Boyish Mannerisms and Womanly Coquetry: Patients with the Diagnosis of Transvestitismus in the Helsinki Psychiatric Clinic in Finland, 1954–68

Abstract

This article examines the case files of patients diagnosed with Transvestitismus [transvestism] in the Psychiatric Clinic of the Helsinki University Central Hospital in the years 1954–68. These individuals did not only want to cross-dress, but also had a strong feeling of being of a different sex from their assigned one. The scientific concept of transsexuality had begun to take form, and this knowledge reached Finland in phases. The case files of the transvestism patients show that they were highly aware of their condition and were very capable of describing it, even if they had no medical name for it. Psychiatrists were willing to engage in dialogue with the patients, and did not treat them as passive objects of study. Although some patients felt that they had been helped, many left the institution as frustrated, angered or desperate as before. They had sought medical help in the hope of having their bodies altered to correspond to their identity, but the Clinic psychiatrists insisted on seeing the problem in psychiatric terms and did not recommend surgical or hormonal treatments in most cases. This attitude would gradually change over the course of the 1970s and 1980s.

1 Introduction

The years after Second World War witnessed the recognition of new forms of sexual anomalies in Finnish psychiatry, the most notable being the concept of transsexuality. ¹ In the 1950s and the 1960s, the Psychiatric Clinic of the Helsinki University Central Hospital, ² which was the first mental hospital in the country, founded in 1841, held the longest traditions of psychiatric care in Finland. The Clinic admitted numerous individuals who were then diagnosed with Transvestitismus. These individuals did not only want to cross-dress, as the diagnosis might lead us to believe, but also had a strong feeling of being of different sex from their assigned one.

From 1954 onwards, the National Board of Health required all Finnish hospitals to use the Tautinimistö [The Nomenclature of Diseases], the Finnish version of the International Classification of Diseases, Revision 6 (ICD-6). The manual placed Transvestitismus cases under ‘sexual anomalies’, one of the eight subcategories of ‘psychopathy’. ³ The difference between ICD-6 and its Finnish equivalent was terminological, and so, the diagnosis of Constitutio psychopathica was used instead of the more international term ‘pathological personality’. The diagnosis of psychopathy had been in use in Finland since the beginning of the twentieth century. Psychopathy was understood along German lines as a degenerative, or, later, constitutional condition. Finnish psychiatrists applied the diagnosis to ‘abnormal’ personalities who were not mentally ill but who were nevertheless in need of psychiatric care, or at least psychiatric evaluation. The diagnosis, first used mostly in rare forensic psychiatric assessment cases, gradually became one of the most common diagnoses, used for patients coming from the battlefield and rural households alike. The 1954 change in classification reduced the number of diagnoses of psychopathy radically: the proportion of diagnosed psychopaths dropped from twenty-five percent of all mental hospital patients in Finland in 1952 to five percent in 1955. ⁴ This was due to a conceptual change in the classification, as only constitutional and not reactive states were diagnosed as exhibiting an actual psychopathy. ⁵ Sexual anomalies were perceived as constitutional, but no separate percentages of the subcategories are available. After 1968, ‘psychopathy’ was renamed ‘persona pathologica’, meaning a personality disorder, and sexual anomalies became a distinct category.

Helsinki Psychiatric Clinic was known for its expertise on sexual problems. Some patients with a sexual anomaly are reported as stating that they had come to the Clinic because they had the impression that the best expertise was to be found there. ⁶ Sexual deviations were not commonly diagnosed in Finnish mental hospitals in the pre-war years. ⁷ This may have been part of the silence that, according to the Finnish historian Jan Löfström, surrounded homosexuality from the late nineteenth until the mid-twentieth century. Löfström claims that sexuality was not strongly polarised in agrarian Finland and homosexual desires were therefore not culturally as significant as they would later come to be. ⁸ After the Second World War, sexual problems, in marriage in particular, were increasingly seen as a social concern. ⁹ The 1960s witnessed both a sexual revolution that encouraged a more liberal attitude towards individual choice and a revitalisation of the human rights movement. In this environment, some medical scientists studied transsexuality. ¹⁰

It was only the publication of ICD-6 in 1954 that brought the sexually deviant into psychiatric treatment for the first time in separate categories. This article examines the lives of individuals diagnosed with Transvestitismus in the Helsinki Psychiatric Clinic between 1954 and 1968. ¹¹ It asks how the patients found their way to the Clinic, how they described themselves and how the psychiatrists diagnosed and treated them. The period is particularly interesting, because it was the period during which Transvestitismus was introduced as a separate diagnosis and new scientific knowledge on transsexuals began to reach Finland. The diagnosis of Transsexualismus, 302.31, was added to the disease classification in 1969.

