TRANSSEXUALISM AND TRANSVESTISM

chosis or is in danger of suicide or self-mutilation cannot be turned down with an unequivocal "no." On the other hand the physi- cian's sympathy should not tempt him to give in too easily to the patient's persuasive arguments and thus obscure his sound clinical judgement.

The psychiatrist must have the last word. He has to evaluate the personality in regard to possible future consequences and also as to the likelihood of somehow making life bearable under the status quo. If it is evident that the psyche cannot be brought into sufficient harmony with the soma, then and only then is it essential to consider the reverse procedure, that is, to attempt fitting the soma into the realm of the psyche.

In weighing the indication for the operation, another factor should be considered, namely the physical and especially facial characteristics of the patient. A feminine habitus, as it existed for instance in Christine Jorgensen, increases the chances of a success- ful outcome. A masculine appearance mitigates against it. Such patient may meet with serious difficulties later on when he expects to be accepted by society as a female and lead the life of a woman. A conversion-operation is an infrequent procedure, even allow- ing for the fact that it may often be kept a deep secret (as a sup- posedly illegal procedure). Treatment with estrogens would have to follow in order to control castration symptoms, aside from having its feminizing effect. We must remember, of course, that castration produces a eunuch and not a woman.

Whenever the surgical intervention is contraindicated, "chem- ical castration" can be attempted with large doses of estrogen (nat- urally in combination with psychotherapy.) The psychological side-effects of such endocrine therapy can be of great value in addi- tion to its hormonal result which is the suppression of the andro- genic activity of the testes and the adrenal cortex. Repeated determinations of the 17-ketosteroids could show the degree of suppression. These steroids would be best kept at an average fe- male level. If the estrogens do not suppress the 17-ketosteroid production sufficiently, cortisone may be used in addition. In that case the treatment of male transsexualism parallels that of female virilism (10).

Clinically, the hormonal castration can gradually produce an increase of mammary tissue, a reduction of body hair, and probably a slight atrophy of testes and penis. A decrease of libido and cor- respondingly diminished sexual tension is likely.

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