Hormonal Treatments for HSTS

These divide into hormonal (endocrine) and surgical treatments. This article discusses the former.

Hormonal or endocrine therapies and treatments have three basic strategies.

  • Preventing or delaying the onset of puberty. These are known as ‘puberty blockers’
  • Preventing the body’s natural sex hormones from inducing physical changes. These are known as ‘hormone blockers’ or, in males, ‘testosterone blockers’ (T-blockers)
  • Introducing cross-sex hormones, ie those typical of the opposite sex, to induce physical changes more like those found in the opposite sex. In males the principal one will be oestrogen and in females, testosterone.


The differences between adult men and women exist mainly because of the actions of sex hormones on their bodies, during the pre-natal period, then in childhood, adolescence and young adulthood. This is what causes the noticeable physical differences between the sexes and also most of the psychological ones, though some people dispute this.

Transgender homosexuals are individuals who have one sex but whose sexual orientation is similar to that found normally in the other. So, boys are attracted to males and girls to females. However, in addition to this sexual orientation, they have strong cross-gender ideation, that is to say they identify, either wholly or partly, as the opposite sex. They are likely to show significant gender non-conformity (GNC) indulging in cross-sex role play and appearance and this will be consistent and persistent, that is, not a passing phase; and they are likely to show more or less childhood gender dysphoria, that is, feelings of strong discomfort at being identified as the sex they were born.

Usually, in transgender homosexuality, this manifests prior to puberty and in those most likely to be HSTS, as young as 2-4 years of age. But this is a scale of variation; some transgender homosexual males, while feminised on some parameters, are less so on others. At the same time, they may feel a sense of discomfort at the mismatch between what their sexuality makes them feel they should look like and present as, and their actual appearance and presentation, which is called Gender Dysphoria. This too, is on a variable scale, so some people feel this very strongly and others less so.

If these parameters come together such that the individual’s Gender Dysphoria is stronger than his or her fear of social rejection or intolerance, that individual is likely to desire to transition.


To do that, HSTS desire to modify their bodies and faces so that they appear to be of the opposite sex. This goes far beyond cross-dressing or wearing feminine make-up (for a male). They desire to ‘pass’ in society and they know that in order to do so, their resemblance to conventional opposite-sex models must be convincing.

The place they usually will begin is with growing their hair, if male, or cutting it if female. Then they will explore feminine, for males, or masculine, for female, clothing styles. HSTS MtF might grow their hair long and wear dresses and heels, for example. This can work as long as the individual is young, but, especially for MtF, their natural sex hormones make it increasingly difficult to maintain a cross-sex appearance.

The way to combat this to impact the endocrine system. Today, in the West, this is done using a two-prong approach: firstly to counter the effects of the natural sex hormones and secondly to introduce cross-sex ones.

In this, the sexes are not equal.

Male-to-Feminine (MtF) or Transfeminine

The primary sex hormone for males is testosterone, which is, unsurprisingly, produced in the testes. For females there are two, oestrogen and progesterone, but the former has far greater effect on physical appearance.

Endocrine therapy for males consists of two stages. The first sets out to prevent a male puberty occurring, to minimise its effects or to delay it.

Blocking Puberty

This is the first step for most MtF HSTS. These are male and testosterone is extremely powerful. It masculinises a boy rapidly. Although HSTS MtF are often remarkably neotenous, or baby-faced, eventually testosterone will catch up. But in order to pass successfully as a woman in society, the exposure to the masculinising effects of testosterone must be limited. This means that puberty-blockers should be prescribed as soon as a confirmed diagnosis has been made. In order to initiate the system that allows for bone growth to be halted and to avoid excessive tallness, puberty should be allowed to initiate and then be stopped. The height-limiting function is not affected by the puberty-blockers and any increase in tallness will be minimal.


Testosterone’s ongoing effects can be suppressed using three different drugs. These are  Cryptosterone acetate, Spironolactone and Finasteride. The last was developed as a counter to male-pattern baldness and is usually not used alone, in transitioning.

