Harry Benjamin's Syndrome

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The findings of medical researchers about the neurological root of Harry Benjamin's Syndrome (Schwaab et coll, 1985. Zhou et al, 1995) increased understanding of physiological sex. We know now that sex is not only defined by our genitals, reproductive organs, endocrine system (sexual hormones), or genetic structure (sexual chromosomes), but it is also defined by the structure of the brain (neurological system or also called brain sex). This causes a larger variation of intersex conditions.

Besides the neurological nature of Harry Benjamin's Syndrome, there are other characteristics like hypogonadism or variations in the endocrine system, which are not so unusual. Recent research strongly suggests a genetic basis linked to the condition too. It is common for people with Harry Benjamin's Syndrome to present characteristics of their "opposite" sex even before HRT, i.e.: many females with Harry Benjamin's Syndrome have lower levels of antigen HY (Eicher et al., 1981). These levels would be abnormal in males. Other morphologic characteristics are also common. Many girls with Harry Benjamin's Syndrome already had clearly feminine physical forms and bone disposition before starting HRT, as example too.

A Human Rights report from Australia, explains the syndrome as follows:

"Transsexualism is now regarded by the world's leading experts in the field as another of the many biological variations that occur in human sexual formation -an intersex condition- where the sex indicated by the phenotype and genotype is opposite the morphological sex of the brain. People with the condition of transsexualism are therefore born with both male and female characteristics and, like many others with atypical sexual development, seek rehabilitation of their phenotype and endocrinology to accord with their dominant sexual identity; an identity which is determined by the structure of the brain. Transsexualism is about being a particular sex, not doing it. It is also about recognising gender norms, not challenging them." -Karen Gurney & Eithne Mills. 2005. Murdoch University Electronic Journal of Law, Vol 12, No #1 & #2

Most intersex people have a defined gender identity as a man or as a woman and this is the reason why these people have the need to be reaffirmed as their true gender. Intersex people nowadays are fighting for their right to choose when and how they want to be reaffirmed. People want to put an end to the corrective surgeries that doctors perform to intersex newborns and wait until the person is old enough to decide -just in the same way as Harry Benjamin's Syndrome is treated today.

Some intersex communities have refused to see Harry Benjamin's Syndrome as another intersex condition. This is caused by misinformation or the stereotypes of the past. We know that Harry Benjamin's Syndrome is not a conventional intersex condition. It could be better classified along with other rare conditions. However, it would be even better to establish communication between both communities to understand the needs of each other and develop a better relationship among the different intersex communities.

Harry Benjamin's Syndrome is not a part of a person’s identity, but a physiological issue that needs to be reaffirmed. Due to the old relation between transsexualism and homosexuality or transvestism, transsexualism was considered a part of a person’s identity. We have become used to making our condition part of our identity, to the point where there are people just becoming aware of the term Harry Benjamin's Syndrome wondering if now they should call themselves “Benjamins”. This is a big mistake. Harry Benjamin's Syndrome is a physiological condition, not part of someone’s identity. Women with Turner’s syndrome do not call themselves “Turner Women”, in the same way, we should not call ourselves “HBS Women or HBS Men” just “Women” or “Men” since that is what we are, the syndrome is something apart.

It is more adequate to refer to this condition as a Reaffirmation of gender instead of a gender transition. People with Harry Benjamin's Syndrome that are under HRT or getting GRS are people that are reaffirming their gender, not transitioning from one gender to another.

Ultimately, Harry Benjamin's Syndrome is just another natural biological variation in human sexual formation, and it does not have to be seen as an illness or a problem. However, medical treatment is required in most cases, and that is why it is so important an adequate and updated definition and placement of the condition by the international standard diagnostic classifications.

In relation with any possible criticism towards the intersex nature of Harry Benjamin's Syndrome or towards the Syndrome itself, see the special section: Respondiendo algunas Críticas

Three Final Statements.