This article also serves as a more general commentary on the emergence of new diagnoses. Research on the discovery of new psychiatric diagnoses has usually relied on published research and has focused on psychiatry as the main agent of change. Doctors tend to think of their role as pivotal in the case of transsexuality as well. ¹² Instead, I will rely primarily on unpublished case files and highlight the interaction between patients and psychiatrists, as well as the active role of the patients in the construction of psychiatric knowledge on transsexuality. The patient records shine light not only on the patients’ own conceptions but also on the hesitations and insecurities of the psychiatrists at a time when the notion of transsexuality was new to psychiatric discourse. This case shows that the people diagnosed with transvestism were, on some level, aware of the concept of transvestism, even if they were not aware of the word itself. They insisted that their gender, and sometimes sexual, identity did not correspond to their assigned sex. This conception, and this experience, existed before any scientific knowledge or expert intervention. This manner of ascribing a concept to someone without the linguistic (in this case, in the scientific sense) means to express it has been discussed by Gad Prudovsky. He claims that the doctrine of priority of talk over thought, supported by Quentin Skinner and G. E. R. Lloyd, is too restrictive. According to Prudovsky, by favouring the doctrine, some historical interpretations would be counted as anachronistic, despite their validity. ¹³ I thus separate this to some extent both from strict psychiatric constructivism ¹⁴ and from Ian Hacking’s ‘dynamic nominalism’, where kinds come into being when they are invented. ¹⁵ My study illustrates that there was a murky borderland where the knowledge-production of ‘the object’ (patient) and that of ‘the subject’ (psychiatrist) are difficult to tell apart from each other.

Jay Prosser sees transsexuals as participants who have shaped medical practices. ¹⁶ Moa Holmqvist emphasises the combination of different factors, such as the importance of fiction, in the formation of trans identities. ¹⁷ My focus is on the nameless concept that the patients experienced, lived and expressed. The awareness or pre-knowledge of the concept among the patients was crucial in the formation of their identities.

The core material consists of patient files of eleven cases with the diagnosis of Transvestitismus, 320.6. Four of them are assigned female, seven assigned male. The material was collected from one psychiatric clinic only, but there is reason to believe that this clinic is where the majority of people like this would end up in Finland. ¹⁸ Due to the small sample, I have omitted all information that might allow any identification of the individuals, including file numbers and aliases. ¹⁹ The aim has been to respect the patients’ privacy, but to allow their voices to be heard. In Finnish, the first person singular is ungendered, as in English and most European languages: hän refers to both men and women. In discussing the cases, I have used the English pronoun singular they to resemble the grammar in Finnish sources. Although the present-day recommendation in discussing transsexual individuals is to use the pronouns that the person in question prefers, ²⁰ my ungendered choice is in line with the historical sources. Besides, it is not always possible to know how the patient saw his or her gender identity at the different stages of the treatment.

2 Case Impi: The Psychopathic Female Homosexual

Although transsexuality became a clearly defined medical problem only after the Second World War, its prehistory can and has been traced further back in time. ²¹ Early references to individuals who felt that their identity differed from their assigned sex can also be found in the Finnish medical discourse. In 1882, an article on ‘contrary sexual feeling’ was published in Finska Läkaresällskapets Handlingar [Proceedings of the Finnish Medical Society], the leading medical periodical. This was the case study of X.Y.Z., who suffered from hysterical fits and hallucinations and self-identified as male. The article referred to the studies of the German psychiatrists Wilhelm Griesinger and Karl Westphal and to the case of the pseudonym Numa Numentius, who also displayed ‘contrary sexual feelings’. ²² According to the Finnish article, X.Y.Z.’s sexual feelings had been perverted since childhood, and this perversion had intensified during puberty. ²³ Finnish psychiatry followed German psychiatry very closely. The work of Magnus Hirschfeld, the German physician and sexologist, who studied sexual minorities and advocated for their rights, was well known by the state mental hospital during the first decades of the twentieth century. ²⁴ However, Hirschfeld’s Die Transvestiten [The Transvestites] (1910) was probably not known among psychiatrists, since it was not mentioned in the following case.

In 1919, the psychiatrist Akseli Nikula (1884–1956) at the state mental hospital, Lapinlahti (later to become the Helsinki Psychiatric Clinic) treated a patient called Impi. He discussed the case in the leading Finnish-language medical journal Duodecim the same year, as part of an article on the significance of homosexuality in court cases. According to Nikula, Impi, who was diagnosed with degeneratio psychopathica, had shown signs of same-sex orientation already prior to puberty. Impi had been interested in horses and woodwork and hated girls’ activities, such as needlework. Later, Impi had smoked tobacco and drunk alcohol, activities not considered appropriate for a lady. They worked as a teacher. Their masculine behaviour had not ‘evoked respect’ in the pupils – although it is by no means certain that the pupils themselves had taken a stand on the matter. Impi had asked the vicar in their parish to re-enter their name in the parish register under the male name Esko. When the vicar had refused to do this, Impi had forged their name in the register. They explained that they did this because they wanted to be a man, work like a man, and live like a man. When the forgery was discovered and Impi was put on trial for it, the municipal court ordered a forensic psychiatric assessment. ²⁵

Impi seemed confident about their sexuality. They had had various love affairs with women, and was also said to have harassed female patients, nurses and cleaning ladies at the psychiatric ward. They wore men’s clothes, kept their hair short and parted in a men’s style, and preferred male company and men’s chores. According to Nikula, Impi repeatedly insisted on changing to a male name, and they asked the doctors if their genitals could somehow be changed into male genitals. They said they claimed their right to be a man, even if that meant bleeding to death. ²⁶ This happened long before the world’s first well known sex reassignment operation was conducted in Magnus Hirschfeld’s Institute for Sexual Sciences in Germany in 1931. ²⁷ In this respect, Impi was well ahead of the times.