Using testosterone-blockers like these allows a far lower, and therefore less risky, dose of oestrogen and still produce significant feminisation. It is important, however, to realise that the feminising effects of oestrogen apply only to bodily soft tissues and not to bones.

This means that an MtF using oestrogen, with or without a t-blocker (although the dose will have to be much higher in this case) can look forward to, for example: softening of facial features through changes in fat distribution; similar effects to the hips, legs and buttocks, some thinning of the waist and the development of breasts, which are mainly made up of fat. At the same time, she can expect to acheive a softer, smoother skin. Finally, through time, some changes to musculature may occur, leading to reduced upper-body strength and muscle mass.

What she cannot expect to change is her skeleton. Bony material, once laid down, is fixed, more or less for life. Some minor adjustments may be achieved through cosmetic surgery, such as reshaping jaw or brow lines, reducing a prominent nose and so on, but things like overall height, shoulder width and so on are not mutable.

This means that, for the MtF HSTS, time is of the essence. As she progresses through adolescence, she will rapidly masculinise and this may reach a point where it becomes so marked that it will be impossible for her to pass successfully as a woman. This means that, as soon as an the MtF HSTS is identified as such, hormonal treatment should begin. It is unwise to begin t-blockers prior to puberty, for the reason of possible height increase, but as soon after puberty, with a confirmed diagnosis of homosexual Gender Dysphoria, they should begin. By age 16, if possible, full doses of feminising oestrogen should be administered.i

Female-to-Masculine (FtM) or Transmasculine

For FtM, something similar is indicated, but parents iun particular ahould remember that genuine HSTS in females is far more rare than it is in males. Why this should be is not clear. However, another condition, called ‘Rapid Onset Gender Dysphoria, can easily be mistaken for genuine homosexual Gender Dysphoria. As we explain in the diagnostic guide, however, genuine homosexual GD, in almost all cases, gives many years of forecast, in childhood GNC, childhood Gender Dysphoria and in their expressions of sexuality. It almost never sets on quickly and in cases where it does, especially in females, extreme care should be taken.

While Mtf cross-sex therapy does have some raised risk of certain complications, like various cardio-vascular diseases,ii the effects of the treatment are mainly cosmetic. Despite the known tendency for feminising HRT to reduce the size of the penis and testes and render the subject unable to gain an erection or to ejaculate, there are reported cases of MtF transwomen getting women pregnant, even after many years of cross-sex HRT. (Clearly, these are not HSTS.)

For the female body, however, testosterone is a literal poison. It will effectively destroy the ovaries in short order, rendering the subject permanently sterile. This makes accurate diagnosis of Gender Dysphoria that much more critical in young females. At present, we advise that no cross-sex HRT should be administered to any female whose claim of Gender Dysphoria is suspected to be ROGD.

The simple fact is that the transition window of opportunity for females is much longer than that for males. There is not the time pressure, but instead significantly raised risk of misdiagnosis and harm.

i In some circles, today, there is an unfortunate move by some to delay t-blocker and oestrogen treatment, for MtF HSTS, until after the age of 18 or even later. This is a catastrophic approach that must be resisted. Doing so will compromise the individual’s ability to pass as a woman, perhaps to the extent that she abandons hope of a successful transition. We strongly suspect that this is, in fact, the covert intention of those who propose this.

It is definitely the case that, while some individuals may be able to transition successfully without beginning HRT before 18, most will have a happier result if they do and parents and carers of MtF HSTS, and the individuals themselves, may have to strongly oppose attempts by ‘gender critical’ individuals, be they therapists or others, to delay beginning the process of transition.

ii This elevation of risk is tiny: according to a recent study, around 0.16% over 8 years.

HSTS and medicine in history

Today, HSTS has become a subject for medical intervention on two levels: hormonal (endocrine) and surgical. But for thousands of years, HSTS lived without the benefits of modern medicine and science. So how did they manage?

Ancient Sumer: a tradition that persisted.

