The Medical “Disinterest”: Transmasculine Absence in Early Archives of Trans Medicine
“The Problem of Billy A.”: A Brief Appearance
In 1960, two colleagues in the nascent field of transgender medicine discussed a relative rarity in their professional experiences. A urologist based in California, Dr. Elmer Belt, presented to his colleague, Dr. Harry Benjamin, a German American endocrinologist, “the problem of Billy A.”[1] Belt explained that “Billy is a mannish, swaggering, deep-voiced, somewhat hippy-female, who at first glance looks every inch a man.” He continued, “Inquiry reveals the fact that there are four or five inches lacking in one area and quite a little too much in others. Billy would like, first, to have his somewhat ample breasts amputated…. ALL of his feminine features are a great source of embarrassment to him, and well they should be, because he is bald and looks so mannish.” Belt told Benjamin that he planned to perform a double-mastectomy for Billy. He explained with relief, “Hospitals which would not think of allowing me to alter the genitals will not question the bilateral amputation of the breasts for chronic cystic mastitis in this 45 year old patient.”[2]
The approval of hospitals was a core obstacle in the treatment of trans patients during this time, as Belt and Benjamin discussed many times in their correspondence. Belt ended his work treating trans patients soon after this letter, at least in part because he could not find hospitals willing to host the surgeries due to their controversial nature (other reasons for Belt’s retirement included family pressure, patient dissatisfaction, a fear of lawsuits, his advancing age, and difficulty in getting paid for his services).
Belt also mentioned that he was considering performing a phalloplasty for Billy. He outlined in detail how he might construct a penis from an attached abdominal graft called a “tube graft,” which he would then move to its final location and reinforce with cartilage from one of Billy’s ribs. But Belt concluded that, while this procedure went uncriticized when it was used to treat “industrially injured males,” he would “almost surely get into difficulties if [he] did this for Billy.” Belt opined to Benjamin, who was not only his colleague but his friend, “I keep almost subconsciously trying to figure a way out of this dilemma but so far I haven’t come up with an idea on which I should care to take a chance.”
In response, Benjamin revealed that he had “a ‘Billie [sic],’ too who [was] originally a normal female but whom [he had] masculinized over a number of years with most satisfactory success.” Benjamin said that this patient had accessed a double mastectomy from a surgeon in Beverly Hills and a full hysterectomy in San Francisco, in addition to Benjamin’s hormone treatments. “Fortunately or unfortunately,” Benjamin noted, this second transmasculine patient had a cystic ovary which provided the medical rationale for his procedure.[3]
The details of this patient resemble those of Reed Erickson, the white trans man who was the great benefactor of trans medicine during this period and another patient of Benjamin’s. Erickson underwent hormone treatment with Benjamin in 1963 before having two surgical transitions in 1965. In the second year of his transition, Erickson, “a wealthy industrialist from Baton Rouge,” founded the Erickson Educational Foundation (EEF). As homophile activist Ada Bello explains in a biographical profile on the OutHistory website, “It is difficult to exaggerate the magnitude of the impact of the EEF in bringing the question of gender identity to the forefront, where it could be discussed on scientific, humanitarian and educational terms. Its influence has been without equal in this country and even internationally.” While Erickson, a trans man, was so fundamental to the development of trans medicine, transmasculine patients remained largely invisible in historical records of the field.
Erickson’s surgeries, said to be some of the first female-to-male procedures in the United States, took place five years after the “Billy” letter was written. [4] This “Billy” conversation spanned only two letters, one from each doctor. While Benjamin promised to update Belt about the “Billy” case, it is not clear whether he ever did.
“Less Complete”: A Medical “Disinterest” in Transmasculine Patients
Belt and Benjamin corresponded from at least 1958 to 1975 in hundreds of pages of letters that covered a vast array of subjects, from specific patient care recommendations, comments on the field, collaborations for publication, personal updates, and all too often, blatantly discriminatory views of their patients. In a letter to Benjamin in 1958, for example, Belt wrote, “These transsexuals are surely the most annoying people.”[5] In 1968, Benjamin queried, “But should we punish the ‘good and deserving’ transvestites because some others behave so abominably? After all, that’s part of their illness. They’re irresponsible misfits.” To be fair, it was more common for the doctors to express sympathy for their patients and a true desire to relieve their suffering, but there were also comments like these, creating a hodgepodge of responses to the population that the doctors worked with so closely and for so long.
What is most remarkable about Belt’s and Benjamin’s letters about their “Billys” is not their suggested treatments nor their opinions on transmasculinity. Instead, it is most notable that in their more than 300 pages of correspondence over the course of eighteen years, transmasculine patients are mentioned in only two instances while transfeminine patients are the focus of most of their conversations. The doctors’ comments on transmasculinity span just four letters and very few sentences. Belt’s and Benjamin’s use of the term “transsexual” in the letters exclusively refers to transfeminine people. Each time a transmasculine person was mentioned, they were delineated as a “female transsexual,” not just a “transsexual.” In other words, transfemininity was the default and transmasculinity the exception for these medical professionals.
