Abstract
In the 1950s and early 1960s, Harry Benjamin and his colleague Elmer Belt corresponded at length about which transsexuals they would and would not approve for genital surgery. Benjamin defined transsexuality primarily through a desire for medical transition, but merely being a transsexual in this definition did not automatically result in surgical eligibility. Benjamin and Belt remained preoccupied with the possibility that transsexuals would regret their surgeries and seek legal or personal revenge, and thus their assessments of who should have surgery focused more on the possibility of a bad outcome than adherence to gender norms or classification as transsexual. The informal clinical practices they worked out to protect themselves in these early years of American trans medicine would ultimately go on to structure more formalized Standards of Care. Benjamin and Belt's fears, and their resulting decision-making processes, thus played a crucial role in the production of the category “transsexual.” Throughout their correspondence and clinical practice, the transsexual emerged as a threat to medical providers, and a subject incapable of making their own bodily decisions, needing to be protected from themselves. While assessments of gender identity and gendered behavior factored into these decisions, their decisions about who might regret transition treated gender as primarily practical and functional, and made an unshakable internal gender identity a necessary but insufficient criterion for granting a patient access to surgery.
“Each of us will probably die by getting shot by some patient like E. V.,” wrote urologist Elmer Belt to Harry Benjamin, endocrinologist and so-called father of transsexuality, in February of 1960.1 He was joking—kind of. Belt had sent along a citation for a new book on heart disease that struggled to define maleness and femaleness, and the joke was that the two of them were more likely to be murdered by an angry transsexual than to die of heart disease. For nearly two years before Belt sent the letter, he and Benjamin had been debating whether Edie V. Hutchens should be eligible for the removal of her penis and testicles and the construction of a vagina.2 The longer they delayed, the more desperate Hutchens became, but they hesitated to allow the surgery for fear that Hutchens would regret her transition and turn on them, whether with gun in hand or by other means.
Since its beginnings, trans scholarship has emphasized the importance of performing normative gender and “proving” that one was “really” a transsexual in the history of medical transition (Stone 2006; Meyerowitz 2002; Gill-Peterson 2018). Belt's sarcastic remark exemplifies another central force in how clinicians made decisions in the early years of American trans medicine: fear of transsexuals' ruining doctors' lives.3 While adherence to normative gender roles certainly played a part in who doctors allowed to medically transition, fears of being sued or otherwise facing retribution from patients could easily shift the balance in the final decision of who could have surgery. Focusing on this aspect of clinical decision making shows how informal evaluative practices rooted in anticipation of bad outcomes became standards of trans care. It also illuminates how gender operated as a functional, rather than ontological, designation in doctors' understanding of transsexuality. The question for Benjamin and Belt was not whether someone was really a woman but if they could pass as a woman, nor if they were really trans but if they would regret transitioning.4 The answers to these questions, however, were not remotely self-evident. That uncertainty carried significant perceived risk of getting it wrong, even as it made space for doctors to insist that only their expertise could be trusted to get it right. Throughout the 1950s and early 1960s, as Benjamin and his colleagues, especially Belt, invented new ways of dealing with trans patients, the transsexual emerged as someone to be feared, not for their potential to unsettle gender norms and hierarchies but for the hypothetical harm they might cause to medical practitioners who treated them.5
This article takes as its base assumption that the categorical transsexual emerged through a set of practices. As scholars in science and technology studies (STS) have argued, concrete and coherent things do not simply exist out in the world waiting to be described but are, rather, produced through naming and interaction, often in convoluted and contradictory ways (Bowker and Star 1999; Law 2004; Mol 2005; Murphy 2006; Barad 2007). That process played out in the creation of the transsexual (Latham 2019). This article is the result of tracing such productive classification in action, and it builds on the methods of the scholars in STS cited above who have trained their attention toward the on-the-ground work involved in making things things. I look primarily to unpublished source materials, especially Benjamin's correspondence with colleagues and patients as well as the subset of his clinical records open to researchers at the Kinsey Institute. Doing so makes visible, in messy and granular detail, how Benjamin and his colleagues negotiated the many ambiguities that emerged as a result of their attempted sortings, which Benjamin largely smoothed over by the time he published texts for wider reading. The approach I take here is part of a broader research agenda that investigates the unnaturalness of cisness and the tremendous amount of effort that went into making it seem as though most people simply fit into their assigned gender category (Velocci 2021). My reading of Benjamin's letters is thus shaped by many years of engagement with scientific and medical experts' anxious grappling with the slippery incoherence of gender and sex writ large.
My approach to the category “transsexual” and its creation opens up a different way to think about how sexual categories function. Historians of transness have engaged in extensive thinking about who should be considered the subject of trans history, particularly before the category “trans” existed, and have largely settled on an idea of someone who “moves away” from the gender they were assigned at birth (Stryker 2008; Skidmore 2017; Manion 2020). The post-mid-twentieth-century trans subject tends to be regarded in contrast as self-evident, with the “transsexual” especially emerging as a particular construct of mid-twentieth-century medical discourse (Meyerowitz 2002; Stryker 2008; Gill-Peterson 2018). Looking solely at the category “transsexual” in Benjamin's published writings would, after all, indicate that the “true transsexual” was merely someone who wanted to change their body, especially their genitals, to “at least resemble those of the sex to which they feel they belong” (Benjamin 1966: 22, 14). Indeed, Benjamin (1966: 21) wrote in his book The Transsexual Phenomenon, “The request for a conversion operation is typical only for the transsexual and can actually serve as definition.” The way that he actually interacted with transsexuals, though, suggests that the stated classification system did not map onto clinical practice. Not everyone who was diagnosable as a transsexual should, in his measure, have the surgery they wanted. Thus simply being a transsexual wasn't enough to have surgery because the transsexual was constructed as someone whose desire for surgery simultaneously defined them and was likely to produce a bad outcome. Attending to exactly how Benjamin determined who was eligible for surgery demonstrates that even as it was being produced, the category of the transsexual formed less around a set of coherent gendered contents and more in terms of the possible effects of trans surgery. The mid-twentieth-century transsexual was not the self-evident cousin of the less categorically delineated nineteenth-century trans subject. Figures like Benjamin did not define transness by establishing solid criteria and then assessing people by how closely they matched them; rather, they constructed transsexuality as a space of uncertainty through their fear-based practices and used that uncertainty to maintain clinical control.