The earliest references that we have to HSTS come from Sumer, a region of Eastern Mesopotamia, now Iraq. This was made up of independent city-states, some of which, including the most prominent, Uruk, were Goddess cities. Although we can’t be sure of the political make-up of these societies, there is considerable evidence that there was at least a power-balance between men and women in them, even if this did not extend to full female authority. (There has never been, as far as we know, a culture that was genuinely ‘ruled’ by women.)

However, these societies do appear to have been matrifocal with women, and motherhood, at their centre. This replicates circumstances found in other, more modern cultures in which motherhood is venerated.

One intervention that was common in these ancient societies, amongst HSTS, was castration. Typically a young boy would enter the temple in service of the Goddess. In Sumer this was Inanna, who had a sister, Ereshkigal. These were actually two aspects of the same goddess. Inanna was the light or daytime aspect; she represented birth and life, love, physicality and the pleasures and pains of the flesh. Ereshkigal was the dark aspect; she represented death but also regeneration, reflection and mysticism. Inanna walked the Earth while Ereshkigal was the Queen of Darkness and her abode was the Underworld.

This binary pair was the model for many, across the region and down the centuries, notably Aset (later Isis) and Nephthys, who played exactly the same roles in Egyptian culture. Aset was married to the god of life and light, Osiris, while Nephthys was the consort of Seti (Set), who is the model for the Biblical Satan. Aset was the mother of the saviour god Horus, who was the model, or own of them, for the Christian Jesus.

In mythology, deities that are equivalent to others, in different cultures, are called ‘cogantes’. One cognate of Ereshkigal was the Phrygian goddess Cybele and we know a lot about her and her devotees, because her cult was imported to Rome.

In the cult of Cybele, young males known as ‘galli’ by the Romans (this was pejorative) would work themselves into a trance using music, dance and narcotics, and then, after tying a blessed cord around their penis and scrotum, would, with one upward cut, remove all at once. If they survived, they would be ‘reborn’ as women. They would then enter the service of the goddess as priestesses.

This practice, in every detail, is carried on even today amongst the hijra of India.

We know from accounts of its effects on castrati, the Italian opera singers whose voices were once so prized, that castration prior to puberty tends to have different effects to when it is carried out after. In the former case, one side-effect can be excessive tallness. This was clearly not an issue for the opera-house managers; in an era when most Italian males were around 5’8″, castrati might reach 6’6″. When carried out after puberty, however, this effect does not occur. In both cases, castration produces an immediate cessation of masculinisation.

This was the effect that the galli, the hijra and others sought. Unfortunately, it does carry a risk of osteoporosis, since the body requires normal levels of sex hormones to prevent this.

What about less drastic methods? Well, there are tantalising accounts, from the Roman author Herotodus and others, of Scythian transwomen using the distilled urine of pregnant mares. We presume the function of the distillation was to drive off excess water and to concentrate the solution. It must have tasted disgusting. Nevertheless, the story is plausible, since pregnant mare urine is used even today as a source of oestrogen, notably in the preparation PreMarIn. Pharmaceutical companies, producing this and similar products today, keep herds of horses simply for the production of urine.

Today, thankfully, more palatable methods of feminisation are available and these have crossed the sex barrier and can be used to treat FtM transitioners too. But in essence they are not so very different from the ancient methods.

Risk Analysis of Long Term Hormone Replacement Therapy in MtF Transsexuals

By Amanda Grimes

Author’s Note:

It is important to point out that this article is an observational piece and not a clinical study. As the author I am not medically qualified, or a clinical researcher. I have though, been a patient who has consistently used Hormone Replacement Therapy (HRT) as part of a treatment regime for Gender Identity Disorder (GID) and Transsexualism for the last 32 years. During that time I have meticulously monitored my general health and done my upmost to keep abreast of the latest clinical studies involving the use of HRT and hormone suppressant treatment. For this reason I will only address the use of HRT in Male to Feminine (MtF) transsexuals, with which I am familiar.


