. We have really this time hit upon a

topic which needs very serious consideration. And I trust

that the tape recording that we've made today will be

seen by many people in the future. And will

they will follow up on the references so that we

can open up this whole field and hopefully come up

with what Bob Stoller was asking for. The the

creation off Centers of excellence for research into this very

difficult topic. Thank you very much.