It is a fascinating read and covers Benjamin’s history of publishing on transvestism and transsexualism from 1948 through to 1979 when he wrote his last publications.
Benjamin believed wholeheartedly in a biological explanation. He wrote in 1967:
“Most satisfying to me is a working hypothesis based on the experiments of brain physiologists and psycho-biologists . . . Their possible explanation for the transsexual phenomenon would be neuroendocrine in nature . . . If something interferes, perhaps an abundance of the mother’s estrogen or lack of response of the neural target organ, this particular center (a hypothalamic brain center) remains female, determining the later sexual behavior and possibly causing gender role disorientation”
But he also believed causation could be influenced by childhood conditioning which could possibly help reinforce it.
In the very beginning of his writings, Benjamin made clearer distinctions between transvestites and transsexuals but as time wore on he began to see a type of progressive disconnect from one's birth sex which led to his fashioning a six type SOS scale:
Type I - Pseudo TV
Type II - Fetishistic TV
Type III - True TV
Type IV - TS, Nonsurgical
Type V - TS, - Moderate intensity
Type VI - TS, - High intensity
In 1953 he wrote:
“The most disturbed group of male transvestites are those who want to be changed into women, even anatomically. They are the transsexualists.’
The term gender dysphoria was not yet in existence and Benjamin stuck with his disorientation terminology. He also noted that his high intensity patients (types V and VI) were in his words “invariably homosexual”
From 1955 through 1966 Benjamin treated approximately 350 patients at the end of which he produced his magnum opus “The Transsexual Phenomenon”. During this phase he also began to make the clear distinction between sex and gender where sex was the libido and gender the internal identity. He stated “transsexualism is a sex and gender problem” and noted that the origin of the condition was still largely an obscure one.
From 1967 through 1979 he saw an additional 1,200 patients and further consolidated his position on transsexuality and, once again, emphasized its biological etiology by stating:
“Gender identity is so firmly established by the age of four that traditional psychotherapeutic approaches have been quite unsuccessful in resolving adult gender identity conflict"
He also described the principal distinction between transvestites and transsexuals as:
"....the degree of gender discomfort and the measures necessary to relieve that discomfort”
Ekins concludes the article with a fascinating text stating that Benjamin worked within the hetero-normative framework of his time and, since transgender people are today pushing against that envelope, it might open up varying options for clinicians:
“Psychiatrists and other health professionals work very much from the center. They are engaged in what might be termed a socio-practical activity in the world as it is, rather than as it might be. More specifically, they are in the business of trying to relieve individual distress in an imperfect world. If, in doing so, they reinforce an allegedly outmoded binary gender divide, so be it, they might well reply.
Perhaps, the most radical intervention that can be expected from clinicians is that if transgender people choose to put themselves on the front line by living daily in ways that challenge the binary divide, then it should be the work of any clinicians whom they consult to help them. Clinicians at the forefront of transgender clinical intervention are now beginning to articulate that standpoint (Bockting and Coleman, 1992). Furthermore, these same clinicians (Bockting, 1997a, 1997b, 1999) are beginning to detail something of the complexities of transgender sexualities ‘beyond’ the ‘heterosexual imaginary.
As this line of development gains momentum, it will become increasingly necessary to revisit Harry Benjamin’s legacy, but a legacy shorn of its heteronormative cast, if his pioneering work is to maintain a contemporary impact. This article is offered as an initial contribution to that enterprise.”