The treatment of transsexuals with HRT is often criticised by those who oppose the medical treatment of transsexuals generally, without any real understanding of the effects and risk factors surrounding their use. All too often, gender critical commentators will claim increased risks of cancer and other life threatening conditions inherent in the use of HRT. While there is some validity in the nature of their statements, these are often misdirected as there have been no long term studies carried out in relation to the use of HRT by transsexuals.

(Note: see Addendum. Ed.). All available studies of the effects on health of HRT use have to date been carried out on groups of postmenopausal natal females aged between 50-79 years old. While there are elevated risks from certain morbidities in long term use of HRT they are for the most part overstated or of more import not relevant to the treatment of MtF Transsexuals.

While taking any medication carries the risk of side effects and complications, claims that “taking hormones” causes cancer, stroke and cardio vascular disease, are vastly overstated and misleading. In this article I will examine these claims and in comparison to the significant and more up to date medical research in this field and I shall to reference it to its application in MtF Transsexual patients.


There are several types of hormonal medication in use for the treatment of transsexualism the more common of which are:

Oestrogen – Being either synthetic oestrogens such as Estradiol® or naturally occurring equine oestrogens such as Premarin®. Oestrogen is the primary feminising hormone and is responsible for the redistribution of fatty tissue on the body and the reduction in body hair.

Progesterone – Being ordinarily used for short term periods during the initial stages of transition. Long term use of this type of hormone should be avoided. These drugs are derivatives of Medroxyprogesterone such as Progestin® and Provera®. Use of progesterone is usually discontinued following Genital Reassignment Surgery (GRS) such as Vaginoplasty or Orchiectomy as they are primarily used to consolidate the redistributed body fats and after that their use is limited if not null in respect to non-uterine conditions (i.e. they are only relevant if you have a uterus).

In addition to these drugs, though I personally have no first hand experience of effects of them, as they were not in use when I transitioned, are Hormone Blockers used to negate or “block” the effects of the natal hormones of the patient. These are split into two types of drugs: Gonadotropin Releasing Hormones (GnRH) antagonists such as Lupron® and hormonal suppression drugs like Spironalactone and similar based drugs like Aldactone®. GnRH derivatives are used in pre-pubertal subjects to “block” the onset or continuance of natal puberty and Spironalactone-type drugs are used to suppress natal hormone production in post-pubertal subjects. We shall address these and the risk/benefit of these types of drugs in another article, as they deserve closer examination.

The Claims

HRT increases the risk of Cancer!

Early trial studies were carried out by the Women’s Health Initiative (WHI) between 1993 and 2006 and the results published at various points throughout the trial. 160,000 subjects were studied. They were in three groups, two receiving active HRT and one a placebo. One using HRT took a combined 0.625mg of conjugated oestrogens and 2.5mg Progestin daily, a second group took oestrogen only HRT and the third was a control group medicated with a placebo. All groups were monitored for instances of increased colorectal, breast, ovarian and uterine cancers. In addition subjects were monitored and recorded for instance of venous thromboembolism, stroke and coronary heart disease (CHD).
Increased risks were noted in all but a few morbidities for the groups using HRT, though the elevated risks were not significant. We shall deal with the elevated numbers and what they mean in a moment, but there are certain aspects here which are important to note.

1. MtF TS are at no risk from uterine or ovarian cancers as we possess neither a uterus nor ovaries.

2. The elevated risks in other areas were in a group who commenced HRT between 50 and 79 years old; that demographic is already at increased risk for all listed morbidities.

3. The study looked only at subjects taking the combined Oestrogen and Progesterone HRT.

Results in both the HRT groups showed that cases of endometrial cancers were decreased in relation to those in the general population. However the results were affected by the larger number of women who had undergone hysterectomy before or during the trial period.

The combined oestrogen/progesterone (EP) group showed a marked increase in the instances of breast cancer, being an increase of +8 cases on the Attributable Risk to the Global Index, of 19 cases per 10,000 person-years seen in the general population.