While these records cannot speak to how many transmasculine patients either doctor saw over the course of their careers, they are aligned with a larger trend among early doctors of trans medicine: a relative disinterest in transmasculine patients.[6] In her critical work on trans children, Jules Gill-Peterson offers two reasons for the preference for transfeminine patients in medical archives: first, an “obsessive focus on [trans women’s] bodies by medical science,” and second, a “conceptual and clinical disinterest in trans masculinity.”[7] This trend may have endured until the 1990s, when trans men are said to have had their medical “coming of age.”[8]
How the Phallocenstrism of Intersex Medicine Shaped Transgender Care
The “obsessive focus” on transfeminine bodies that Gill-Peterson refers to might have been inherited from intersex medicine, a field that overlapped with and shaped trans medicine in the United States. The Johns Hopkins Clinic, which was the first U.S. clinic to treat transgender patients, began by taking intersex patients who were offered very similar procedures. This was the case for many of Johns Hopkins’s medical practitioners, including psychologist John Money, the architect of the field of intersex medicine and the cofounder of the revolutionary clinic.
In his abundant and field-shaping publications over more than thirty years, Money used a phallocentric framework to define successful gender transition, which resulted in a preference for vaginoplasties over phalloplasties in the field. First, there were technical concerns about the surgical process used to construct a penis from a small penis or a vagina. From the 1950s, when Money was advising on intersex procedures at Johns Hopkins, “clitoridectomy and vaginoplasty were seen as more effective procedures for producing normative-looking genitals.”[9]
Money was also skeptical of phalloplasty procedures because he thought that a small penis could be psychologically damaging to males. Throughout his career, Money directed doctors to be cautious about the psychological impacts of a micro- or small penis on the male psyche when deciding how to treat intersex children. As late as 1985, Money reasoned that a small penis could cause an array of undesirable outcomes, explaining that “the functional morphology of the genitalia is a better criterion for [physical] sex than is the chromosomal or gonadal status.” He continued, “When a micropenis is vestigially small, it can, with vaginoplasty, be surgically reconstructed as a clitoris, whereas nothing can be done to make it coitally functional as a penis. A baby with such a birth defect of the sex organs can be rehabilitated to have a successful life as a girl and woman.”[10]
By contrast, Money and his colleagues asserted through a study of nine intersex children that should a child be left with a micro-penis, the incidence of both homosexuality and sexual sadism would increase. These results demonstrated, in their view, that a micro-penis “dislocates…ordinary heterosexual…differentiation.”[11]
It is difficult to understand why Money and his colleagues thought that such a small sample size might be representative, or why they exhibited such confidence in the theory that a micro-penis caused these outcomes. Furthermore, they expressed blatantly homophobic and transphobic views in addressing this issue. Money declared most explicitly, “It is mortifying enough for a boy to have a micro-penis without in addition having the mortification of unspeakable sexual secrets.”[12] In the end, Money’s anxieties about small penises and the fact that it was an “easier” process to construct a vagina led him to recommend that more intersex children be assigned female.[13]
Money’s work at the Johns Hopkins Clinic also helped to shape transgender care in the United States and the protocol for transmasculine care specifically. Money argued that gender is malleable, which served as the medical justification for transsexual care in and after the 1950s.[14] As Gill-Peterson explains, however, “While the architects of trans medicine, such as Benjamin and Money, had seen trans men as patients since the very beginning of their clinical research, they continued, like most practitioners, to give massively more emphasis to trans women.” As a result of Money's focus on the “functional” penis, the protocol for transmasculine patients that was developed by early doctors of trans medicine was a combination of testosterone treatment and double mastectomy without phalloplasty. In consequence, Gill-Peterson continues, “One of the distorting effects of this asymmetry between trans masculinity and trans femininity is that the medical archive repeats a certain disqualification of trans masculine transition as less complete.”[15]
What did early physicians’ different treatment of transmasculine and transfeminine patients reveal about their attitudes concerning physical sex and gender? Jules Gill-Peterson explains that transmasculine social transition “profoundly increased a [trans] man’s legal rights, social and economic mobility, and it commanded, therefore, a pretty genuine degree of sympathy.” This contrasted with trans women’s relinquishing of social power and their corresponding stigmatization.[16] Yet within the early trans medical framework, male bodies seem to have been viewed as more transformable than female bodies, regardless of the stigma that transfeminine people experienced.[17]
Harry Benjamin, along with influential sexologists Havelock Ellis and Magnus Hirschfield, understood transsexualism through decidedly sexist ideas of maleness and femaleness. These physicians shared the perspective that people who were assigned male at birth are active sexual agents while people who are assigned female at birth are passive.[18] In his theory of “eonism,” Ellis stated that trans women had mistaken their sexual attraction for women with a desire to be a woman, which, while pathologizing, also points to a degree of personal agency.[19] Ellis’s arguments routinely reduced assigned female people to nothing more than objects to be desired. Hirschfield described assigned female people as “the receiver, responder, the succubus, and the more passive partner, who, as the one who conceives, strives to be the opposite of the man, the incumbent and more active partner.” By framing assigned male people as active and assigned female people as passive, Hirschfeld and others made it theoretically plausible for “males” to “receive” sexually as a function of their sexual agency, but not for “females” to penetrate.[20] This framework undermined any logical explanation for the existence of the assigned female transsexual.