Harry Benjamin's Syndrome is an intersex condition. -At least neurologically speaking, as it is pointed out now by different medical research.

Denominate to somebody with Harry Benjamin's Syndrome as "a transsexual" is contraindicated. -It is contraindicated if we care of the psychological well-being and emotional balance of someone affected by this condition, which already is neurologically of the sex that he or she feels to belong.
The corrective medical treatment of Harry Benjamin's Syndrome is an Affirmation of one's own gender, not a transition of gender. – Certainly, there is not a transition of gender involved at all, and anyway this would be not possible to do.

Resources in other languages and for people living
with Harry Benjamin's Syndrome in Europe

Harry Benjamin

Biography and Links

by Charlotte T.GA.

Harry Benjamin (1885-1986) was a German-born doctor. He is best known for his pioneering work with Transsexualism (Harry Benjamin's Syndrome). He received his doctorate in medicine in 1912 in Tübingen for a dissertation on tuberculosis. Sexual medicine interested him, but was not part of his medical studies. After several failed attempts to start a medical career in New York, in 1915 Benjamin started his own general medical practise. Later he also practised in San Francisco in the summer of every year. His special interest was hormonal research, and thus he became a disciple of Eugen Steinach, whom he visited in Vienna every summer through the twenties and early thirties. On these occasions, he also took frequent side trips to Berlin, where he visited both Magnus Hirschfeld and Albert Moll and participated in their congresses.

In 1948, in San Francisco, Benjamin was asked by Alfred Kinsey, a fellow sexologist, to see a child who "assured to be a girl", despite being born male, and whose mother wished for help that would assist rather than thwart the child. Kinsey had seen nothing of the like previously. Neither had Benjamin. This child rapidly led Benjamin to understand that there was a different condition to that of transvestism, under which adults who had such needs had been classified to that time (see for a competent history of earlier cases). Despite psychiatrists whom Benjamin involved in the case failing to agree amongst themselves on a path of treatment, Benjamin eventually decided to treat the child with oestrogen (Premarin, introduced in 1941), which had a "calming effect", and helped arrange for the mother and child to go to Germany where surgery to assist the child could be performed, but from where they ceased to maintain contact, to Benjamin's regret. However Benjamin continued to refine his understanding, in 1954 introducing the term Transsexualism, and going on to treat, with the assistance of carefully selected colleagues of various disciplines (such as psychiatrist John Alden and electrologist Martha Foss in San Francisco and plastic surgeon Jose Jesus Barbosa in Tijuana), several hundred patients with similar needs in a similar manner, often without accepting any payment. His patients regarded him as a man of immense caring, respect and kindness, and many kept in touch with him until his death.

Medical attitudes toward Harry Benjamin's Syndrome were very diverse among different countries, and many doctors considered all such people (including children) best treated by forced treatments such as drugged detention, electroconvulsive therapy or lobotomy.

Although Benjamin's 1966 book, The Transsexual Phenomenon, was immensely important as the first large work describing and explaining the affirmative treatment path he pioneered, he had already published papers and lectured to professional audiences extensively. In his work, Benjamin believed in a biological cause or explanation for Transsexualism, he was very much biologically oriented as himself declared jokingly to Freud in a meeting "that a disharmony of souls might perhaps be explained by a disharmony of endocrine glands."

Charles L Ihlenfeld, who worked with Benjamin for 6 years, was to become his heir apparent, but then left the practice to undertake a psychiatric residency, has written that: "By and large psychiatrists of this time considered gender dysphoria as a manifestation of significant psychopathology and considered the treatment Benjamin was then prescribing as psychiatrically contraindicated. Rather than discouraging Benjamin, this response simply reinforced his feeling that psychiatry as a discipline lacked 'common sense.'"

Harry Benjamin was married to Gretchen, to whom he dedicated his 1966 major work, for 60 years. In 1979 the Harry Benjamin International Gender Dysphoria Association was formed, using Benjamin's name by permission. In his long and distinguished career, Benjamin came to know many famous American and European scientists, scholars, and artists.

An interview with Harry Benjamin on
the occasion of his 100th Birthday.

A brief biography of Dr. Benjamin with
additional pictures and writings by him.

Intro | Syndrome | Perspective

Diagnosing Benjamin's Syndrome

Benjamin's Syndrome is not easy to diagnose. Though it is highly probable that there are biological indications for the syndrome, current medical technology isn't sophisticated enough to detect them. Autopsies carried out on people with Benjamin's Syndrome have suggested that they do exist, and genes that may be responsible for some cases have recently been discovered, but gender is a very poorly understood thing and we are a long way from being able to carry out reliable medical tests for the syndrome. But even if such tests were possible, they would not be very useful. There may be multiple causes for the syndrome, so testing for a single cause would be far from conclusive, and the appropriate treatment for any given individual depends much more upon their own feelings than on anything physical.

So, it is generally up to the sufferer to diagnose their condition for themselves. Psychiatrists and counsellors can sometimes help, but the person with Benjamin's Syndrome has to realise that they have a problem and something needs to be done about it. That something is wrong is usually clear from a young age; many if not most children with Benjamin's Syndrome feel different from other children, and uncomfortable with people's expectations of them. They may also be unhappy with their bodies, especially when puberty begins. But that doesn't automatically translate into an understanding that they're not really of the gender that they've always been told they belong to. Gender has such a fundamental importance to human society that the possibility of being so wrong about it can be literally unthinkable, especially when the concept is kept hidden and not talked about. While some people with Benjamin's Syndrome do know who they are for virtually all their lives, many do not figure it out until in their teens, twenties, or even older.

It does not help that Benjamin's Syndrome has significant social stigma associated with it, and much misinformation about it is perpetuated. Most people who've diagnosed themselves with Benjamin's Syndrome just want to deal with their condition as thoroughly as possible, then forget about it and get on with normal lives. So the people who get the most publicity are an outspoken minority who are not at all representative of people with Benjamin's Syndrome in general, and people who don't have Benjamin's Syndrome at all but are lumped into the same category by ignorant or sensationalist media. This makes it hard for people with Benjamin's Syndrome to recognise themselves in the way the condition is portrayed. And society's attitude towards Benjamin's Syndrome makes it scary to talk to anyone about the possibility that you may be suffering from it, or even think about it.

People with Benjamin's Syndrome are usually uncomfortable with their bodies, ranging from simply feeling that they're not quite right in some way through to outright loathing of the aspects that don't match their gender identity. They tend to relate better to people of their actual gender than those of the gender they were raised as, and have interests and personalities more typical of people of their actual gender (not stereotypes - people with Benjamin's Syndrome are just as varied as anyone else, and it isn't possible to label any particular trait as exclusively masculine or feminine), albeit influenced to some extent by socialistaion and hormones. People with Benjamin's Syndrome usually respond very favourably (emotionally if not physically) to hormone replacement therapy to bring their endocrine system in line with what is normal for their actual gender, and find changing gender roles to be of immense psychological benefit (disregarding the negative effects of social disapproval).

Not everyone who claims to or believes that they have Benjamin's Syndrome really does. Some gay men have been known to seek to become women to "make themselves straight", and there are mental disorders which can result in the expression of a desire to change sex without any genuine identification with the matching gender. Though psychiatric evaluation and counselling can not diagnose Benjamin's Syndrome, they can be useful in weeding out people who have some other problem, and coming to terms with it for those who do suffer from the condition.

Causes Of Benjamin's Syndrome

Overview

The real cause or causes of Benjamin's Synrome are not known for certain. Some might say people with Benjamin's Syndrome are born with souls of the opposite gender to their bodies, which may be true but isn't verifiable. Others consider it to be simply an issue of upbringing, which seems unlikely given that it has occured throughout history in all societies and social classes. But the most plausible explanation is that people with Benjamin's Syndrome have brain structures that do not match the sex of the rest of their bodies, due to some genetic or hormonal irregularity.

A Basic Guide To Human Sexual Differentiation

When a human egg is fertalised by a sperm, a new life begins from a single cell containing a mixture of DNA from both parents. This DNA (usually) contains either the chromosome pair XX or the pair XY. The cell replicates itself, and after a while the cells seperate into three distinct groups: one that will later form the skin, nervous tissue, and brain; one that will form bone, blood, and muscle; and one that will form most internal organs. A placenta forms to connect the embryo to its mother. This transfers substances such as nutrients from the mother's blood stream to the embryo, and also produces hormones to regulate the embryo's development.

The embryo begins developing gonads which will later differentiate into either testes or ovaries by means which are not well understood, but involve hormones and the XX or XY chromosomes. The embryo also develops the beginnings of both male and female internal reproductive structures, one of which is absorbed back into the body depending on certain hormones. The presence of testosterone causes the male structures to develop further, and the presence of AMH causes the female structures to be reabsorbed. Both are produced by the testes. In the absence of both hormones, the male structures will be reabsorbed and the female structures will develop. The external genitalia is initially female, but the presence of testosterone causes further development into a male configuration. The seam where the proto-labia fused together can sometimes be seen on the scrotum and the underside of the penis of adult males.

The sexual differentiation of the brain is not as clear cut, but is similarly affected by hormones. The brain develops quite independently from the reproductive system, with the cells that will form the two systems differentiating very early in the embryo's development. Sexual differentiation for the two occurs at different times, may involve different hormones and different genes, and involves tissues that may respond differently to the same hormones. The brain is also exceptionally complex, and could be affected by much smaller hormonal variations than other parts of the body.

What Can Go Wrong

The embryo's DNA is essentially the blueprint from which it knows how to develop. This blueprint contains much more information than the embryo will actually use. Genetic abnormalities can cause errors in the parts of the blueprint that the embryo is using, or tell it to use the wrong parts of the blueprint. So some parts of the body might not know they're supposed to make certain changes when they're exposed to testosterone, for example. Also, the presence of various hormones at various stages during the embryo's development helps regulate which parts of the blueprint are followed. If the wrong hormones are introduced at critical times (eg by the mother taking pills), or something prevents the right hormones from being present, the embryo will not develop as expected.

Abnormalities in sexual differentiation as a group are known as Intersexuality. Androgen Insensitivity Syndrome (AIS) is a good example. Embryos with Total AIS do not recognise testosterone, so their external genitalia is female. However, they are affected normally by AMH, so if they have XY chromosomes they will not develop female internal organs (eg the uterus).

Benjamin's Syndrome is a form of intersexuality in which the brain of a person with XY chromosomes fails to masculinise for some reason, or the brain of a person with XX chromosomes does masculinise (there may be many ways in which this can happen). It is often (but by no means always) accompanied by other signs of mild atypical sexual differentiation, eg a particularly large clitoris or small penis, unusually pronounced proto-labial seam, late or minimal puberty, etc. It can also coexist with other types of intersexuality, though if another kind of intersexuality is present then an additional diagnosis of Benjamin's Syndrome would generally be considered superfluous.

Technically speaking, this makes the brain structure/gender identity of a person with Benjamin's Syndrome the thing which is "wrong" (unless their brain matches their chromosomes and everything else is wrong, but that isn't common). However, the brain is by far the most important part of the body; the rest is just a shell to keep the brain alive. While the gender identity of a person with Benjamin's Syndrome may not be what was intended by their DNA, it is a perfectly normal, healthy state, and for all practical purposes they are the same as if their brain was as intended and their body the "mistake". The XX/XY chromosomes do affect the sexual differentiation of the embryo, but are by no means the only factor, and are not a useful means of determining a person's actual sex. In some species, chromosomes are completely irrelevant, and sex is determined by, for example, the temperature at which the eggs are incubated. Members of other species naturally change sex during their lifetimes.

Women with Benjamin's Syndrome are more common than men (there is no consensus on the exact ratio), which is a natural consequence of human development being female by default (it's generally easier for something to fail to happen when it should than for something to happen when it shouldn't).

Artificially Induced Benjamin's Syndrome

One situation in which the cause of Benjamin's Syndrome is quite clear is the sexual mutilation of children or infants. This most often occurs with physically intersexed infants, where the individual is operated on to make them conform more closely to a sex chosen by a doctor with no possibility of consent or regard for their brain structure/gender indentity. It can also occur if a male infants's penis is acidentally damaged or removed, and it is easier to surgically transform him into a female and raise him as such than to reconstruct the penis. It is common for people in these situations to be very unhappy with what was done to them, and revert to living according to their actual gender later in life.

External Links

Human Sexual Differentiation
Sex Differentiation, Psychological
The Visible Embryo - information on human development from conception to birth.
Intersex Society of North America
Intersex Voices
John/Joan - an example of artificially induced Benjamin's Syndrome.
Transsexuality may be genetic - a post at Deja.com regarding a Swedish study that may have identified the cause of some cases of Benjamin's Syndrome.
A sex difference in the human brain and its relation to transsexuality

Resources for Women

Hormone Replacement Therapy

An overview of HRT for women with Benjamin's Syndrome. Details of the main types of hormone medication and their effects, focusing on my own experiences. This should not be used to plan your own HRT regime without a doctor's assistance, as individual respones to HRT are highly variable and what works for me may not suit you.
More...

Genital Reconstruction Surgery

Genital Reconstruction Surgery (GRS) corrects the most obvious physical symptom of Benjamin's Syndrome by constructing a vagina and vulva from the existing genital tissue. The techniques are very sophisticated (though not perfect and not without risk) and a good surgeon can create a result virtually indistinguishable from the natural version.
More...

GRS - My Experience (Part 1, Part 2)

A description of my experience of GRS with Dr Toby Meltzer, and the long term results.
More...

Electrolysis

Unless you begin HRT very young, you'll probably need electrolysis (aka zapping) to remove facial hair. This is not fun, or quick, or cheap.
More...

Miscellaneous Advice

Some random advice for women with Benjamin's Syndrome, regarding voice, makeup, and cosmetic surgery.
More...

External Links

TS Road Map - a comprehensive site on practical issues for women with Benjamin's Syndrome.
Becky Allison "Friends and Family Issues" - Becky Allison's pages about Benjamin's Syndrome.
Transsexual Women's Resources - presents some extremely weird ideas about Benjamin's Syndrome, but does have a lot of good information as well.
Transgender Support Site - presented by Melanie Anne Phillips.

Resources for Men

Overview

This section is unfortunately rather less detailed and accurate than the section for women, since being a woman myself that is what I know most about. I will try to expand this in time, and suggestions and corrections for these pages are particularly welcome.

Hormone Replacement Therapy

An overview of HRT for men with Benjamin's Syndrome. Details of the main types of hormone medication and their effects. This should not be used to plan your own HRT regime without a doctor's assistance, as individual respones to HRT are highly variable.
More...

Surgery

Information on mastectomies, hysterectomies, and genital reconstruction surgery (GRS).
More...

Miscellaneous Advice

Some random advice for men with Benjamin's Syndrome.
More...

External Links

FTM International - resources for men with Benjamin's Syndrome.
FTM Informational Network - resources for men with Benjamin's Syndrome.
American Boyz - a support and social group for men with Benjamin's Syndrome and others.
TransBoy Resource Network - internet resources for FTM transgender and transsexual youth and others.
FTM 101 - a guide to medical issues for men with Benjamin's Syndrome
Calling All Trans* - a gender related web page focusing on masculinity.
Transland Resources - resources for men with Benjamin's Syndrome.
MtMInFo - email support list, with Book/Ordering List.