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Gender Reassignment Surgery Pre-Jorgensen Kaitlyn Rogers North Carolina State University May 9, 2013 When you meet a human being, the first distinction you make is male or female? And you are accustomed to making this distinction with unhesitating certainty.1 Yet there are many for whom Freuds distinction cannot be so unhesitatingly made. For some individuals, there is a disconnect between the sex defined by their genitalia and the gender with which they identify. Individuals who experienced this inversion of sex roles, historically, had to rely upon the use of clothing, makeup and mannerisms to change their outward appearance. In the last sixty years, however, doctors and scientists have developed a combination of surgical and hormonal techniques, collectively referred to as gender reassignment surgery, to actually change the physical sex of some patients. Books discussing the history of transsexuals and gender reassignment surgery generally start in ancient Rome where certain gods were said to have been worshipped by transsexuals who castrated themselves during the initiation rites dressed as women, called themselves priestesses and carried out feminine tasks.2 These same books then go on to describe the Roman emperor Elagabalus (203-222 CE) who is reported to have offered half the Roman Empire to any physician who could provide him female

Freud, Signumd. Femininity. Edited by Peter Gay (New York City: W. W. Norton & Company, 1990), 1.

Carlisle, David Brez. Human Sex Change and Sex Reversal; Transvestism and Transsexualism (Lewiston, Queenston, Lampeter: The Edwin Mellen Press, 1998), Reversal 257.

genitalia.3 Most authors then jump from Elagabalus surgery in 222 CE to the year 1953 when Christine Jorgensen, Manhattans No. 1 glamour girl, brought transsexualism into the limelight after having received gender reassignment surgery in Denmark.4 While the intervening millennia and a half may not have provided authors with the with the same drama and scandal Elagabalus and Jorgensen did, the fact remains that there is a long history of medical advances, especially in the one hundred years proceeding Jorgensons surgery, which played a vital role in the development of gender reassignment surgery. Perhaps the easiest way to determine how a set of individuals fit into society is to examine how society labeled them. Starting in the mid 18th century, transgendered people were often called eonists after the French diplomat and spy Chevalier dEon who lived his first 49 years as a man and her last 33 as a woman. Eonism continued to be used through the 18th, 19th and even the fist half of the 20th century although it was soon joined by other terms. In 1871 the term sexual invert, had been developed to describe both homosexuals and transgender individuals. The term carried a certain medical connotation, fitting into a culture that pathologized any number of sexual perversions. Literature discussing transsexuals before the 1920s can be confusing to read because Western culture did not distinguish between sex, gender and sexuality. It was assumed, therefore, that homosexuals were simply men who, for whatever reason, experienced a female
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The original tale of Elagabalus may be found in Dio, Cassius. Roman History, trans. Earnest Cary, (Cambridge: Harvard University Press, 1914), 465-471. This particular reference is quoted from Carlisle, Human Sex Change and Sex Reversal 259. 4 The Case of Christine, Time Magazine, April 20, 1953, 82.

yearning for men5. It seemed only natural, therefore, that a certain subset of homosexuals, called transvestites or psychical hermaphrodites, would attempt to use feminine (or masculine) wiles to try and attract members of their own sex. It was not until Magnus Hirschfeld, a German sexologist and homosexual, wrote Transvestism: An Investigation into the Erotic Impulse of Disguise in 1910 that transvestites were placed in a separate category from homosexuality. At about the same time gender variant men and women, understanding that they contained elements of both sexes, began to call themselves bisexual.6 It should come as no surprise that a term used to describe individuals desperate to change their sex through the use of surgery and hormone therapy was coined around the same time that Jorgensen set out for Denmark, looking for a surgeon who would deliver her personal miracle.7 The term transsexual, in fact, was created less than a year before Jorgensen left for Denmark and was used only to describe individuals who wish to be members of the sex to which they do not properly belong. 8 It was only after the term was adopted by Harry Benjamin in the 1950s that transsexual came to define a person seeking gender reassignment surgery.
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Victorians understood desire for a woman to be a masculine instinct while desire for a man, or no desire at all, was considered to be feminine. The theory that homosexuals contained a feminine soul in a male body, or vice versa, was proposed by Karl Ulrichs, a German lawyer and advocate for homosexual rights, in a series of twelve writings published between 1864 and 1879. For more information about Ulrichs and his scientific theory of homosexuality see Hubert Kennedy, Karl Heinrich Ulrichs First Theorist of Homosexuality, Science and Homosexualities (1997). 6 Terms like bisexual and transvestite today hold very different connotations than they did at the beginning of the th 20 century. The term bisexual was used to describe individuals who had both male and female characteristics rather than individuals who were attracted to both males and females. Although the term transvestite today is a pejorative used to describe cross dressers, it was used as an umbrella term at the turn of the century by the medical community to describe any man or woman who dressed as the opposite sex for any reason. 7 Jorgensen, Christine, The Story of my Life Part I, American Weekly, February 15, 1953, 4. 8 Cauldwell, David O., Psychopathia Transsexualis, in The Transgender Studies Reader, ed. Susan Stryker & Stephen Whittle (New York: Taylor and Francis Group, 2006), 40.