In the findings of the 2002 stage report and a review of all papers brought together by James Clarke carried out in 2006, significant risk reductions were noted in the Oestrogen (E) only group across a wide number of risk factors. Below are excerpts from the report in respect of each of the significant risk to TS patients. The links to the reports via the Lancet review are contained at the end of this article.

Invasive breast cancer (IBC) 2002 paper

Risk ratio

The value of 26% increase in the relative risk of invasive breast cancer in the E+P group has been cited over and over by many people in the scientific and non-scientific media, even though the authors of the WHI paper acknowledge that it “almost reached nominal statistical significance”. Since “almost” is not statistical significance, the statement should have been: there was no significant difference in IBC risk between the placebo group and the E+P group. As in the analysis of CHD, if the authors had used adjusted confidence intervals there would be no doubt that risks were not increased.

The authors then indicate that “the weighted test statistic used for monitoring was highly significant”. This statistic would not have been elevated if the authors had examined the data more carefully. The apparent increase in risk ratios from years 2-5 is accompanied by a decline in the placebo groups (Figure 3A and Figure 3B). As discussed below, in the final analysis of these data this upward trend is not statistically significant (Figure 4A and Figure 4B). The final hazard ratio of 1.26 has an adjusted 95% confidence interval of 0.83-1.92, and the absolute risk increase is 0.08% or 8/10,000 person years. Such a broad confidence interval which includes 1.0 indicates there is no significant increase in risks due to hormone use. In addition, mere inspection of the data in Figure 3A clearly shows that four of the six values are not different from the no effect level, thus making it very unlikely that any real differences in risk existed.

Invasive breast cancer in the estrogen only studies

In the estrogen only arm of the WHI study invasive breast cancer was decreased by estrogen treatment [Anderson et al., 2004]. The hazard ratio was not statistically significant: 0.77 (CI, 0.59-1.01). A protective effect may be likely since the number of risk ratios which were near or below the no effect level were greater than those above this level (data not shown). In the final report on this aspect of the study similar data and conclusions were reached [Stefanick et al., 2006]

Venous thromboembolism in the estrogen only study

No data on a yearly basis were published for VTE in the estrogen only study; therefore, it was not possible to graph risk ratios or percent incidence as a function of time [Anderson et al., 2004]. The authors indicate the final hazard ratio was 1.33 (95% CI, 0.86-2.08) and that this was not significant. However, they say that the risk for the subgroup, deep vein thrombosis (DVT), is significant (HR 1.47; CI, 0.87-2.47). Since no yearly data were provided for DVT it was not possible to draw a graph; however, the authors did provide yearly data for pulmonary thrombosis (PE) which show the same erratic risk ratio and incidence values as in most of their other data (data not shown). Therefore, it is likely that the data for deep vein thrombosis shows similar, if not greater variation. This likelihood, plus the small absolute increase (0.06%) and the broad confidence intervals which cross 1.0, make it difficult to accept these values as significant.
This expectation of a high degree of variability and uncertainty was borne out by the data in the final paper from the WHI studies on venous thrombosis [Curb et al., 2006]. In this paper the authors provide hazard ratios and non-adjusted 95% confidence intervals for DVT, PE and venous thrombosis, VT (Figure 7). If adjusted 95% CIs had been used, all values would have included 1.0 and would have been judged insignificant. It is clear why the authors of this paper make no statement concerning statistical significance.

Instead, they state that VT risk is associated with the use of estrogen during the first two years of exposure. It is clear that the very wide non-adjusted confidence intervals associated with the 0-2 year span for all three groups make it impossible to conclude anything concerning this period. The later time periods show no increased risk due to hormone treatment. It is puzzling why the authors in the 2004 paper conclude that the HR for DVT is significant and yet in the 2006 paper they conclude the HR is not significant, yet the data are virtually identical.