Similar reports were published in other countries as well. Between 1915–19, the Boston press discussed a patient called ‘man-woman’ or ‘girl-man’. The person treated at Boston Psychopathic Hospital, and had lived twelve years as a man. Like Impi, they enjoyed smoking and drinking. They had had many relationships with women. They told the psychiatrist that they were meant to be a man, and even their environment mixed the use of personal pronouns while talking about them. Their conduct was described as ‘gentlemanly’. ²⁸

Nikula concluded that Impi was a female homosexual who came into conflict with the social order because of their perverted sexual drive. ²⁹ This was in line with the psychiatric thinking of the time: most psychiatrists did not distinguish between those who hoped to change their own anatomical sex and those who preferred same-sex relations. ³⁰ Nikula placed no special importance on Impi’s certainty that they were actually a man. Nikula admitted that he would need to study more cases in order to know more about the subject. It is also possible that other ‘homosexual’ patients described similar sentiments, and that had been left out of psychiatric reports because they were considered irrelevant. As Ludwik Fleck has pointed out, closed systems of opinion offer persistent resistance to anything that contradicts them. ³¹

Impi’s case serves as an example of the sort of knowledge that they had in them, as part of them. Of course, as Maja Bondestam and Jonas Liliequist have shown in their studies on the history of hermaphroditism and cross-dressing in Sweden, ³² it is possible that Impi knew women who dressed as men, or individuals who did not define their sex in binary, either-or terms. However, it is unlikely that Impi had any knowledge of the scientific discourse on transsexuality. The Finnish newspapers and periodicals, excluding sporadic book shop advertisements, had not published on the topic, and despite going to the teacher training institution that qualified Impi to work as a teacher, they were not highly educated. Moreover, it is very unlikely that they knew German. ³³ Harry Oosterhuis emphasises that although the essentialist, common-sense understanding of human sexuality as fixed in nature or in the psyche is not supported by recent research, there is also a risk that critical attitude might lead to losing sight of sexual identities as self-experience, and as social and historical realities. ³⁴ Despite the lack of models and information, Impi was certain they were meant to be a man and was assertive regarding their needs and rights, so assertive it led them to commit a crime.

3 The Body as a Burden

I wish, with all my heart, that I were a girl. I want to be a girl and then I will love my life and be happier as a girl in my life and I will enjoy it to the fullest. I do not want to continue my life as a man, I want to be released from the chains, to really dress as a woman. This is my requirement. ³⁵

While Impi most probably had no role models, many if not all of the patients who entered the Helsinki Psychiatric Clinic after 1954, had heard about people like themselves. These caused a notable increase in the number of people who contacted the Clinic. There was also more scientific knowledge available about various aspects of sex and sexuality thanks to findings in various scientific fields, including endocrinology, sexology, biology and psychiatry. The modern medical concept of transsexuality had begun to take form. It is important to note that this knowledge reached Finland in phases. Between 1954 and 1968, Finnish psychiatrists followed international developments and showed great interest in the Transvestitismus phenomenon.

Psychiatric treatment of transvestism was often preceded by somatic tests and examinations. Many of the patients had been examined at Internal Clinic of the City General Hospital ³⁶ before being admitted to the Helsinki Psychiatric Clinic. Some had undergone exploratory laparotomy and their hormones and sex chromosomes had been examined, with the purpose of determining whether the patient was a hermaphrodite. The social historian Geertje Mak sees the history of hermaphroditism in the nineteenth century as ‘doubting sex’. This doubt could be expressed in many different kinds of circumstances, by many kinds of people, and it could be about numerous objects such as the growth of beard or menstruation as much as about the relation between sexual desire and anatomy. Mak’s focus is in historicising the ways in which doubting sex was enacted in medical practices. ³⁷ Likewise, in Finland, practitioners in internal medicine and psychiatry wanted proof in order to be able to dispel their doubts. Examinations were also done at the Children’s Hospital in Helsinki. ‘Nuclear membrane-related sex chromatin formations’ were sought in skin samples taken from the thigh and in the nuclei of the epithelial cells in the mucous membrane of the mouth and the urethra. The examinations also involved searching for drumsticks, structures that occur amongst leukocytes and are found only in females, employing the May-Grünwald-Giemsa staining technique. ³⁸ The sex-specificity of drumsticks among leucocytes was discovered in the 1950s. ³⁹ If the test results showed no definite signs of hermaphroditism, as it was defined in the 1950s, the patient’s problem was seen as psychiatric.