Wreaking Mayhem
Through a fairly arbitrary series of events—having the right background, knowing the right people, being in the right place at the right time—Benjamin became an obligatory passage point (Callon 1984) in the mid-twentieth-century world of trans medicine. As Benjamin's reputation for being willing to recommend surgery and hormones increased and he became known as the doctor who knew what to do with transsexuals, other doctors referred patients they couldn't or wouldn't treat to him, and trans people told each other to write to Benjamin for a sympathetic doctor who believed in the legitimacy of their experience and could help them (Meyerowitz 2002: 133).6 Throughout the 1950s, anyone seeking what was then called a “conversion operation” essentially had to go through Benjamin's private practice for a surgical referral.
Finding someone to send patients to, however, proved difficult. Many of Benjamin's colleagues thought trans people were mentally ill and needed to be protected from their own desires; the prospect of removing healthy tissue just because a patient wanted it gone seemed absurd, not to mention bad medical practice. Moreover, in the 1950s, trans surgery was decidedly, as Belt described it, “experimental.”7 While doctors affiliated with Magnus Hirschfeld's Institut für Sexualwissenschaft had performed transsexual vaginoplasties in the 1930s, the development of the surgical technique ground to a halt with the rest of the Institut's activities when Nazis destroyed it and burned its records in 1933 (Meyerowitz 2002: 20). Doctors in the 1950s would have to develop new surgical methods, which, as Belt reported on his own experiences, often resulted in complications.8 Trans medicine, then, offered doctors a chance to be on the cutting edge of a new field, but, with concerns about how individual patients would fare, not to mention how it would be publicly perceived, most surgeons had little interest in it.
Others were more open to the idea and viewed surgery as a positive intervention that could improve transsexuals' lives—but they, too, were reluctant to perform it, primarily on legal grounds. While no law explicitly criminalized genital surgery for trans patients, surgeons and their lawyers interpreted an old statute outlawing “mayhem,” intended to prevent the harming of men who might become soldiers, as prohibiting the castration of patients with healthy organs who wanted their testicles removed (Sherwin 1954). In 1948 Benjamin ran into this fear of legal trouble with the first trans patient he attempted to refer for surgery, Val Barry.9 Barry, whom Alfred Kinsey had stumbled across and sent to Benjamin, had been admitted to the State of Wisconsin General Hospital's psychiatric ward after reportedly attacking her parents when they refused to allow her to leave the house dressed as a woman.10 According to a note Benjamin attached to the psychiatrist's report, even though the hospital recommended castration and vaginal reconstruction to manage her psychological distress, the attorney general of Wisconsin intervened and refused to allow the surgery to take place because it would be prohibited under the mayhem statute.11 Undeterred, Benjamin pressed on in his efforts to find a surgeon for Barry, but legal concerns continued to dissuade anyone from operating. Max Thorek, perhaps best known as the founder of the International College of Surgeons, had agreed to perform Barry's surgery but changed his mind after hearing about the legal risks. “As I had expected,” Benjamin wrote to Kinsey, “Thorek has been strictly advised by his attorney not to perform the operation on [Val] as he would open himself up to criminal charges.”12 Thorek, according to the same letter, eventually agreed to provide Barry with estrogen but recommended that she seek out a surgeon elsewhere in the world, like Mexico, where there was no such mayhem law.13 For him, it was not worth the legal risk.
A solution to the legal conundrum emerged in further conversations with surgeons: prospective patients could be required to undergo a psychiatric evaluation. Before he declined to operate, Thorek had apparently told Benjamin that he “would perform the operation only on the advice of a psychiatrist, and then only with the permission of the authorities,” as Benjamin put it to Barry.14 To obtain such a recommendation, Benjamin approached Karl Bowman, a psychiatrist at the Langley Porter Clinic in San Francisco. “In attempting to find an urological surgeon interested in [Val]'s case,” Benjamin wrote to Bowman, “I was impressed with the fact that probably only an authoritative advice, as it could come from you, could induce a reputable urologist to agree to operate.”15 In another case, a patient named Caren Ecker, who had attempted to remove her own testicles, reported to Benjamin in October of 1953 that Dr. Frank Hinman Jr. was willing to complete her efforts and remove her penis.16 According to Hinman's lawyer, there was no legal barrier to his performing the surgery, since Ecker had already started the process. “However,” Ecker wrote to Benjamin that December, “as it may become an item of controversy, he wants me to obtain a second opinion of both an urologist and a psychiatrist.”17
The psychiatric evaluation became even more firmly enshrined as a de facto requirement when Benjamin began sending patients to Belt for surgery. Belt, a Los Angeles–based urologist and the protégé of Hinman's father, Dr. Frank Hinman Sr., became Benjamin's go-to referral for penectomies and vaginoplasties as early as 1954, but he remained concerned about the possible consequences of performing trans surgeries for years.18 The two quickly settled on a psychiatric evaluation as a necessary component of the decision, and their informal practices congealed into a set path toward surgery. First, patients contacted Benjamin, whether self-referred or sent to him by another doctor. If the patients seemed suitable for surgery, Benjamin referred them (although he repeatedly insisted that he was not referring to specific surgeons or recommending surgery, merely offering a name of a sympathetic surgeon and “consenting” to surgery) to Belt. Belt then sent patients to Carroll Carlson, a psychiatrist, for assessment.19 By May 1958, this process was so engrained that Belt wrote saying that he had sent a patient to Carlson “in accordance with our established routine.”20
Even with this routine in place, the pair struggled to decide who should be eligible for surgical interventions. Rather than negotiate the ostensible gendered truths of patients' lives, their debate focused on who might cause trouble for them if they regretted their surgery. Belt and Benjamin were both particularly concerned about a patient named Edie Hutchens, the one Belt joked was likely to shoot them. Though Benjamin encouraged Hutchens to make the trip to California for a consult with Belt in May of 1958, by June he had written to Belt to advise that although Hutchens would probably psychologically benefit from surgery, he had concerns about the practicality of Hutchens living as a woman.21 Belt agreed, writing that he was reluctant to operate on Hutchens because she would likely have to “undergo physical examination in the course of [her] work as a teacher.”22 Because the surgical technique Belt used was still in its infancy, it would be obvious to any examiner and result in Hutchens being fired. Belt was sure that when this happened, “[her] resentment against the man who carried out this work will rise and grow—no matter what [she] thinks of [her] feeling now.” A lawsuit, Belt was sure, would follow. “Hardly a jury in the world would condone [the surgery],” he concluded the letter, spelling his professional demise. Over the next six months, Belt continued to obsess over the imagined penalties he would face for operating. Hutchens, he wrote to Benjamin that December, “would most certainly get anyone in trouble who dared to operate on [her]. I still have that feeling about [her] regardless of what the psychiatrists say.”23 To assuage Belt's fears, Benjamin emphasized the role of the psychiatric evaluation in warding off legal consequences. “I understand your hesitation to operate,” he wrote, “although the psychiatric evaluation would protect you.”24 The psychiatric evaluation was not, then, for Hutchens's mental well-being or even diagnosis, but for the benefit of Belt, who was afraid of being sued.
Concern about legal censure and public controversy thus produced the requirement of a psychological evaluation, rather than any attachment to diagnostic clarity. Benjamin did not task psychiatrists with making any kind of diagnosis of transsexuality or innate femininity. “All I would expect of a psychiatrist,” he wrote to Belt, “is to pass judgment as to whether the respective patient has a sufficiently normal mentality, to allow him to make his own decision.”25 The desire for surgery in and of itself was supposed to be enough for a diagnosis of transsexualism, but it was not enough to convince Benjamin and Belt that the risk of “treating” transsexualism was worth it. Rather, the psychiatric evaluation existed to protect surgeons from legal backlash. Certainly the law didn't require it—again, there was no law specifically outlawing castration or surgical construction of a vagina, and so there were no legal specifications for how to go about obtaining either of those surgeries. But with a psychiatric evaluation, if anyone attempted to sue a surgeon, the surgeon could appeal to the authority of the psychiatrist who had signed off. Another expert's approval would diffuse responsibility for the decision.
Future Regret of Surgery Past
As is clear from the Hutchens case, regret, and ensuing anger toward the surgeon, was a persistent concern for Benjamin and Belt, and managing an imagined future of regret became a key aspect of deciding who would get surgery and who wouldn't. Benjamin did his best to weed out patients who seemed like they might regret their decision because they would not pass as successfully as they hoped, or might change their mind later. The problem with not passing was that people might regret their transition; the problem with regret was that they might blame the people who had facilitated their surgical and hormonal treatments and sue them or, as in Belt's “joke” about Hutchens, show up to their office and shoot them. As Benjamin wrote to Belt about a patient he declined to approve for surgery, “I am afraid if anything is done now it may backfire.”26
Transsexuals were apparently particularly prone to psychological states that would lead them to both make poor choices and lash out. Whether these states were due to an inherent trait or difficult lives, Benjamin saw trans people as constitutionally unstable and difficult to deal with. “Many of these patients are utterly unreliable,” he wrote to surgeon F. Hartsuiker as an explanation for a patient's seemingly erratic behavior. “After all, nature has made them misfits.”27 To Kinsey's associate Wardell Pomeroy, he confided, “Most of these people are narcissistic, completely lack judgment, and some of them easily develop ideas of persecution.”28 In a letter to Kinsey himself, Benjamin said simply, “Those T.V. cases of mine (transvestism, not television) are a damned nuisance most of the time.”29 Trans people thus wound up on a circular path: they were transsexual because they wanted surgery, and they could not be trusted to make their own decisions about surgery because they were transsexual.
Benjamin tended to reject patients he viewed as emotionally volatile, particularly if they seemed likely to question his authority. “Since this young man does not seem to be too cooperative,” he said of one patient, “I would not treat [her].”30 Anyone Benjamin saw as impatient, pushy, or demanding could find themselves ineligible for surgery or at the very least reprimanded. “You will have to learn to be patient,” Benjamin told another patient in a veiled threat (see Pitts-Taylor 2020). “Otherwise, you may jeopardize your future chances for the operation.”31 Benjamin sometimes cut off correspondence with patients he felt were challenging him. Early on in their three-year correspondence, Carlotta Dorta shared her experience with doctors who resented patients who tried to assert their own knowledge of transsexuality. “Slowly but surely I reached the conclusion that it doesn't pay to be honest and open-minded about it, specially with medical-doctors, and even more specially, with psychiatrists,” Dorta wrote in March 1965.32 “The minute they have the slightest to suspect or guess that the so-called ‘patient’ knows-too much, or that he knows more than he is supposed to know . . . they cool off and crawl back into their shells, and run away like scared rabbits.” Evidently, this experience repeated with Benjamin: he eventually cut off their correspondence owing to the “tone” of a postcard that Dorta had sent to him, as he explained in an October 1968 farewell.33 He told Margaret Harrison that he could “no longer be your doctor or your friend” because “it was very inconsiderate of you to disturb me on a Sunday morning just to request that I should write to your brother.”34 When Stephen Wagner asked Benjamin to write to her physician about her estrogen dosage, and whether Benjamin might send before-and-after pictures of people who had had surgery, Benjamin's research associate and secretary Virginia Allen wrote on top of the received letter, “read—no reply—‘TOO DEMANDING.’”35
In an attempt to counteract the possibility of regret, Belt and Benjamin both emphasized the irreversibility of surgical interventions as justification for limits on eligibility, as though patients had not considered that. As Benjamin advised Rhonda Wallace, “The operation you are contemplating is a serious and irrevocable step. Safeguards are required.”36 The safeguards Benjamin mentioned, though, were meant to protect him and Belt from transsexual regret, and they used uncertainty about who might regret an irreversible surgery to justify agonizing over their decisions. Belt, too, expressed the importance of scrutinizing and denying surgery to anyone who might have second thoughts. This was not just scrutiny in the present, though, but accurately telling the future. Belt wrote of one patient in 1958, “So far, by carefully evaluating them, we have not had any disappointed patients, but this particular boy seems to be beyond prediction.”37 This unpredictability made Belt want to proceed with extreme caution, and Benjamin concurred: that patient was “one of the most ‘dangerous’ cases. I say at present, HANDS OFF.”38 In this emotional register, each transsexual was a dangerous, unknown quantity who had to be delicately managed at every step, even as clinical assessors apparently had preternatural powers to see who would cause trouble down the line.
In their selection apparatus, degrees of inherent masculinity and femininity did come up. Occasionally, Benjamin used “wrong body” language that implied a true, stable, internal gender that could be without doubt identified as masculine or feminine. For example, Benjamin told Val Barry that he “would consider [her] definitely a woman that accidently possesses the body of a man.”39 When it came to making the final call of whether surgery was appropriate for a given patient, though, practical considerations came to the fore. In a June 1958 letter written in the midst of the back-and-forth over Hutchens's future, Benjamin outlined three prognostic factors to be considered in approving a patient for surgery to avoid the production of regret: surgical, psychological, and practical outcomes. Benjamin's faith in Belt's surgical technique, he wrote, meant that he was not concerned about the first. The second factor was increased happiness and decreased fear of being arrested for cross-dressing. Benjamin mentioned that all of his patients whom he had approved for surgery had experienced an improvement in psychological well-being as a result of hormonal treatments, and also “due to the realization that they have come as close to the female sex as medicine can provide.” But who would benefit psychologically? Those with the best practical outcome. The practical outcome, as Benjamin put it, “refers to the prospect of producing a reasonably successful ‘woman.’ In this respect, the physical structure and appearance of the patient is of importance. If this appearance is unchangeably masculine, the outcome is, of course, not only problematical but definitely doubtful, if not unfavorable.” This practical outcome, he continued, was likely to be problematic in the case of Edie Hutchens, and was why he thought Hutchens should resume living as a man instead of obtaining surgery and continuing with her transition.40 Hutchens, in this framework, would come to regret her transition because she was, in Benjamin's account, unlikely to successfully pass as a woman.
In other words, what mattered for these outcomes was not who really was a woman, but who would look feminine enough to pass. In a 1957 letter to Wardell Pomeroy, for example, Benjamin mentioned a patient who had managed to have surgery even though he had not agreed to it. “The reason that I did not consent was the strong masculine appearance,” he wrote, though he admitted that the patient had had a positive surgical outcome—in part because rhinoplasty had given her a more feminine-looking face.41 Being a “convincing” woman, meanwhile, could be grounds for surgical approval. A report from Walter H. Peterson, the director of the Chicago Psychological Institute, to surgeon Daniel Lopez Ferrer reported positively that the patient under consideration “gives the impression of a fairly ‘handsome’ not overly seductive woman,” and her appearance “could best be described as an image of a refined, attractive, maiden aunt.”42 Similarly focusing on appearance, Benjamin wrote in a 1958 assessment of a patient for Belt, “I know too little about him to pass an opinion, but agree with you that he may look very well as a girl. He probably ought to be one.”43 By focusing on external characteristics, Benjamin and his colleagues made an unshakable internal gender identity a necessary but insufficient criterion for granting a patient access to surgery.
Passing concerns were not only about appearances. Benjamin also worried about patients' capacity to “do all the things that women do (household duties, etc.)” and particularly to find employment as women.44 Kinsey told Benjamin that all of the patients he knew of who had had surgery and attempted to socially transition were struggling to find jobs, unless they were willing to earn “their living on the lecture platform or some type of public exhibition.”45 This was also a key point in the Hutchens case. Benjamin and Belt feared that Hutchens would be fired from her job as a result of not passing. This focus on employment echoes a longer history of queerness being attached to a fear of dependency and becoming a public charge, as well as the intense gendering of the labor market at mid-century—not to mention the regret that might stem from being unable to find work posttransition (Canaday 2009; Kessler-Harris 2001, 2003).
A focus on passing—and the consequences of not passing—thus took precedence over gender classification. A prospective patient's failure to adhere to gender norms might lead to regret, but Benjamin and Belt did not categorize people according to intrinsic gender so much as how they might be read by others. While Benjamin believed that transsexuals possessed a degree of what he called “constitutional femininity,” he took issue with what he felt was a misreading of this statement that suggested he believed that transsexuals were actually female. Benjamin wrote to the editor of the Journal of the American Medical Association to correct an article that had described his perspective as such. The “concept that these subjects (transvestites) are ‘constitutionally female’ . . . is not and has never been my concept,” Benjamin specified. “Naturally an assumption of a certain degree of constitutional femininity is not to say that these subjects are constitutionally female.”46 In other words, Benjamin did not assess his patients to determine whether they were women—he assumed that they were not.
True Transsexuals and Real Women
Scholars have discussed the reluctance of medical professionals to grant trans people access to transition care in terms of a defense of binary, stable sex, but neither Benjamin nor his colleagues seemed concerned that the binary, or womanhood, or femininity were under threat (Meyerowitz 2002; Stone 2006; Valentine 2007; Gill-Peterson 2018). On the contrary, they viewed transition as largely functional and cosmetic—while estrogen and vaginoplasty, along with new clothes, a new job, and a new set of familial and social relationships, might enable someone to live in the world as a woman and be more comfortable with herself, none of those things would make her a real woman. In these doctors' framework, their patients were not women but transsexuals. The category “transsexual” served not as a condition of being for which there was an appropriate medical response but, rather, as a state of rejecting reality that required careful handling.
Benjamin stressed that patients had to demonstrate a “realistic assessment” of their future to qualify for surgery. They could not think of themselves as real women, only imitations of such, and if they believed otherwise, they were deluding themselves. Benjamin remained unconvinced that trans women were actually women, even after transitioning, and he was clear with patients on this point. “You must realize, of course,” he responded to Edith Williams's inquiry, “that living as a woman and taking female hormones does not make you a woman.”47 To Winnie Dunning he wrote, “Please remember that no operation can ever make a normal female out of a male. Sex cannot be changed—only the secondary sex characters.”48 So framed, medical transition was a long-term masquerade, an intervention that could treat the symptoms of gender dysphoria but not one that could produce a fundamental change in someone's sex. Medical transition could certainly help a patient feel better, but only the appearance of the body would be transformed, and only partially at that. The category that a patient would fit into would not change, and it was disqualifying to imagine otherwise.
Acceptance of one's “real” sex suggested that a patient would be satisfied with the outcome of their transition, further enshrining it as a selection criterion. Belt in particular found it endlessly frustrating that his patients continued to pester him for more surgical interventions that were beyond his capacity, like implanting ovaries and a uterus. “No matter what we do for these patients they will never be satisfied,” he wrote to Benjamin in 1956, after he had operated on several trans women. “As each procedure is performed, they come up with further desires and requests which makes the job of dealing with them and handling their problem very difficult.”49 Belt cautioned a patient similarly. “It is in the nature of things that a transvestite will never be wholly satisfied with her appearance,” he wrote to Barbie Owens. “In the most successful operation we have had, a young person with so great a tendency toward femininity that her very perineum was constructed by nature wider than the male, . . . the patient came in after all was done expressing dissatisfaction because there was not a uterus with tubes and ovaries projecting into it from above and she could therefore not have a baby. ‘You have performed a miracle so far for me, Doctor, why can't you do just this one more thing?’”50 Even with an intrinsic “tendency toward femininity,” a “realistic” set of expectations—here taking the form of an acceptance of material limits—was apparently lacking.
Beyond casting patients as failing to understand both the limits of modern science and how sex works, Belt's view on the necessity of realistic expectations circled back to possible legal problems. In 1969, when journalist Burton Wolfe asked why Belt had stopped performing trans surgeries, Belt highlighted the expense of malpractice insurance and legal settlements in light of the perceived risks of treating trans patients. Belt told Wolfe that he was concerned about lawsuits in which amounts of “money demanded by the dissatisfied transsexual who had dreams of becoming a mother and other such nonsense were beyond the wildest imaginings.”51 While turning down Lorna Harding for treatment, Belt likewise claimed that he had stopped performing peotomies and vaginoplasties “due to a series of unfortunate experiences with patients who have felt that they wished this type of work done but who expected more than the surgeon can possibly deliver in the way of alteration even though the limitations of the method were most carefully set forth preoperatively.”52 Fear about regret, then, was paired with a frustration with patients wanting more.
Though less personally threatened by the possibility of regret than Belt, Benjamin conflated “unrealistic” hopes with emotional instability. “Do try hard to give the impression of a well-balanced sensible person who does not expect miracles,” he wrote to Debbie Mayne as she sought a psychiatrist's approval for surgery.53 His reference to “miracles” firmly placed transsexual hopes in the realm of the fantastic and likely impossible. Benjamin himself had written to Dr. F. Hartsuiker, Mayne's potential surgeon, saying, “It is quite important in my opinion that the patients retain their realistic attitude toward their own status even if they live the life of a woman to which I feel they are entitled.”54 Here, ontological “status” as a transsexual contrasted with merely functioning as, but not being, a woman. Though Benjamin may have coached Mayne on how to convince Hartsuiker that her expectations for her surgical outcome would not be too high, Benjamin expressed doubts about Mayne's grip on reality. “[Debbie] impressed me as so highly emotional as to be almost called psycho-neurotic and certainly very unrealistic,” Benjamin wrote in the same letter to Hartsuiker. “I think [Debbie] is a more serious problem than many other transsexualists and it is really often difficult to decide which is the lesser of the two evils: to operate or to refuse operation.”
Benjamin would eventually, unlike his patients, come to possess a sense of objective reality in the form of a classification system. Complex diagnostic criteria for transsexuality were developed after Benjamin and Belt had already established their routines for assessing patients for surgical approval. When Benjamin first started recommending trans patients for surgery in the early 1950s, there were no meaningful diagnostic criteria other than his own gut feelings. While an October 1964 letter from Ruth Rae Doorbar to Benjamin suggests an eventual psychiatric approach that put potential surgical candidates through a battery of intelligence, personality, and perception tests, these served more of a research purpose in their early incarnation than a diagnostic one.55 In the mid-1950s, Benjamin was effectively on his own, making diagnoses of transsexuality according to his own judgment.
To formalize the process, Benjamin developed what he called the Sex Orientation Scale, or the S.O.S. The scale, based on Kinsey's sexual behavior rating system, described seven categories of “sex and gender role disorientation and indecision,” from “Type 0,” those with “normal sex orientation and identification” who find the idea of cross-dressing and surgery “foreign and unpleasant” and consist of “the vast majority of most people,” to “Type VI,” the true transsexual of high intensity (Benjamin 1966: 22). However, Benjamin emphasized that the types “are not and never can be sharply separated” and were “approximations, schematized and idealized” (23). Most patients would “fall in between two types and may even have this or that symptom of still another type” (24). Even with this diagnostic tool, then, transsexuality and assessment of who would benefit from surgery was anything but self-evident, and required a clinician's interpretation.
Within the S.O.S., as with Benjamin's earlier interactions with patients, transsexuals were not transsexuals because they were actually a gender other than the one they had been assigned at birth. Rather, they were transsexuals because dressing and living as women was not enough to alleviate their gender dysphoria, because psychotherapy did not work to relieve their symptoms, and most of all because they wanted genital surgery. As is clear, though, clinical action did not directly follow classification. If anything, classification as transsexual itself created barriers to transition, at the same time that those barriers reinforced the need to carefully circumscribe surgical eligibility. After all, barriers would not be needed if transsexuals were not inherently unstable, as evidenced by their resistance to such barriers. The transsexual was constituted as different from the nontranssexual through a separate set of clinical practices that applied only to patients already deemed transsexual (Latham 2017). It was the inability to suppress gender dysphoria that made someone both a good candidate for surgery and a risky candidate for surgery precisely on the basis of their failure to cope with psychic pain.
Diagnostically and practically, little changed with the development of the S.O.S. Benjamin occasionally responded to inquiries with an S.O.S. diagnosis—in November 1961, for example, he sent a copy of the S.O.S. to patient Joan Sewell with the note, “Judging by your description, you most likely belong to Type III of Transvestism, as I described it in the enclosed reprint.”56 But references to S.O.S. type in correspondence were rare, and I found no indication that Benjamin actually used the scale in his decision making. In a spreadsheet of all his trans patients, a column listed patients' “TV-TS type” and what appears to be an intake form likewise has a space to note S.O.S. type.57 Based on how little the scale came up in correspondence, though, it seems like patients' scale rating served a primarily organizational and research purpose, with little practical clinical relevance. The rating was given after the clinical encounter, based on a conclusion that Benjamin would have come to anyway, because the rating depended on how much someone wanted surgery to begin with. If there were now types of person according to degree of gender dysphoria, those types could be determined in the same way that Benjamin had been assessing patients all along. S.O.S. ratings were an afterthought that justified the recommendations he had been making for the past decade.58 Nonetheless, as a post hoc attempt to make his practice seem more systematic and scientific, the S.O.S. gave an air of objectivity to Benjamin's decision-making process.
For Benjamin and Belt, larger questions about what sex was and how it worked were distilled into a question of who should and should not be allowed to access surgery. Despite Benjamin's claims to transsexual diagnostic expertise, it was not obvious who should qualify for medical transition, which opened up the possibility for terrible mistakes, which in turn required expert regulation of the process. Assumptions about masculinity and femininity certainly played a role in this process, especially as time went on and gender clinics developed institutionalized screening practices. But in the early days of trans medicine, sorting masculine from feminine paled in comparison to assessing possible risk. This quotidian clinical practice would continue to shape the experiences of trans people attempting to access surgical care for decades to come.
Epilogue
Ultimately, the legal threat that Belt so feared proved a nonissue, and the anticipated lawsuits never materialized (Meyerowitz 2002: 121). But the specter of litigation had a tremendous impact, shaping both the availability of surgery for trans patients and the requirement for psychiatric assessment before a surgeon would operate. For much of the 1950s, Belt was the only urologist in the United States and one of few in the world who would perform trans surgeries. His methods for soothing concerns about retribution thus became effective requirements, leading to selection criteria based on a general sense of a patient's likeliness of regretting their surgery and turning to Belt for revenge. By 1962 his anticipation of legal trouble was enough to make him shutter his trans surgical practice, leaving transsexuals with even fewer options for medical care.
There was another effect of Belt and Benjamin's anxiety: it helped them solidify their own importance and the role of medical expertise in making decisions about trans bodies and lives. Because of the potential for disaster, one needed an expert to make the right choice. To maintain control over who could access surgery, Benjamin and Belt created an anticipated problem that only their careful selection of patients could prevent from happening. Their own track record of happy post-op patients and the actual needs of people who desperately wanted surgery could, in their minds, be justifiably ignored in the face of an anticipated future disaster. This fear of the future had a material legacy as trans medicine coalesced around a model that functioned as if disaster were imminent. Though trans people rarely changed their minds, trans people's changed minds dictated the entire trajectory of trans medicine in the second half of the twentieth century. Practitioners of trans medicine could position themselves as experts precisely because they cast transition outcomes as both possibly good and inevitably bad, with their expertise hinging on a regime of anticipation that came to exist through “simultaneous uncertainty and inevitability of the future” (Adams, Murphy, and Clarke 2009).
Trans medicine gained legitimacy and coalesced into a recognized field of expertise throughout the 1970s, thanks in large part to the rise of university-supported gender clinics and research projects that gave clinicians and researchers institutional backing. Positive press coverage and legal victories in favor of trans people further supported a sense of optimism about public and professional acceptance of medical transition (Meyerowitz 2002: 254). This did not, however, result in greater trans self-determination or diminished fears about bad outcomes. On the contrary, clinicians doubled down on limiting access to both hormonal and surgical interventions. What had functioned as informal habits at the height of Benjamin's influence in the 1950s and 1960s became codified as official regulations in 1979, in the form of the Harry Benjamin International Gender Dysphoria Association (HBIGDA) Standards of Care. The HBIGDA Standards continued to foreground possibilities of regret and the need to protect clinicians through a system of “peer review,” given the controversial nature of transsexuality itself.59 That included a psychological evaluation.
Access to transition care has become more available in some respects—though still tremendously limited by expense, ridiculous waiting times, and general lack of access to health care, even if requirements have loosened somewhat—but the approach set in motion by Benjamin, Belt, and the founding members of HBIGDA continues to put clinicians' needs over patients' in a long-standing model of the emotionally unstable trans person likely to regret their transition. Today, anxieties about regret continue to limit access to surgical transitions, whether from efforts by concern trolls to “protect” young people who want to transition or continued requirements for evaluation by mental health professionals before being able to access surgery.60 As of this writing in spring 2021, a recent spate of successful legislative efforts in the United States and United Kingdom to ban trans youth from accessing medical transition are finally bringing mid-twentieth-century doctors' fears about the illegality of providing trans medical care to fruition.
The transsexual was made transsexual by their desire for surgery but was denied it on the same basis: because they were transsexual, they could not be trusted to have surgery. I highlight this absurdity not merely to point out an illogic but also because doing so makes visible how trans clinical practice has never needed to make sense from trans perspectives. Benjamin and Belt constructed good medicine and transness as mutually exclusive. In their framing, one could not be transsexual and also an expert on one's own needs. There has decidedly been a push for a different kind of good medicine in the years since Benjamin and Belt controlled access to surgery, ranging from the inclusion of nonbinary people in the HBIGDA-descended World Professional Association for Transgender Health's most recent Standards of Care, to informed consent models of accessing estrogen and testosterone. But these efforts continue to frame medicine as possessing a “gate” that needs to be “opened,” as though a slight tweak to clinical practice is the solution to the problems that clinical practice has caused, while fears of uncertainty tend to be combatted with insistence that trans people are in fact certain about their gender and bodily desires (Lane 2018; Callahan 2015; shuster 2016). Perhaps, though, medicine is not the right source of knowledge for structuring decisions about the shapes that peoples' bodies can take. Maybe uncertainty is not a dirty word. Maybe if doctors and senators and trans-exclusionary radical feminists on the internet stopped treating hormones and surgery as last-ditch tragedies, we could finally talk about something interesting, like making them free to everyone who wants them.
Notes
Elmer Belt to Harry Benjamin, February 22, 1960, series IIC, box 3, folder Belt, Dr. Elmer (1959–1962), Harry Benjamin Collection, the Kinsey Institute for Research in Sex, Gender, and Reproduction, Inc., Bloomington, IN (hereafter HBC).
Patient names have been changed in accordance with Kinsey Institute policy. I have maintained original initials to facilitate reference and, when possible, used the same pseudonyms as Meyerowitz 2002.
I use “trans medicine” as a shorthand for the clinical apparatus that developed around hormonal and surgical interventions for trans people. While this was not an actor's category, I gesture with “trans” toward the ways that these clinical practices exceeded the highly contingent category “transsexual.”
Benjamin also treated trans men according to the same principle. Most of his initial patients, however, were trans women. For brevity, this article contends with Benjamin's treatment of trans women specifically, but a comparison of the precise ways that Benjamin's treatment of trans women and trans men differed is a crucial area of further investigation.
On the potential for the transsexual to unsettle gender norms, see, among others, Stryker 1994 and Meyerowitz 2002.
See also correspondence between Louise Lawrence and Alfred Kinsey, series IB, box 1, folder 1, Louise Lawrence Collection, Kinsey Institute, Bloomington, IN.
Belt to Benjamin, December 15, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Belt to Benjamin, July [n.d.], 1956, series VIB, box 23, folder 34, HBC.
While the mayhem statute does not seem to have led to the feared crackdown on trans surgeries, it's worth nothing that in the twenty years leading up to Barry's case, there had been at least two high-profile, nationally reported cases in which San Francisco surgeons had run afoul of the law for using the same kinds of sexualized surgeries that trans people wanted—but in these two cases, coercively for eugenic purposes. See Blue 2009; Washington Post1936; and Boston Daily Globe1936. See Amin 2018 for the eugenic history of the technologies of transsexuality.
H. M. Coon to W. B. Campbell, July 19, 1948, box 3, folder B, VB, HBC.
Harry Benjamin to Karl Bowman, n.d., attached to Coon's report, H. M. Coon to W. B. Campbell, July 19, 1948, box 3, folder B, VB, HBC.
Benjamin to Alfred Kinsey, Oct. 4, 1950, File Benjamin, H., Alfred Kinsey Correspondence [digitized], Kinsey Institute, Bloomington, IN (hereafter AKC).
Barry was finally able to access surgery in Sweden in 1953. Benjamin to Kinsey, December 1, 1953, file Benjamin, H., AKC.
Benjamin to Barry, December 27, 1949, series IIC, box 3, folder B, VB, HBC.
Benjamin to Karl Bowman, n.d., series IIC, box 3, folder B, VB, HBC.
Caren Ecker to Benjamin, October 5, [1953], series IIC, box 4, folder E, C, HBC.
Caren Ecker to Benjamin, December 3, 1953, series IIC, box 4, folder E, C, HBC.
The earliest mention of Belt operating on one of Benjamin's patients is in Benjamin to Kinsey, September 22, 1954, File Benjamin, H., AKC. Based on a 1960 letter from Benjamin to Belt, suggesting that Belt experimentally remove only one testicle from a patient and implant the other in the abdomen because “You won't castrate anybody that way,” it seems like Belt did not want to perform castrations out of a legal concern. Harry Benjamin to Elmer Belt, July 12, 1960, series IIC, box 3, folder Belt, Dr. Elmer (1959–1962), HBC.
Carlson was by no means an expert on transsexuality. He had, however, treated Belt's daughter-in-law for “puerperal insanity,” according to an August 20, 1956 letter from Benjamin, so Belt trusted him. Belt to Benjamin, August 20, 1956, series VIB, box 23, folder 34, HBC.
Benjamin to Belt, May 12, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Benjamin to Belt, June 11, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Belt to Benjamin, June 12, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Belt to Benjamin, December 15, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Benjamin to Belt, December 30, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Benjamin to Belt, March 3, 1958, series VIB, box 23, folder 34, HBC.
Benjamin to Belt, September 12, 1957, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Benjamin to F. Hartsuiker, November 24, 1954, series IIC, box 5, folder Hartsuiker, Dr. F, HBC.
Benjamin to Wardell Pomeroy, January 8, 1959, File Benjamin, H., AKC.
Benjamin to Kinsey, December 3, 1954, File Benjamin, H., AKC.
Benjamin to Morton M. Garfield, March 7, 1967, series IIC, box 6, folder N, W, HBC.
Benjamin to B. S., September 29, 1955, series IIC, box 6, folder S, B, HBC.
Carlotta Dorta to Benjamin, March 13, 1965, series IIC, box 4, folder D, C, HBC.
Benjamin to O. S. [Carlotta Dorta], October 16, 1968, series IIC, box 6, folder S, O, HBC.
Benjamin to M. H., May 15, 1956, series IIC, box 5, folder H, M, HBC.
Stephen Wagner to Benjamin, January 8, 1967, series VIC, box 25, folder 7, HBC.
Benjamin to R. W., November 3, 1969, series IIC, box 8, folder W, R, HBC.
Belt to Robert P. McDonald, June 2, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–59), HBC.
Benjamin to Belt, June 2, 1959, series IIC, box 3, folder Belt, Dr. Elmer (1958–59), HBC.
Benjamin to Barry, May 31, 1949, series IIC, box 3, folder B, VB, HBC.
Benjamin to Belt, June 11, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Benjamin to Wardell Pomeroy, June 27, 1957, File Benjamin, H., AKC.
Report sent to Daniel Lopez Ferrer by Walter H. Peterson, director of Chicago Psychological Institute, RE: PW, May 21, 1956, series IIC, box 8, folder W, P(H), HBC.
Benjamin to Belt, March 3, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Benjamin to W. J. D., August 18, 1955, series IIC, box 4, folder D., W. J., HCB.
Kinsey to Benjamin, January 5, 1955, File Benjamin, H., AKC.
Benjamin to Editor of JAMA, April 20, 1955, File Benjamin, H., AKC.
Benjamin to E. W., June 30, 1958, series VIB, box 24, folder 22, HBC.
HB to W. J. D., August 18, 1955, series IIC, box 4, folder D., W. J., HCB.
Belt to Benjamin, July 29, 1956, series VIB, box 23, folder 34, HBC.
Belt to B. O., September 5, 1956, series IIC, box 6, folder O, B, HBC.
Belt to Burton H. Wolfe, March 24, 1969, series IIC, box 3, folder Belt, Dr. Elmer (1965–1971), HBC.
Belt to L. W. H, August 29, 1958, series IIC, box 3, folder Belt, Dr. Elmer (1958–1959), HBC.
Benjamin to D. M., March 15, 1954, series IIC, box 6, folder M, D, HBC.
Benjamin to F. Hartsuiker, February 15, 1954, series IIC, box 6, folder Hartsuiker, F., HBC.
Ruth Rae Doorbar to Benjamin, October 18, 1964, series VIB, box 24, folder 43, HBC.
Benjamin to J. S., November 24, 1961, series IIC, box 8, folder S, J, HBC.
Patient spreadsheet and intake form, series VIE, box 28, folder 20, HBC.
See Mol 2005 for a similar process in the relationship between pathological studies and clinical encounters in cases of atherosclerosis.
Harry Benjamin International Gender Dysphoria Association, “Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons,” February 1979, series VIC, box 25, folder 19, HBC.
On affects of regret and future happiness in contemporary conversations about trans surgery, see Chu 2018.