The illegibility of the female-to-male transsexual also supported the notion that transmasculine transition was less complete. Since doctors such as Money saw the “coitally functional” penis as a key determinant of gender, while viewing the phalloplasty as a flawed procedure, transmasculine transition was rendered a fool’s errand.[21] This likely shaped doctors’ lack of interest in treating transmasculine patients, and when they did treat them, they may have been less likely to create records of their cases. Due to these biases, transmasculine people have often been under-documented in trans medical history from this period, even though, as in the case of the two “Billys,” they repeatedly sought, and sometimes accessed, this type of care.[22]
Returning to Benjamin and Belt, the former expressed doubts about whether phalloplasty should ever be recommended to trans patients, even though he had witnessed satisfactory results of the procedure in the Great Britain.[23] In this regard, Benjamin’s skepticism about phalloplasty, a stand-in for gender transformability, was highly representative of the field’s general disinterest in transmasculinity during this period.
[1] “Billy A.” is a pseudonym.
[2] Elmer Belt to Harold Benjamin, February 22, 1960, Correspondence, Box 3, Series II, The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University. To my knowledge, “Billy A.” is the only documented transmasculine patient of Elmer Belt.
[3] Harold Benjamin to Elmer Belt, March 7, 1960, Correspondence, Box 3, Series II, The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University.
[4] Ada Bello, “Reed Erickson, Pioneering Transgender Activist and Philanthropist, 1917–1992,” OutHistory, 2016, https://outhistory.org/exhibits/show/erickson.
[5] Elmer Belt to Harold Benjamin, July 7, 1958, Correspondence, Box 3, Series II, The Kinsey Institute for Research in Sex, Gender, and Reproduction, Indiana University.
[6] I borrow this term from Jules Gill-Peterson. See Gill-Peterson, Histories of the Transgender Child.
[7] Gill-Peterson, Histories of the Transgender Child, 166.
[8] Gill-Peterson, Histories of the Transgender Child, 175.
[9] Gill-Peterson, Histories of the Transgender Child, 118.
[10] John Money, Gregory K. Lehne, and F. Pierre-Jerome, “Micropenis: Gender, Erotosexual Coping Strategy, and Behavioral Health in Nine Pediatric Cases Followed to Adulthood,” Comprehensive Psychiatry 26, no. 1 (1985): 29–42.
[11] Money et. al. “Micropenis,” 40.
[12] Money et. al. “Micropenis,” 41.
[13] Gill-Peterson, Histories of the Transgender Child, 118.
[14] John Money, John G. Hampson, and John L. Hampson, “Hermaphroditism: Recommendations Concerning Assignment of Sex, Change of Sex, and Psychologic Management,” Bulletin of the Johns Hopkins Hospital 97, no. 4 (1955): 284–300; Scholars have importantly demonstrated how early practitioners’ ideas of gender malleability were also highly racialized. Regarding race and gender in the history of medicine, see Gill-Peterson, Histories of the Transgender Child and Kyla Schuller, The Biopolitics of Feeling: Race, Sex, and Science in the Nineteenth Century (Durham, NC: Duke University Press, 2018).
[15] Money et. al., “Hermaphorditism,” 172.
[16] What Sort of Work Is Transition? Class, Labor, And Trans History, directed by Jules Gill-Peterson, Howard Zinn Memorial Lecture Series, 2023.
[17] I am using transformable as an umbrella term to refer to the idea of medical malleability, including specific processes such as the ones Gill-Peterson discusses when addressing racialized “plasticity.”
[18] Harry Benjamin, The Transsexual Phenomenon (New York: The Julian Press, 1966); Ellis Havelock, Studies in the Psychology of Sex, Volume 1: The Evolution of Modesty the Phenomena of Sexual Periodicity Auto-Eroticism, Third Edition (Wilson & MacMillan, 1927); Magnus Hirschfield, The Transvestites: The Erotic Drive to Cross-Dress, Part One, trans. Michael Lombardi-Nash, One (Urania Manuscripts, 1992).
[19] Ellis, Studies in the Psychology of Sex, 16-17..
[20] Hirschfield, The Transvestites, 465.
[21] Money et. al., “Micropenis,” 40.
[22] Alan Hart and Reed Erickson are famous examples of early transmasculine patients. There are several examples of anonymous transmasculine patients from medical archives such as those in Gill-Peterson, Histories of the Transgender Child. Pauli Murray, for example, was denied medical treatment. See Cooper, Beyond Respectability. For discussion on the general prevalence of transsexual patients, see Meyerowitz, How Sex Changed; Melanie Fritz and Nat Milkey, “The Rise and Fall of Gender Identity Clinics in the 1960s and 1970s,” American College of Surgeons, April 1, 2021, https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/2021/04/the-rise-and-fall-of-gender-identity-clinics-in-the-1960s-and-1970s/.
[23] Harry Benjamin to Elmer Belt, March 7, 1960; Gill-Peterson, Histories of the Transgender Child, 172.