The first attempts at genital reconstruction surgery were performed, not on transsexuals, but on (pseudo)hermaphrodites.9 It is difficult to know exactly what attempts were made prior to the 19th century to correct ambiguous genitalia due to the stigma associated with atypical genitalia and poor (or perhaps compassionate) record keeping on the part of doctors.10 Nevertheless, there are intriguing references from the 18th century of hermaphroditic men and women, incapable of consummating their marriages, seeking out surgeons to fix their malformed genitals. One Parisian woman sought out the surgeon Dejours after having been married six years without ever consummating the marriage, due to the area where her vagina should have been being occupied by a solid body.11 In 1734 Dejours made an incision in the solid mass and, despite finding she had no sexual organs, contented himself with keeping the wound open, and an aperture was thus preserved so that she could perform her marital duties. One hundred years later the Bostonian doctor, John C. Warren described a similar procedure but implied that, by creating a vagina capable of penetration, he had made a hermaphroditic woman who lacked both a vagina and uterus into a normal woman who might one day be able to bare children.12 By the late 19th century doctors had graduated from simply cutting away flesh to create a neovagina
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Today we would refer to these individuals as being intersex. Before the mid 20 century, however, these individuals were alternately called hermaphrodites or pseudo-hermaphrodites, depending on the decade. The problem was that doctors did not believe a true human hermaphrodite, defined by having two sets of perfectly formed genitalia, could exist. Humans were either male or female. Thus, when confronted with individuals they could not readily place into a single category, they labeled the patient a pseudo-hermaphrodite. 10 Reis, Elizabeth. Bodies in Doubt; An American history of Intersex (Baltimore: The Johns Hopkins University Press), 2009.
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Beck, Theodric Romeyn, and John B. Beck, Elements of Medical Jurisprudence (Philadelphia, 1838), 104-105. Reis, Elizabeth. Bodies in Doubt, 46.

and were instead using portions of the rectum or ileum to fashion a new vagina.13 This was an improvement since it not only created a deeper and wider vagina but was also capable of self lubrication. Of course, 18th century genital surgeries extended beyond the mere fabrication of a new vagina to also performing castrations and clitoridectomies. Castration could involve either the surgical removal of ovaries from a male patient or the removal of the testicles from individuals who otherwise appeared female. Dr. Samuel D. Gross justified just such a castration in 1849 arguing that leaving the gonads in place would cause his three year old female patients to develop sinful, homosexual desires. Clitoridectomies were much more common than castrations and involved the reduction or removal of an over large, penis-like clitoris from a hermaphroditic patient. The decision to perform a clitoridectomy or not was, it could be argued, the very earliest form of GRS. In 1903 Dr. J. Riddle Goffe was heavily criticized for removing the penis of a psuedohermaphrodite. The self-identified female hermaphrodite came to Dr. J. Riddle Goffes office seeking to have her enlarged clitoris, which measured three inches in length and three and a half inches in circumference. The patient had heavy beard growth, thick eyebrows that met over the eyes, no breast development of menstruation but because she preferred to be made a woman and, more importantly, was attracted to men, Goffe reduced the clitoris and enlarged the opening to her vagina. 14

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Stewart, Francis T., Formation of an Artificial Vagina by Intestinal Transplantation, Annals of Surgery, (1913): 210-216. 14 For more details on Gross, see Reis, Elizabeth. Bodies in Doubt, 46-48. See pages 78-79 for more information about Dr. Goffes case.