Coronary heart disease in the estrogen only study

In this study the authors conclude that estrogen alone does not affect the risk of CHD in post-menopausal women (HR, 0.91; 95% CI, 0.75-1.12; [Anderson et al., 2004]). The final results of the estrogen alone study were divided into age groups of 50-59, 60-69 and 70-79 years [Hsia et al., 2006]. The conclusion was that estrogens provide no protection against CHD with the possible exception of those in the 50-59 age group (HR, 0.61; 95% nominal CI, 0.25-1.50). However, the incidence and risk ratio data for CHD in each of these groups is more erratic and variable than any of the data shown thus far. These results will be the subject of another paper and will not be discussed further here.

Stroke in the estrogen only study

Risk ratios and incidence

The risk ratios for stroke in this study are low but generally above the no effect level (Figure 9A). These minimal ratio values are the result of very variable incidence levels, which indicate that these groups were not different from one another for the first five years of the study (Figure 9B). This period is followed by a small increase in the estrogen group at year 5, which is followed by a steady decline to low levels equal to those of the placebo group. Such declines in the risk ratio and incidence in the estrogen group suggest a beneficial effect of estrogen treatment. The authors indicate that the final hazard ratio of 1.39 was significant; however, this was based on non-adjusted 95% CI. When the adjusted 95% CI is used (0.97-1.99), the HR becomes statistically insignificant.

What This Means


These and further studies, carried out by Stamford University and the WHI in 2012, 2015 and 2016, support the initial findings that increased risks of breast cancer are associated only with combined Oestrogen and Progesterone HRT and that no significant increase arises from Oestrogen only HRT. So if you are taking Oestrogen-Only HRT you are at no more risk of developing breast cancer than the general population.

Since the publication of those later reports Wyeth has withdrawn its production and sale of combined HRT such as PremPak C® in most Western countries.
In respect of colorectal cancers, there was a small but marked reduction in the instances of these in both the Oestrogen Only and Combined HRT groups. This means you would be less likely to contract bowel cancer than a woman who is not prescribed HRT.

Coronary Heart Disease (CHD)

The studies in Oestrogen Only HRT showed no significant change in instances of CHD except in the 50-59 age group where a reduction of CHD was noted. No conclusions are drawn from this and the issue is subject to further studies.

Venous Thromboembolism (DVT)

A slight increase of 0.06% risk was noted in the instances of DVT in the Oestrogen Only group and that was only noted within the first 2 years of treatment. This is a strong indicator that these instances were elevated in subjects with a predisposition for DVT and other venal condition. After year 2 there was no noted increased risk.


There is an elevated risk of stroke in both Combined and Oestrogen Only HRT though that equates to a hazard ration of 1.99 compared to 0.97 Global Index. This means for every 10,000 women per year taking Oestrogen Only HRT and additional 1 will be subject to stroke. The authors of the report concluded that this was insignificant.


As can be seen from the results of the studies cited above the risk from HRT in FtM Transsexuals is minimal and often overstated by the general media and those who are critical of their use in TS. Many of the elevated cancer risks associated with HRT affects body parts which are not relevant to TS patients. There is it seems no elevated risk beyond that of the general female population for those body parts which are common to both natal female and MtF TS.
It is though important to note that all the risks listed herein are subject to environmental and lifestyle factors.

It is essential therefore that TS do their best to avoid things like excessive alcohol consumption, smoking and higher levels of obesity just as it is for the general population. Where possible TS should also keep regular checks on their general health including blood pressure, liver function and breast health as a precaution. Personally as a woman in my 50’s now I have a doctor applied blood pressure check every six months, liver function every twelve months and mammogram every eighteen months in addition to my own personal checks.

In addition to these it is also reasonable to assume a decreased risk in typical male cancers such as testicular and prostate cancer. The first is obvious in post-operative TS and the second results from the fact that the majority of treatments available for men with prostate cancers involve blocking testosterone or the administration of female hormones.

The risks therefore are at best positive or neutral and at worst minimal and I would encourage all those concerned with transsexuals and their care to carefully research all the available data for themselves before believing statistics bandied around on the main or social media platforms.


