SIR: An editorial in the Journal (August 11) and some of my work1 was recently criticized, the former for inaccuracy and the latter for inappropriateness.2 I welcome the opportunity to myself comment on both the editorial and subsequent letter.
I think your editorial was quite balanced and unbiased. I say that not because the author accurately and appropriately cited my work but because he tried to present both sides of a highly complex issue that is yet not completely resolved. The issues and questions I first raised in 1965 and amplified and clarified in 19683 must still be dealt with by serious and honest clinicians trying to meet their patients’ needs.
The letter raising objection is particularly flawed for many reasons. Several errors by Walker were correctly indicated by the editors. I am, however, most disturbed by Walker’s undocumented or unsubstantiated claims that my work forces upon hermaphrodites
a sex of reassignment, based on the chromosomes and hormones, even when their genital anatomy is unsuited to the decision or when the mind, with its fully differentiated gender identity, cannot assimilate the change.
I am thankful that your editors cited Walker for his mistake. Juxtaposing the article and my work in regard to the area of transsexualism, it is in this area of patient treatment that perhaps my papers served to be more humane than the extrapolations that came from then extant propositions of Money et alii. Prior to publication of my 1965 paper, the prevailing opinion of Money and his colleagues was, despite the patient’s wishes or genitalia, to attend primarily to the sex of initial rearing to determine sex assignment. After 1965 and to the present, they altered their course to maintain primary concern with rearing but pay attention to the genital anatomy in determining neonatal sexual assignment or reassignment.
In the overwhelming majority of cases, individuals will be reared and comfortable in their assigned sex since it will coincide with their genital (biological) structure. In the case of transsexuals, however, their desire is to attain structural alteration of their genitalia to conform with their psychosexual identity. My conclusion in 1965 and still today is that sexual predisposition at birth is only a potentiality, setting limits to a pattern that is greatly modifiable by ontogenetic experiences. Life experiences most likely act to differentiate and direct a flexible sexual disposition and to mould the prenatal organization until an environmentally (socially and culturally) acceptable gender role is formulated and established. In deciding on how to best formulate and establish an acceptable gender role, the patient himself or herself must be allowed to make the crucial decision of sex assignment and receive professional help in that direction. This is in keeping with the recommendations of Bettinger,4 who considered that individuals should be given treatment, medical and sociological, in accordance with the sex of personal preference and irrespective of the sex of rearing, and Roth and Ball,5 who have stated:
The anatomic equipment will limit or dictate what treatment can be undertaken but the patient’s social circumstances, sexual identification and personal wishes have to be allowed to decide the issue in the majority of cases as far as this is practicable.
Other clinicians have expressed similar convictions. This certainly would then be the most humane way to deal with transsexuals, for they by definition are individuals who have been brought up in a sex appropriate with their genitals, and yet prefer to be surgically altered to live as the other sex. Since these individuals are generally no longer children when they consult physicians for help, they must be given a right to choose their own destiny. We as professionals can offer our expert advice as authorities to help the patient decide, but we must not be authoritarian and force him to decide “our” way.
Subsequent changes may be traumatic, but so might be continuous living in a non-desired sex. I would leave it to the individual to decide whether the chance of trauma is worth the procedures involved.
In my more recent paper,3 I present some clinical cases to be considered in any discussion of the theoretical framework for human sexual orientation. Particularly appropriate is the expansion of the theme that in most cases of sexual assignment or reassignment, where little information on psychosexual orientation is available as in newborns. following the external genitals present at birth would be the preferred practice. This is because the external genitalia can be a good bioassay of the psychosexual bias of the (behaviour mediating) nervous system. Regrettably, for transsexuals, it is probable that they have a nervous system which has been potentiated toward a sexual identity opposite to that concordant with their genitalia. Benjamin,6 one of the foremost clinical authorities on transsexualism, also essentially maintains this view. After birth ontogenetic experiences will determine how far and in what manner the diasthetic potential of transsexuals (or anyone else) will be developed. The potential, however, cannot be transcended. Luckily, humans are quite flexible in what they can live with or adjust to sexually, but we must do all we can to adequately and humanely reconcile the individual’s desires and biological heritage.