The first genital reconstruction surgery to be performed on an anatomically normal patient was overseen by Hirschfeld (who readers will remember for coining the term transvestite) on a Danish painter named Lili Elbe. Between 1930 and 1931 Elbe underwent a series of five surgeries the first of which removed all her male organs and the last of which was an unsuccessful uterine transplant which killed her.15 Later in 1931 German sexologist Felix Abraham performed the first successful GRS on Dorchen Richter (born Rudolph Richter) who had been castrated years earlier.16 There is some evidence other, unnamed male-to-female transsexuals also underwent gender reassignment surgery in Hirschfelds lab but the records were lost in a Nazi raid in 1933. World War II signaled the end of gender reassignment surgeries for more than a decade. Surgeons were recruited for the war effort and labs were shut down due to social pressure, raids or lack of funding. The next gender reassignment surgery to be performed was on a female to male patient in 1946. Sir Harold Gillies had been working to develop surgical techniques that could construct a phallus for female-to-male transsexual patients prior to the war and, in 1946 performed the first in a series of thirteen operations to create male genitalia for the British physician Laurence Michael Dillon (Born Laura Maude Dillon).17 About the same time Gillies completed the last of Dillons surgeries, Jorgensen was sitting down

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Nair, Rajesh & Seshadri Sriprasad, 1129 Sir Harold Gillies: Pioneer of Phalloplasty and the Birth of Uroplastic Surgery, The Journal of Urology 183 (2010): e437. 16 MacKenzie, Gordene Olga. Transgender Nation (Bowling Green: Bowling Green State university Popular Press), 40. 17 Nair, Rajesh & Seshadri Sriprasad, 1129 Sir Harold Gillies: Pioneer of Phalloplasty and the Birth of Uroplastic Surgery, The Journal of Urology 183 (2010): e437.

with Dr. Christian Hamburger to plan the first male-to-female gender reassignment surgery to take place since WWII. Unlike Richter and Elbe, Jorgensens surgery was limited to castration and peotomization, with no attempts at creating a vagina or other external female genitalia. Despite this, Jorgensen considered her transformation a success since the removal of her male gonads, combined with the delivery of feminizing hormones caused her voice to lighten, breast to develop and facial hair to disappear. While genitalia may have the final say in sex determination, at least in our culture, we most often rely upon secondary sex characteristics as sex indicators in our day-today interactions. Scientists and laypeople alike understood this concept long before they had any understanding of what a hormone was or how it functioned. They had been observing the effects of castration (both before and after puberty) in humans and livestock for centuries. By the mid nineteenth century doctors had identified the ovary as the essence of femininity itself and were quite familiar with the physiological effects of their removal since ovariectomies were a common gynecological practice.18 With a clear understanding of the role ovaries and the testes play in the body, the stage was set for the discovery of the sex hormones. In 1875 Dr. BrownSquard began trying to engraft the testicles of dogs and guinea pigs into other

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Oudshoorn, Nelly, Beyond the Natural Body An Archeology of Sex Hormones,( London and New York: Routledge, 1994) 19.

animals in an effort to prove the therapeutic value of testicular extracts. 19 Prior to 1800, testicular extracts had been used as sexual stimulants and cures for a variety of illnesses, but had been abandoned to the realm of folk-wisdom and quackery for nearly a century.20 By 1888 Brown Squard, having determined both the innocuity of the process used and the good effects produced in all those animals decided to give himself ten subcutaneous injections of the blood of the testicular veinssemen; and juices extracted from a testicle, crushed immediately after it [had] been taken from a dog or a guinea-pig. Brown Squard, then seventy two years old, found that he was able to lift more weight, work longer hours and, all in all, felt like a younger man. In 1896 and 1900 respectively, Emil Knauer and Josef Halban identified a similar, rejuvenating and feminizing agent, which was secreted by the ovaries. This set off a frenzy amongst chemists and pharmacologists to manufacture and sell this new Elixir of Life.21 Between 1905 and 1920 scientists believed these two hormones were limited exclusively to males, in the case of testosterone, and females in the case of estrogen which supported the concept of there only existing two sexes. In the early 1920s, however, scientists started to find evidence of the male hormone in females and oestrogenic, female hormones in males. With the discovery that both masculinizing and feminizing hormones existed in every individual, scientists now had a biological basis for why homosexuals (and transsexuals) existed. It made
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Brown-Squard, Charles-douard. The Effects produced on Man by Sub-Cutaneous Injections of a Liquid Obtained from the Testicles of Animals, The Lancet (1889): 105-107. 20 Oudshoorn, Beyond the Natural Body, 18. 21 Freeman, Erica R., Bloom, David A. and Edward J. McGuire, A Brief History of Testosterone, The Journal of Urology (2001): 371.

sense that while, in the normal male, the male hormone predominates in the homosexual the dominance is reversed.22 If there was a physiological cause for effeminate men and masculine women then it stood to reason that there should be a biological fix. Steinach, having observed the bisexual nature of rats implanted with both testicular and ovarian tissues theorized that the testicles of homosexuals, and by extension transsexuals, contained F-cells which produced a feminizing and thus homosexuality inducing, chemical. In accordance with this theory he transplanted tissue from the testicles of heterosexual men into at least eleven homosexuals between 1916 and 1921.23 Despite the failure of Steinachs cure, scientists continued to experiment with same-sex hormonal therapies for homosexuals throughout the 1940s. At the same time doctors were attempting to cure homosexuality through the application of testosterone to homosexual males and estrogen to lesbians, doctors were using hormones to fix a variety of problems in heterosexual, cis-gendered patients. While testosterone treatments to virilize men were nto nearly as popular as estrogen treatments for women, the biologicals industry for both sex hormones was quite robust in the 1940s and 1950s. Perhaps one of the most important discoveries was made by Cyril MacBryde in 1939 when he discovered that a combination of subcutaneous injection and topical applications of estrogen caused
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Wright, C.A., Further Studies of Endocrine Aspects of Homosexuality, Medical Records (1938): 249 as qtd in Oudshoorn, Beyond the Natural Body, 57. 23 Oudshoorn, Nelly. Beyond the natural body; an archeology of sex hormones (London and New York: Routledge, 1994) 57. Sengoopta, Chandak, Tales from the Vienna Labs: The Eugen Steinach -Harry Benjamin Correspondence, The New York Academy of Medicine 2 (2000): 1-7.

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three women lacking mammary development and exhibiting signs of marked hypogonadism caused them to develop breast tissue for the first time.24 Recognizing the futility in trying to cure homosexuals with same-sex hormones, Dr. Goldzieher decided to try treating them with cross-sex hormones.25 Goldzieher and those who followed in his footsteps knew were convinced that their patients transsexual ideations could not be cured through the use of psychotherapy or same sex hormones. It stood to reason, though that the hormones which could cause breast development in women could do the same in men and was unlikely to cause any medical harm.26 While Goldziehers treatment was adopted by other doctors including Harry Benjamin and Christian Hamburger, most doctors outright rejected any request for cross-sex hormones from their transsexual patients. The popularity of estrogen pills and lotions, however, meant that estrogen was easy to obtain illicitly. When Jorgensens doctor refused her request for female sex hormones in large enough quantities to feminize herself to an extent where [she] could look and act like a womanand really be a woman, she illegally obtained some female hormones and started taking them in large doses on her own.27 Jorgensen was lucky in that she did not suffer any adverse reactions. Since it was much harder to obtain antiandrogen medications, the effects of the estrogen were limited by the testosterone

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MacBryde, Cyril M., The Production of Breast Growth in the Human Female by the Local Application of Estrogenic Ointment, The Journal of the American Medical Association 112 (1939): 1045. 25 Carlisle, David Brez. Human Sex Change and Sex Reversal, 365 26 We now know this to be untrue but doctors had no idea that there was any connection between estrogen treatments and cancer until the 1960s. 27 Jorgensen, Christine, The Story of my Life, Part III American Weekly, March 1, 1953, 17.

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and had not produced much breast development or any other observable bodily changes.28 Under Christian Hamburgers guidance and with the proper androgen blockers, Jorgensens body did begin to develop and the suicidal thoughts and depression which had plagued her for years gradually began to diminish. . Harry Benjamin, the father of transsexualism, once compared gender reassignment surgery and hormonal therapy for transsexuals to insulin for diabetics. What both treatments [insulin for diabetes, sex-reassignment for transsexuals] accomplish is the preservation of life. Otherwise, many of these people would commit suicide.29 While such a comparison is, perhaps, a bit melodramatic the fact remains that gender variant individuals were, and are, at a much higher risk for suicide, substance abuse, depression and self-mutilation than any other group. I will leave it to others to discuss the legal history of gender reassignment surgery in the United States as well as debates on the morality of genital mutilation. It is enough for me, that we have developed the technology to alleviate at least some of the discomfort from being trapped in the wrong body. The original history of gender reassignment surgery is a history of adaptation, appropriating techniques developed to solve other and modifying them to suit the transsexuals needs. It is my hope that, as gender variance becomes better understood and accepted, medical techniques will be specifically developed to address transsexual needs. That, however, is the topic for another paper.

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Docter, Richard F., Becoming a Woman: A biography of Christine Jorgensen (New York: The Haworth Press, 2010): 81. 29 Harry Benjamin as qtd. In Szasz, Thomas, Sex by Prescription: the Startling Truth about Todays Sex Therapy, (Syracuse University Press Edition, 1980): 91.