These patients had resented, or even despised, their prescribed gender role since childhood. Biological males had played with dolls, had had only girls as playmates, and had never taken part in any boys’ games. One assigned female had detested playing with dolls as early as the age of two. One of the patients had worn men’s clothes since they were four years old. Puberty intensified their feelings of being ill at ease in their body and in their prescribed gender role. One patient, after having left their parental home, had grown long hair, had a perm, started using make-up and wearing women’s clothes. Another patient’s mother had pressured them to visit the Clinic because they had wanted to be a boy since they had been a child, and later was sexually interested in girls and wore men’s clothes. For the anatomical female patients, the female body was a burden. The onset of periods and the growing of the breasts had all proved difficult experiences. Aversion to their own body made masturbation repugnant for some, but one patient said they liked to read ‘dirty’ books. ⁴⁰

According to the clinical notes, many of the patients had had an active and satisfactory sexual life. No one reported difficulties in finding partners, and some had had many. One patient claimed that they had gone out with at least a hundred boys, although they had only kissed and fondled them, being afraid to go further than that. ⁴¹ The patients’ relationship to homosexuality was ambivalent, and sometimes troubled. One assigned woman was sexually interested in girls but did not have sexual encounters with them because did not consider themself homosexual. Another, an assigned man, was reportedly disgusted by their ‘manifest homosexuality’, but nevertheless openly disclosed their sexual experiences. Another assigned man had been in a relationship with a man for years, and had also had sexual intercourse with him, but regarded the relationship as heterosexual. Their one experience of intercourse with a woman had felt ‘unnatural’. ⁴² The patients in the Clinic did not want to identify with homosexuality which at the time was strongly condemned by society. Similarly, there were some court cases in the 1950s, where a woman accused of same-sex unchastity denied being a homosexual. Instead, they wanted to avoid that stigma and referred to pathological drives, for example. ⁴³

Some patients felt deeply guilty about their sexual experiences. A patient who described their sexual drive as being ‘upside-down’ had had recurring pleasurable dreams about being a woman and being raped by men. Things had gone from bad to worse after they had fallen in love with one man – and after that with other men. Since they felt they could not have sex with men, masturbation was the only expression of sexuality they allowed. ⁴⁴ Another patient described their desperate urges in a letter:

I do not know how to explain it. Because I cannot talk I’ll try to write. The whole time I have been here I have wanted to touch girls and I have managed to restrain myself, but I cannot do it any more. I did not go on holiday because I would have been with some girl again. If I leave soon, I will do it again. While I am here I do not dare to do anything but at home …I do. And I know it would only cause me trouble. And I do not want that. Can you not make me a boy? So that I could be with girls without any trouble. I would not want to be a perfect woman, if they try to do that I will commit suicide. I cannot restrain myself for much longer (I will go crazy) if I am not already. Now my thoughts are all messed up and I cannot write any longer. ⁴⁵

The issue of guilt was also prominent in the 1950s trials for unchaste behaviour against female homosexuals. It was advisable to show regret in the police interrogations and during the trial. Guilt made the confession irreversible, but it was also a way of showing that the individual was not hopelessly evil and thus also to comply to prevailing morals. ⁴⁶ Not all patients expressed guilt, however. Some, like Impi, were confident that they had the right to do as they wished. One patient wanted to change their name to a man’s name and to get married. They were engaged and they said they were well able to ‘play the man’s role’ in the relationship. They had had ‘some sort of a sexual relationship’ with their fiancé. ⁴⁷ It was primarily the assigned sex these patients wanted to change, not their sexuality.

Some of the patients had been living in constant fear that their assigned sex would be found out. An assigned woman said they did not have any problems in their ‘role’ in their own municipality, because people knew them. They dressed as a man, and wearing women’s clothes would make them feel ‘disheartened’. However, the patient’s mother told the psychiatrist that the local social board was concerned about the patient’s open interest in girls. ⁴⁸ On the whole, it might have been easier for assigned women to live an undetected life as men than it was for assigned men to live undetected as women, because men could more easily adopt a mobile lifestyle.

Although the patients may have had a specific purpose in telling their story in the Clinic, these intimate accounts reflect the trust the patients had in psychiatrists. Had the environment been unsupportive, they would have had the option to remain silent. The Clinic was their safe place to tell about their lives. The supportive environment functioned as an enhancer of their identities, which they perceived mostly as congenital. Although one patient told the psychiatrist they had read foreign literature on the topic, and another had got the idea of surgery after they were told they were like a woman, ⁴⁹ there was an awareness that directed their interests and choices.

4 Father Fixations and Mother Identifications

The psychiatrists described, explained and tried to treat the patients. All the case files contain observations of symptomatic behaviour. Boyish behaviour in females was described in detail. For instance, a boyish woman is described as anxious, depressed and covertly aggressive, emotionally labile, puerile and immature. Their hair was short, their voice was low, and they used slang and curse words. Their gestures were masculine. They liked being in the hospital and found the environment supportive. An assigned male patient, who had ‘eaten hormones for years’, was coquettish and feminine, especially when they talked about sex-related matters. But the patient resented playful comments regarding their femininity; they wanted to be either-or. ⁵⁰ The psychiatrists’ descriptions reflect their view on gender. Cursing and using slang was regarded as masculine whereas ’coquetry’ was feminine. The prevailing polarised norms for behaviour were integrated into the medical descriptions.