Much of the criticism of the use of HRT in TS patients is poised in such a way as to appear revelatory to the unsuspecting user of such drugs. It is however important to recognise that the propensity for elevated risk of cardio conditions and cancers has been highlighted for decades by those prescribing HRT to their TS patients.

Every time one opens a new pack of oestrogen pills the manufacturer’s warning list is enclosed advising of all possible side effects from the mundane to the potentially life threatening ones. This does little or nothing to deter these patients from taking these drugs or undertaking much more risky surgical procedures. For myself (and I have heard similar things to this from others) if the doctor had said unequivocally, “Take this it will allow you to can live as a woman but in 30 years it will kill you!” I would still have elected to take the HRT, so unacceptable would be the alternative.

Amanda Grimes


Addendum (Ed.)

While this article was in editorial review, a paper was published, entitled
‘Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study’. This paper, detailed a broad research study into the incidences of ‘venous thromboembolism (VTE), ischemic stroke (IS) and myocardial infarction in transgender persons’ to see if there was correlation with hormone use.

The study, which is available HERE (link) concluded that ‘The patterns of increases in VTE and ischemic stroke rates among transfeminine persons are not consistent with those observed in cisgender women. These results may indicate the need for long-term vigilance in identifying vascular side effects of cross-sex estrogen.’

However, though some elevation of risk was observed, this was very low, less than for other risk factors like smoking or alcohol consumption and the authors did not recommend changes to the prescribed hormone regimes for transitioning subjects, only that their doctors and other health advisors should maintain vigilance. This is in line with observations in the article above.

We found a number of questionable areas in the 2018 paper:
• There is no mention of the age of the patients at the date of ACVE
• There is no direct subject contact; all data is taken from electronic client records only
• These are variable drug dosages rather than dose-specific studies with only estrodiol (synthetic oestrogen) and Spironalactone (No equine derived HRT was considered, nor alternative testosterone-blockers.)
• There was no distinction between the effects of estrodiol and those of Spironolactone.
• No separation of studies with post-operative TS, who would not have used Spiro; comparable studies in natal females never use testosterone suppressants such as Spiro
• The study could not determine whether patients were obtaining alternative or further HRT outside of the Kaiser Permanente treatment centres or not
• VTE peaked at 2 Years, thereafter levelling just over the control, as in previous studies; showing an inclination towards pre-disposition to such events (in other words, the subjects were already high-risk)
• IS peaked at 6 years after which results levelled to those in the control (similar to above)
• ACVE was only elevated in the higher dosage patients (2-10mg estrodiol 5.6mg mean average daily); there was no elevated level of ACVE detected in the lower dosage group (0.3mg-10mg 4.1mg mean average daily) It is likely that the lower dosages are Post-Operative and so not using Spironalactone.
• It considered only patients using Spironalactone (Spiro) as a testosterone blocker. This is important because while Spiro is widely used in the USA it is much less so elsewhere, with Cyproterone acetate (CPA) being more popular. This may have different side-effects.

As regards ‘transmasculine’ (FtM) respondents, the study was inconclusive and made no comment.


This is an interesting study, but the level of increased risks that were identified would only amount to an increase in hazard of a percentage point or so above that for natal women. That tiny increase in risk, less than for smoking or alcohol use, has to be set against the documented successfulness of transition in cases of Gender Dysphoria, especially Homosexual GD or HSTS, as well as potential reduction of risk in other clinical areas.

The Science of HSTS: The Basics

You might be forgiven, listening to the mountains of woo and pseudoscience surrounding the ‘transgender’ issue today, that there was no real science that could explain transsexualism. You’ll have been bombarded by claims of ‘born in the wrong body’ by married male individuals who look like the bloke next door in a frock. You might, quite reasonably, have found this a somewhat surprising claim, but out of politeness you quietly nod. Well, you would have been right to have been confused.

I’m going to try to explain the basic science that we do have, in simple terms. In future articles, we’ll expand on this and provide more sources and background reading.

In the first place, nobody was ever ‘born in the wrong body’. We all have our own bodies. They’re ours, not someone else’s. So how could they be wrong?

Continue reading “The Science of HSTS: The Basics”

Travestis: Pre-op transwomen in Latin America


Travestis are pre-operative or non-operative MtF transwomen; that is to say, they are feminised males who take hormones and have body enhancements, but they retain their male genitalia. They are found across Latin America and also in southern Europe. They are most often prostitutes. They live in cultures where prostitution may not be considered a desirable career, but it is fully legal. Therefore it is a legitimate way to earn money – perhaps the only legitimate way available.

The most complete description of travesti life was in a book by Professor Don Kulick, called ‘Travesti: Sex, Gender, and Culture among Brazilian Transgendered Prostitutes’1 .

Continue reading “Travestis: Pre-op transwomen in Latin America”

History of HSTS

history hsts stromholm belinda
Belinda. Pic by Christer Stromholm

Homosexual transsexualism, or HSTS, has a recorded history as long as writing itself, from 6,000 years ago and before. It is the natural end point of the developmental scale of human homosexuality. Today, we recognise that homosexuality is an innate sexuality, that is, it’s not learned or ‘socialised’.

Because it is innate, we should expect to find homosexuality across all human cultures at all times and this we do. It is mentioned – often negatively, in many ancient texts like the Bible, the Hindu texts, the Koran and so on. There are numerous reports of it throughout history. Sometimes, as in Europe or where the writers were European, this has been negative. Elsewhere, records are more balanced in tone.

The close link between HSTS and homosexuality, together with the copious records, suggest that it too is a fundamental and intrinsic aspect of human nature. Despite often extreme social intolerance, then, HSTS has lived on throughout the ages of human culture. Its appearance in the West in recent decades should be seen not as a new phenomenon but as the reappearance of a natural part of the human condition that had been suppressed, for centuries, by brutal, often lethal violence, frequently promoted by religion.

This article aims to provide an overview of the history as we know it today.


Writing was not invented until around 4,000 BCE and prior to that, any evidence of HSTS or, for that matter, any human sexual behaviour, remains conjectural.

There is in fact significant prehistoric evidence that HSTS might have been present before the establishment of sedentary cultures and the invention of writing. This is consistent with models found more recently in tribal societies. The evidence comes from multiple burial sites across Europe. It is tempting to include it here but, because we cannot absolutely be sure of the nature of the culture that the deceased lived in or the context of the burials, we will dedicate another article to this. However, I am personally confident that, if ever we were able to definitively analyse this evidence it would confirm the presence of HSTS in prehistory.

While great care must be taken in studying the written, historical evidence, because of the cultural differences between us and the writers, we are on much more solid ground.

The written history

Writing was a product of the first settled, agrarian cultures and probably originated as a way of tallying crop produce and of making contracts. As far as we know, the very first writing was invented in Mesopotamia, which is now Iraq, in a culture called Sumer, which lay between the Tigris and Euphrates rivers.

The city which gives us the first recorded writing was called Uruk. This is the Biblical Erech. The people used a form of writing called ‘cuneiform’ which might have been invented by women. They wrote on clay tablets. This presents us with a problem deciphering Sumerian texts, because, after 6000 years, many of the tablets have been destroyed or are buried in the ruins of the city, which remain, abandoned, in the desert of modern Iraq. This means that for much of the time we have to ‘fill in the gaps’ with later material. Despite this, we have a great deal of information.


history hsts inanna
Inanna, patron deity of Uruk and goddess of love and war

Uruk was a Goddess city and its deity was called Inanna.i The people of the city believed that she was an invisible but incredibly powerful being who actually lived in her dedicated temple, at the heart of the city itself. She was a form — in India this would be called an ‘avatar’ — of the Great Goddess herself, but Inanna was anthropomorphic. That means that even though she was invisible to humans, she actually looked, to those who could see her, like an astonishingly perfect young woman, albeit much larger, with wings.

Naturally, