In 1953 the world was startled to learn about Christine Jorgensen, an American ex-Marine who underwent surgery in Denmark to convert his anatomical appearance from male to female. Since then transsexualism has achieve J considerable notoriety. Jan Morris’s autobiography, Conundrum, provides some fascinating details into her own transsexual odyssey. Renee Richards, an accomplished eye doctor and tennis player as a male, provoked quite a stir when she insisted on joining the women’s pro tennis circuit as a converted female. Transsexual individuals persistently feel an incongruity between their anatomical sex and gender identity. They frequently describe their dilemma as “being trapped in the wrong body.” Their psychological sense of existence as male or female (their gender identity) does not match the appearance of their genitals and secondary sex characteristics. Looking and being biologically male, the male transsexual wishes to change to female anatomy and live as a woman. Conversely, looking and being biologically female, the female transsexual wishes to change to male anatomy and live as a man.Precise statistics on the prevalence of this gender identity variation are not available, but one estimate suggests the figure asone in 100,000 for male transsexuals and one in 130,000 forfemale transsexuals. Among persons who contact gender identity clinics and request change-of-sex surgery, there are manymore men than women. Although there has been considerable speculation about the possible cause(s) of transsexualism, there is little agreement on this matter among researchers in the field.Both biological and psychological factors have been suggested as causes.In the best defined cases of transsexualism, the person has a lifelong sense of being psychologically at odds with his or her sexual anatomy. Typically, this psychological discomfort is partially (but only temporarily) relieved by pretending to be a member of the opposite, desired sex. Many transsexuals describe having had great interest in cross-dressing (i.e., wearing clothes of the “other” sex) during childhood or adolescence. Transsexuals, however, should not be confused with transvestites, who cross-dress to become sexually aroused but usually do not want a permanent change of anatomy or appearance. In at least some cases, discovery of transsexual impulses does not occur until adulthood.Psychotherapy has been generally unsuccessful in resolving the transsexual’s basic distress of feeling trapped in the wrong body. As a result, those judged to be authentic transsexuals have been treated in programs designed to lead to change-of-sex surgery — in effect, redoing the body to match the mind. Since such surgery is irreversible, responsible practitioners take a cautious approach and require a one- to two-year trial period beyond the initial evaluation during which the transsexual patient lives in a cross-gender role. During this time, the transsexual begins living openly as a person of the opposite sex, adopting hairstyles, clothing, and mannerisms of that sex, and also assuming a name that “matches” the new gender.The transsexual male is given estrogens on a daily basis to produce a certain degree of anatomic feminization: breast growth occurs, skin texture becomes softer, and muscularity decreases, for example. However, treatment with estrogens does not remove facial or body hair (electrolysis is required) or raise voice pitch (some male-to-female transsexuals take voice lessons to learn to speak in a more feminine fashion). Estrogen therapy also reduces the frequency of erections and causes the prostate gland and seminal vesicles to shrink.Transsexual women are treated with testosterone to suppress menstruation, increase facial and body hair growth, and deepen the voice. Surgery is required to reduce breast size. For both male and female transsexuals, hormone treatments are given throughout the trial period of cross-dressing and adjusting to a new set of gender roles. At the same time, the patient’s progress is periodically evaluated by a psychiatrist or psychologist. Attention is also directed to achieving legal recognition of the sex change and to personal matters, such as family or religious counseling.If all goes fairly smoothly in the trial period and the transsexual is judged to be psychologically stable and able to adjust socially to the conversion, the final stage of treatment is surgery to change the sexual anatomy. At present, it is much simpler to perform male-to-female conversion surgery than the reverse. The male-to-female operation requires removing the penis and testes and creating an artificial vagina and female-appearing external genitals. The more difficult female-to-male procedure involves creating a “penis” from a tube made from abdominal skin or from tissue from the vaginal lips and perineum. While the artificial vagina created in the male-to-female transsexual often looks authentic and may allow a fairly full range of sexual response (e.g., vaginal lubrication and orgasm have both been claimed but not scientifically verified), female-to-male transsexual surgery creates an artificial penis that cannot become erect or feel tactile sensation.In female-to-male transsexual surgery, it is sometimes possible to attain a degree of sexual function by implanting a mechanical inflatable device inside the penis to produce an artificial erection. Experience with this method is limited at the present time, and in any event, ejaculation is not possible. Many female-to-male transsexuals choose to have hormone therapy and surgical removal of their breasts and uterus but do not opt for an artificial penis.Transsexual surgery is not a cure for this disorder but is only a procedure that may foster a sense of emotional well-being. Recently, the wisdom of surgery for transsexuals has been questioned by researchers from Johns Hopkins University who claimed to find no significant psychological benefits in patients who had undergone such operations compared to those who did not. The matter is unresolved at present, although several prominent medical centers stopped doing transsexual surgery in 1980 because of the lack of solid evidence that the surgery is beneficial.*106\342\2*

Prostex, another over-the-counter medication, is made up of three pure amino acids (glycine, alanine and glutamic acid), according to its manufacturers, who claim the drug works by relieving swelling caused by edema (fluid retention) in the prostate and pelvic tissues. The problem here is that, because this swelling is not a cause of BPH, there is no evidence to suggest that treating edema will improve BPH symptoms.

To the best of our knowledge, there currently is no over-the-counter medication that’s effective in treating BPH. However, it is humbling to realize that one of the most effective medications for the heart, digitalis, is derived from a plant leaf, and one of the newest and most promising anti-cancer drugs, taxol, comes from the bark of the Western yew tree. So, because we don’t know the cause of

BPH, we can’t dismiss these medications out of hand. The makers of these over-the-counter medications have been strongly encouraged to carry out adequately controlled, randomized trials, so their value can be truly assessed.

*290\201\8*

To reach the prostate, a urologist makes an incision in the skin and muscles of the lower abdomen to expose the lower part of the bladder, which is opened next. The surgeon’s index finger reaches into this incision in the bladder and through the bladder neck to remove the tissue at the prostate’s innermost core, the part compressing the urethra. The surgical description for what happens here is that the tissue “enucleates.” For the most part, what this means is that the tissue separates from the surrounding tissue like a walnut from its shell. (At some places, however, a few cuts must be made so some stubborn bits of tissue can be removed along with the rest.)

Because it allows access to the bladder, this procedure is ideal if any problem there, such as a bladder stone or a large bladder diverticulum, needs attention. With the patient’s permission (given before surgery), some surgeons perform a vasectomy during this operation to prevent the development of inflammation in the epididymis. (Epididymitis can result from damage to the ejaculatory ducts, which allows infected urine to “back up” into the vas deferens.) A vasectomy involves cutting the vas deferens, so sperm can no longer exit the urethra during ejaculation but are reabsorbed into the body.

The prostate tissue the surgeon has removed is sent to a pathologist, who will examine it for the presence of hidden cancer. The average hospital stay for this surgery is five to seven days.

*251\201\8*

There are four components to normal sexual function in men—libido (sex drive), erection, emission of fluid (ejaculation), and orgasm. All of these elements are regulated separately; there is no centralized “sex control center.” One major cause for a diminished libido in men undergoing treatment for prostate diseases is a drop in testosterone. However, other factors—environmental as well as psychological—can have an impact on sex drive.

Orgasm happens primarily in the brain. For orgasm to take place, there must be sensation and stimulation. In men who are impotent after radical prostatectomy, TUR or radiation therapy, sensation is not interrupted; therefore, orgasm should always be possible and it should be no different from the way it was before treatment. (Except for men receiving hormonal therapy. For them, orgasm is not an issue—even though a few can still have erections—because the hormone treatment causes a loss of libido, a lack of interest in sexual activity.)

*212\201\8*

Estrogens

Many men, for many reasons, don’t want to undergo surgical castration, so they opt for chemical castration—taking drugs that accomplish the same result without the cosmetic change.

DES, the main oral estrogen, targets a different checkpoint—the hypothalamus and pituitary connection, instead of the testicles. It works by blocking the release of LHRH, which in turn blocks the release of LH and FSH, virtually shutting down the Leydig cells, the testicles’ testosterone-making factories. So testosterone drops to the castrate range.

The effect is not as speedy as with surgical castration; it generally takes ten to fourteen days for testosterone to fall to the castrate range. And, it’s not permanent—in most cases, the testicles start making testosterone again soon after a man stops taking DES.

We talk about DES here because it’s the most widely used oral estrogen, and it’s the gold standard of estrogen therapy for prostate cancer. Other drugs, such as Premarin and ethinyl estradiol (both medications used by women during menopause) are considered as effective as DES; neither is better. Another drug, called cholotriansene (TACE), is a synthetic estrogen that lowers testosterone but doesn’t completely shut down its production; it also permits the body to make a litde bit of LH. (It has proven to be ineffective, and is no longer used in attempts to lower testosterone levels to the castrate range.) A drug called polyestradiol phosphate (Esradurin), injected once a month, may be easier to tolerate for men with gastrointestinal problems; And for men with advanced prostate cancer who haven’t responded to other estrogen drugs, diethylstilbestrol diphosphate (Stilphostrol) may bring relief of symptoms. It is administered intravenously, at 500 to 2,000 milligrams a day.

*175\201\8*

The purpose of radiation treatment is to disable the prostate, to stop cancer there from continuing to grow. Because the prostate is the source of PSA, it’s pretty obvious that something is wrong if PSA is still being made, and there are two possibilities here: Either the cancer has returned locally, to the prostate or surrounding tissue, or a distant metastasis—a tiny bit of cancer that probably escaped the prostate before treatment began—has started causing trouble.

Some doctors advocate “salvage” procedures—additional treatments, such as radical prostatectomy or cryotherapy. Radical prostatectomy is generally not a good idea; the risk of complications after the prostate has been irradiated is so high that many surgeons have a hard time justifying the procedure. Also, by the time most men who initially had radiation treatment seek surgery, it may be too late for surgery to cure the cancer; it has already spread outside the prostate. (This includes men who originally had clinical stage T3 or C disease. Remember, men with cancer that has spread beyond the prostate aren’t considered good candidates for surgery in the first place; having had radiation therapy is just another strike against the odds of cure. Also, surgery is not advisable for patients who have advanced, palpable cancer after radiation therapy, for men with PSA levels greater than 10 or 20, or with poorly differentiated cancer—a Gleason score of 8 or higher.)

*137\201\8*

The early life of the homosexual offender vs. children was characterized by poor relationships with both parents, and a large proportion of broken homes. As though seeking some emotional gratification outside the home, many of these future offenders had prepubertal sex play, largely homosexual. In addition, a large number (nearly one third) of the boys were sexually approached by adult males.

In adult life these offenders resemble the other homosexual offenders in emphasizing masturbation and in being quantitatively (and probably qualitatively) deficient in heterosexual activity. Even their frequency of marital coitus was rather low, and relatively few attempted extramarital coitus.

Their homosexuality far exceeds that of any group except the other homosexual offenders, and most of them were sexually interested in male (and even to some degree female) children and minors; other “reasons” for offense behavior (e.g., drunkenness, mental deficiency, etc.) are much less common, no one of them ever accounting for more than 10 per cent of the men.

In brief, we have here chiefly a group of males who are both homosexually and heterosexually oriented and who are either consciously sexually interested in children or at least willing to accept them as partners. This relative sexual flexibility as to gender and age (and some accept animals of other species) seems to place them in an ambiguous and stressful situation. They are, so to speak, neither fish nor fowl and have difficulty in sociosexual relationships.

*181\161\2*

The incest offenders vs. minors are not unusual with respect to orgasm during sleep. Their age-specific incidence—the percentages who had nocturnal emissions during given age-periods—is moderate to somewhat low among the unmarried, and among the married men it is moderate in comparison to other sex offenders declining from 48 to 33 per cent through the third decade of life. In age-period 36-40 they drop to third from the lowest rank with 24 per cent. In dream content, this group of offenders reported the fewest (2 per cent, or one male) who had homosexual dreams, and none had sadistic or zoophilic dreams. In summary, nocturnal emissions and dreams were rather unimportant in this group of offenders, and the dream content was comparatively limited. Some 17 per cent (the third largest percentage) stated that their emissions were unaccompanied by dreams.

The frequencies with which the incest offenders vs. minors had nocturnal emissions tend to be low prior to age twenty-one and moderate thereafter, and, as is usual among sex offenders, are always substantially less than those of the controls.

The proportion of total outlet contributed by nocturnal emissions is, generally speaking, moderate for both the single and married incest offenders. Among the single this ranges from 2 to 9 per cent (in contrast to 12 to 14 per cent for the control group) and among the married from 2 to 4 per cent (similar to the control group) until their late forties when the proportion increases to 7 per cent, the highest in that age-period.

*139\161\2*

A larger proportion (one third) of the aggressors vs. minors had had specifically sexual contact with animals than any other group. To be sure, only nine individuals constituted this third (hence frequencies are not analyzed), but we feel reasonably safe in attributing an unusual incidence of animal contact to the group as a whole. This incidence is more impressive when one realizes that their background is not notably rural. In age-specific incidence these aggressors rank first by large margins in the two age-periods (puberty-15 and 16-20) for which we have data, a huge 25 per cent being involved in the first period and 17 per cent in the last. These percentages are more than half again as large as the next largest. In their early teens these men ranked fourth in the proportion of total sexual outlet derived from contact with animals, the proportion being 2 per cent.

The incidence is not foreshadowed by nor reflected in the masturbation fantasy or dream content of these sex offenders; none had such fantasy and only one individual dreamed of animal contact. This lack of any obvious psychologic component to their sexual activity with animals fits in with our general concept of the aggressors vs. minors as being unusually sexually active individuals who are relatively uninhibited and, so to speak, willing to “try anything for kicks.” Note their high incidence of homosexual experience. Some aggressive males pride themselves on their indiscriminate sexuality and diversity of experience. Indeed, society (or, to be accurate, the adult males in society) renders such polymorphous persons a curious mixture of approval and disapproval. Like the approval accorded the ultravirile frontiersman, who claims a willingness to do battle with man, beast, or the devil himself, there is a sort of approval bestowed on the man who is willing to “take on” sexually anything animate. This social attitude is reflected in some folkloristic slogans stating that everything should be judged only by whether it is suitable for eating or sexual gratification, and also in some pornographic cartoon strips, in which a man frustrated in heterosexual attempts turns to homosexuality and/or animal contacts.

*97\161\2*

Fourteen per cent of the offenders vs. minors had had postpubertal sexual relationship with animals—a moderate proportion, relatively speaking. Indeed, a higher figure might have been anticipated inasmuch as the offenders vs. minors were more strongly rural in background than most groups.

As usual, this activity was confined almost exclusively to the second decade of life. Beginning with 7 per cent who had animal contact between puberty and age fifteen, the age-specific incidence for unmarried offenders drops to 6, 3, and finally—in age-period 26-30—to 0.0 per cent. These are moderate figures compared to other groups, and follow the usual declining trend. The frequencies are also moderate, the average (median) offender vs. minors having had animal contacts between 4 and 5 times per year. The mean frequency varies from once in three to four weeks between puberty and age fifteen to once in three weeks between ages sixteen to twenty. The proportion of total sexual outlet derived from this activity was always moderate, being between 1 per cent and half of 1 per cent.

*55\161\2*