In some, but not all cases, the case files also discuss psychiatric views of causes. The early understanding of Transvestitismus as psychopathy implies the psychiatric belief that it was congenital. This shows the overlap between the biological and psychoanalytic approaches. The dominant frame of interpretation in the Clinic in the 1950s and 1960s was psychoanalytic. Olli Stålström has shown that the Helsinki Psychiatric Clinic relied on the work of the psychoanalyst Irving Bieber (1909–91) in interpreting homosexual behaviour. According to Bieber, an active and dominant mother and a submissive father enhanced homosexual development. ⁵¹ Similar concepts were applied to Transvestitismus already in the 1950s. One patient was described as having a ‘fixed mother identification’, which underlay their ‘manifestly homosexual’ life. The lack of a masculine role model also contributed to their condition. ⁵² Another patient had a ‘strong father fixation’. The father liked boys better than girls, and the patient’s need to be accepted by the father had caused them ‘psychosexual disturbance’. There was still some ‘feminine identification’ in the background, but it was suppressed by the patient’s fear of men – or, actually, according to the psychiatrist, by fear of the father. The patient resisted therapy. ⁵³ In a published paper from 1956, the psychiatrist Armo Hormia discussed a pair of twins in similar terms. One twin had symptoms of transsexuality and the other had symptoms of nymphomania. According to Hormia, the conditions were caused by the twins’ relationship with their mother and foster mother. Salme, the assigned girl who kept their hair shot and dressed in sports clothes, reportedly got better after recognising the feminine sides in their sexuality. ⁵⁴ By the 1970s, causes were discussed to a lesser extent, possibly because the psychiatrists did not believe that the patients could be cured.

What kind of treatment did the patients receive in the Helsinki Psychiatric Clinic? The leading transsexuality expert Harry Benjamin (1885–1986) regarded psychoanalysis as the best form of therapy ⁵⁵ alongside surgery and hormonal treatment. The literature contains references to transsexuals treated with hormones in order to enhance their assigned sex, and transsexuals locked away in mental hospitals. ⁵⁶ The cases under study do not refer to prolonged psychoanalyses, which might have taken place in the out-patient clinic, but some were given ‘supportive therapy’ in the form of sympathetic, psychoanalytically orientated discussions. Neither are there references to hormone treatments, although it is possible that some patients were prescribed Anabolin, an anabolic steroid, because psychiatrists prescribed it to patients in general. As an exception, one assigned male patient was also given a couple of Primoteston anabolic steroid injections, but these were reported as having had no effect. ⁵⁷ This test took place in the 1950s, before psychiatrists had any guidelines for such cases. The case files do not support the view of psychiatric confinement of transsexuals. If the patients did not suffer from severe depression or have psychotic symptoms, the psychiatrists saw no reason to keep them in the ward. They were discharged and told to contact the out-patient clinic, if needed. ⁵⁸

Psychiatrists were sometimes able to help their Transvestitismus patients with their problems regarding social adjustment. For example, they recommended that an assigned female patient was allowed to fulfil their wish and work in a ‘manly’ environment. On other occasions, too, they tried to find ways for the individual to lead a satisfactory life that did not contradict their identity too much. They also tried to make the patients’ life at the ward comfortable. One patient was upset because they were placed in a female ward. They complained that they did not want to ‘sleep with the bitches’. Neither were they willing to wear women’s clothes. Since it was not possible to place them in the men’s ward, a compromise of sorts was reached: they were given pyjama bottoms and a nightgown and placed in an unlocked isolation cell. However, not all patients disliked living among patients of their assigned sex. One assigned male said they liked the men’s ward, where they received a lot of attention and where the other men would comb their feminine hair. The patient said: ‘You cannot take this femininity from me.’ Some patients were advised to change jobs or find a new place to live. One patient mentioned that all the doctors they had seen had given them the same advice. ⁵⁹ They clearly did not find such help sufficient. All these cases exemplify how the psychiatrists aimed at solving the patients’ problems as they came. One at a time they increased the knowledge in the Clinic.

Another example of the psychiatrists’ attempts to alleviate social maladjustment was a case of a young patient about to be enrolled for military service. They acted in a feminine way, but their genitals were normal. The psychiatrist in charge talked to them and prescribed them Librium. ⁶⁰ The patient was hoping for an operation but was told that surgery was impossible, which made them lose their appetite. After a while, they became resigned to the idea that they could be a woman only inwardly, and decided that they did not want surgery after all. The psychiatrist wrote them a medical certificate recommending against military conscription, on the grounds that being forced to undress in front of other men might lead to difficult mental reactions and possibly even to suicide. ⁶¹ They apparently felt that they had been helped by the Clinic, for they wrote to thank the doctor and the nurses for all their empathy, care and friendliness. ⁶²

There were also less positive experiences, as testified by the directly hostile letters from patients to doctors that can be found in the archives. One patient was regarded ‘impossible as a subject for psychotherapy’ because their only wish was to be castrated. The psychiatrists wrote that the patient realised that the aim of the psychotherapy was to make one accept oneself and one’s perversity, and the patient was determined not to do so. This example shows that the psychiatrists were not always willing to see the matter in the same light as the patients. The patient was not given permission to be castrated. ⁶³ One patient was visibly bitter towards the doctors who did not want to recommend surgery and stated: ‘God will solve it. There are only two options: whether the surgery is performed, or whether I continue this way and go crazy’. ⁶⁴

5 Surgery as the Desired Solution

Many of the patients had sought medical help in the hope of receiving somatic treatment that would make their body match with their identity. Most of them were disappointed.

Many if not all of the patients in the Helsinki Psychiatric Clinic had heard of people similar to themselves and knew about early sex reassignment operations. The case of Christine Jorgensen was ground-breaking in this respect. Jorgensen had been born as George William Jorgensen, the son of Danish Americans living in the Bronx. They were operated on in Denmark in 1953. Danish law allowed the medical castration of people who suffered from their sexuality, and Jorgensen was defined as a suffering homosexual. Jorgensen’s was not the first sex reassignment operation, but it received unprecedented publicity. It became the number-one story in the New York Daily News in 1953 and became known even in the remotest parts of Europe. ⁶⁵ The Finnish magazine Seura [Company] published an article on Jorgensen the same year. Seura’s piece was thoroughly positive and sympathetic and even frowned on the way in which scandalous magazines had written about Jorgensen. The article ended with the wish that one day Christine would be escorted to the altar by a man who would then share his life, his joys and sorrows with Christine the way a husband and a wife would. ⁶⁶ The Jorgensen case has been interpreted in the American Cold War culture: Jorgensen represented American liberalism and individualism. At the same time, Jorgensen was seen as a threat to social order because they did not respect the fundamental laws of nature. ⁶⁷

As Jorgensen was operated on in Denmark, it was not surprising that some Finns, too, turned to Denmark for help. One of the Clinic patients had contacted Danish doctors soon after hearing about the Jorgensen case, but the help from Denmark had not been encouraging. ⁶⁸ Christian Hamburger, the doctor who had started Jorgensen’s hormone treatment, received letters from 465 individuals who felt a strong desire to have their sex reassigned. Most of them were from abroad, the United States (180), Great Britain (75) and Germany (53). Two requests were from Finland, both of them made by assigned men. ⁶⁹ People with no permanent address in Denmark were refused outright, in the fear that the Jorgensen case would create a precedent. ⁷⁰

The first Finnish sex reassignment surgery – a male-to-female case – took place in 1954. The case received exposure in the scandal-oriented Hymylehti [The Smile Magazine]. Other cases and articles followed, including the tragic tale of ‘Weija’, whose story was summed up on the cover of Hymylehti as follows: ‘Can this be true: I was born as a boy, and grew up to be a girl.’ ⁷¹ One of the Clinic patients had agreed to see a psychiatrist after having read about the first sex reassignment operation. ⁷² Another refused psychiatric treatment because they were convinced they could be operated on and hormonally treated in the Soviet Union. ⁷³ They might have heard that women who persistently desired women were recommended sex reassignment surgery in the Soviet Union. ⁷⁴ Some Finns may have sought surgical treatment in the Soviet Union, but the Helsinki Psychiatric Clinic files do not refer to such surgeries. One of the Clinic patients explained that they could have been operated on at the Karolinska Institutet in Stockholm, but did not have enough money to go through with it, and another said the same thing about an operation in Casablanca. ⁷⁵

In Finland, psychiatrists were consulted when medical castration was considered. Castration applications were handled by the National Board of Health. According to Merja Rastas, the National Board of Health received four transsexuality-related castration applications between 1959 and 1969 and rejected them all. ⁷⁶ Rastas also claims that psychiatrists never spoke in favour of the operation. However, there seems to be at least one exception to this rule. In the early 1960s, an assigned man applied for a castration. ⁷⁷ The patient had been in psychotherapy and had had hormone treatment, consisting mainly of oestrogen injections. They had been promised plastic surgery, but had to be castrated before that. A Clinic psychiatrist wrote a psychiatric evaluation for the National Board of Health, supporting the application. He stated that the patient was likely to suffer from serious nervous disorders, caused by their contradictory situation, unless they were operated on. ⁷⁸ The positive statement may be due to the fact that the patient in question had been treated for some years in the United States by Harry Benjamin, the leading international expert on transsexuality. The Clinic psychiatrists may have been impressed enough by Benjamin’s name to recommend the operation, although they were otherwise very cautious regarding surgery. It is also evident that despite hesitation, the psychiatrist understood the patient in the patient’s terms and perceived surgery as the best solution to solve their contradiction.

Compared to earlier cases, the psychiatrist’s opinion had changed significantly. Although many of the patients diagnosed with Transvestitismus had turned to psychiatrists in order to have their sex reassigned, they were to be disappointed. In the early 1960s, the psychiatrists were opposed to sex reassignment operations both out of principle and for more practical reasons. One psychiatrist described the issue of psychiatric versus somatic interpretation in a patient’s case file from his own viewpoint. He described the way the patient perceived their identity and did not question the patient’s femininity in the case file writings, but opposed surgery:

Once again, the patient is told that there is no chance of them becoming a woman. The patient is sorry but settles meekly for the situation. It seems their character stops them from opposing and makes them adapt. The patient thinks it is not decent for a lady to object or to express themself strongly. Does not demonstrate in any way but smiles as if nothing has happened. When discussing the future, they say they plan to go abroad. ⁷⁹

There are also references to unsuccessful operations. There are passing, unspecific references in the case files to negative experiences of sex reassignment operations. ⁸⁰ The psychiatrist Kivi Lydecken later wrote that a particular case of sex reassignment surgery made the National Board of Health take a more cautious view on such operations. ⁸¹ Although there were successful international examples of individuals whose quality of life had significantly improved since the operation, references to negative experiences should not be underestimated. As Jameson Garland points out in the context of gender-‘normalising’ interventions on children who have been diagnosed as different in sex development, individual cases of medical misjudgement can significantly weaken the credibility of medical institutions. ⁸²

In secret, some operations, the number of which is unknown, were conducted. The Helsinki Psychiatric Clinic Professor Kalle Achté (born 1928–) concluded one report by describing how the transsexual patient was no longer anxious and their mother no longer feared suicide. ‘Both the patient and their mother are pleased with the operation and it must be regarded as a success in this case’, Achté wrote. The patient had thus convinced Achté that surgery had been the right option. Ever since the patient was twenty-one years old, they had searched for help for their problem. They had visited a psychiatrist who had prescribed them medication that alleviated their anxiety. Later in their life they visited the Helsinki Psychiatric Clinic, but their physicians did not recommend surgery. According to the report, this reluctance made the patient bitter. The result was similar in another state mental hospital. When the person applied for permission for castration from the Finnish National Board of Health, lääkintöneuvos ⁸³ Kuusisto advised them to ask for help from Professor Paavo Vara (1908–89). They were castrated, and after the castration, operated on altogether thirty-three times. According to the report, the constructed penis worked well. ⁸⁴

6 From Transvestism to Transsexuality

Psychiatric attitudes towards surgical treatment of transsexuality changed after the 1960s. The change is largely associated with the endocrinologist and sexologist Harry Benjamin. He started seeing transsexual patients in the late 1930s. As Leah Cahan Schaefer and Connie Christine Wheeler have emphasised, he developed his views on what he, at this point, called ‘gender dysphoria’, in close interaction with his patients. The patients may have lacked medical terms, but they nevertheless expertly described their condition – the way they had felt as children, their attempts to cross-dress, the secrecy and the isolation that marked their lives, and their efforts to suppress their desires. ⁸⁵ Benjamin became known for his work on transsexuals, and, in 1966, published a seminal book called The Transsexual Phenomenon. Although he did not coin the term, which was coined by Dr David O. Cauldwell in the late 1940s, Benjamin became the most well-known authority on transsexuality. He received questions and pleas for help from all over the world. ⁸⁶

In Scandinavia, the Swedish psychiatrist Jan Wålinder became a leading authority on transsexuality. ⁸⁷ He formulated the preconditions for the operative treatment of transsexuals, and these were also referred to in the Helsinki Psychiatric Clinic. When the assistant physician Antti Alanko was consulted about a patient who had been operated on by Paavo Vara in the Women’s Clinic, he referred to Wålinder’s guidelines in the case file. Alanko stated that a psychiatrist should have been consulted prior to the operation, which implies the lack of guidelines in the early surgeries, and that the patient should have received hormonal treatment and supportive psychotherapy, as Benjamin recommended. Wålinder suggested that a patient should live for two years as a member of the opposite sex prior to the operation, in order to prove his or her ability to survive in this role. The patient in question had not lived as a woman at all. The patient should be strong enough to endure the hardships of a transsexual life. Psychotic reactions were a counterindication. Alanko regarded the patient as an atypical transsexual, because they had started to regard themself as female only during puberty, and not during childhood. However, they were not a case of ‘pseudotranssexualism’ or ‘homosexualism’, and there was no somatic illness that might have had an effect. Based on his discussions with the patient, and on fresh research, Alanko agreed that the operation had been a good choice, because the patient would have remained dissatisfied without it. ⁸⁸

The interest in transsexuals is evident in the published works of psychiatrists. In 1971, Alanko published two articles on ‘transsexualism’, both with Professor Kalle Achté. The one written in English contained a review of existing research and some discussion on transsexuality in Finland. Alanko and Achté emphasised the risks in sex reassignment surgeries but admitted that many patients had benefited from them. This statement was a direct consequence of their experiences with the patients. According to Alanko and Achté, transsexuality as such does not involve ‘other psychic symptoms’ but transsexuals might develop such symptoms as the result of maladjustment and the lack of understanding they faced from both laymen and physicians. ‘The most pivotal symptom belonging here is, however, isolation from society and from interpersonal relations, leading to despair and solitude. Frequently the transsexuals do not even receive from their close relatives the support and understanding that they often need.’ Emphasising the lack of support as the reason for maladjustment was another conclusion following interaction between the two psychiatrists and their patients. Alanko and Achté found the treatment of transsexuals challenging, because these patients would rather have their bodies changed to fit their identity than their identity changed to fit their bodies. According to Alanko and Achté, their request was problematic: ‘This often leads to ethical and legal problems, similar to those once met in connection with lobotomy and, today, in the context of heart transplantation operations.’ ⁸⁹ Similarly, in the late 1980s, psychiatrists were concerned that operating on psychotic patients or transvestites surgically as a result of diagnosing the individual incorrectly would have disappointing results. ⁹⁰ As Jameson Garland has shown in the case of sex assignment and gender ‘normalising’ treatments on children, such fears have not always been unwarranted. ⁹¹ The psychiatrists hesitated not so much about the operations as effective help for some patients, but more about their own level of expertise in making the evaluations while knowing the risks of surgery and their finality.

Alanko and Achté recommended psychotherapy for combating possible psychological symptoms. Sex hormones that corresponded to the patient’s anatomy were not helpful, whereas sex hormones corresponding to the patient’s identity could be. The authors concluded that sex reassignment surgery was the only means to help certain severe cases, but they also hoped that medical research would eventually provide new, ‘less traumatising methods’ for help. ⁹² They emphasised the importance of accurate diagnosis, since mistakes could be costly. The examination scheme included in the article followed Wålinder’s and Benjamin’s work, but also the work of Robert Stoller and of Richard Green and John Money. ⁹³ In comparison to the 1950s, when there were no guidelines available, the work of the psychiatrists eased, not only because of their own gained experience but also because of other available research in the field, research that had been moulded by similar experiences with the patients.

According to the psychiatrist Kivi Lydecken, an estimated 35 individuals were operated on in Finland by the end of the 1980s. ⁹⁴ The numbers were higher in other countries: 153 in Sweden, 80 in Denmark, 103 in Belgium, and over a thousand in Germany and the United Kingdom. ⁹⁵ It is more than likely that the Swedish numbers include some Finnish patients as well. The castration applications filed to the National Board of Health might work as an indication of the extent of the practice in Finland. There were no applications by transsexuals in the 1970s, possibly because it was not explicitly required from them. In the 1980s, there were twelve applications from people diagnosed and treated as transsexuals in the Helsinki Psychiatric Clinic. The psychiatric statement was positive in all except one case, which illustrates the general attitude of the psychiatrists. The National Board of Health accepted nine applications, and rejected three. ⁹⁶ The scarcity of castration applications may be due to the transsexuals’ unwillingness to let the authorities decide on their sex reassignment surgery, as only castration was subject to permission. Many more were operated on abroad because it was easier to get a new name and social security number afterwards. ⁹⁷ It is noteworthy that a patient undergoing a sex reassignment operation that was one of the earliest in Finland had to sign an agreement not to make their case public. ⁹⁸ This may be because of the publicity given to some surgical failures by the scandal-mongering magazine, Hymylehti. ⁹⁹ As research on the later developments regarding their rights and treatment in Finland has shown, the psychiatric, surgical and hormonal treatment of transsexuals, apart from treating them as equal human beings, has been far from unproblematic. ¹⁰⁰ There are grounds for assuming that the clash in norms, values and beliefs hindered the development of the rights of transsexuals more than is suggested by mere medical findings – which show hesitant support for surgeries. Even today, there is pressure on Finland to change policies on those regarded as ‘transgender’. Amnesty International has pointed out that a psychiatric diagnosis is stigmatising and should not be a precondition for assessing health treatments and legal gender recognition. Legal recognition, it argues, should not be tied to non-necessary medical treatments such as sterilisation. The length of the process of obtaining documents that reflect gender identity, the single status requirement and the exclusion of those transgender people who are not diagnosed with ‘transsexualism’ according to the criteria in ICD-10, are seen as violating rights to private and family life and to recognition before the law. ¹⁰¹

The findings from the Helsinki Psychiatric Clinic offer some historical perspective on the complexity of treating transsexuals. They also show how sex reassignment surgery became essential in defining and determining one’s identity for those seeking help from the Clinic, whereas today the concept of transsexuality has varying forms, terms and interpretations, and sex reassignment treatments are not necessarily hoped for. The aim of this article has been to highlight that the Helsinki Psychiatric Clinic patients wanted to reassign their sex to match the social circumstances of the time, because they knew who they were.

7 Conclusion

This article has focused on a phase in the development of the concept and treatment of transsexuality, a phase when the diagnostic concept of transvestism had not yet been replaced by transsexuality. The analysis of the case studies has shown that the patients were highly aware of and very capable of describing their condition, even if they had no medical name for it. Psychiatrists, too, were willing to engage in a dialogue with the patients, and did not treat them merely as passive objects of study. The study of patient records makes it possible to hear the voice of the patients, albeit mediated, and also see the insecurities and hesitations of the psychiatrists in a way that the study of published accounts seldom does. While some patients felt that they had been helped in the Helsinki Psychiatric Clinic, many left the institution as frustrated, angered or desperate as before. They had sought medical help in the hope of having their bodies altered to correspond to their identities, but the Clinic psychiatrists insisted on seeing the problem in psychiatric terms and did not recommend surgical or hormonal treatments. This would change in the 1970s and 1980s. The change was mostly gradual, and took place as a result both of interaction with the patients and of international developments regarding surgical treatment as a viable therapeutic option.

Transsexuality was and still is a special diagnosis that the patients know more about than the doctors do – claiming otherwise entails the risk of objectifying the patient’s view on their own identity. The problematic relationship between the rights of the individual and the responsibility of the physicians in making the correct diagnosis and treating patients in the best way possible has remained – not to mention the relations with other authorities on whose expertise transsexuals need to rely on in order to get help. The great paradox in transsexuality lies in that an individual should be able to define their own identity without asking for permission from others to do so, but in practice the individual needs to rely on society’s acceptance of it. Operative help is highly interventionist and non-operative help calls for society’s open-mindedness regarding perspectives on sex. The World Health Organisation may bring about changes when the new ICD-11 comes out in 2018. Possible changes to the Finnish legislation have also been discussed. Although new changes in legislation and the classification of diseases may help many individuals with transgender identity in this respect, it remains to be seen what kind of role psychiatry will have in the near future.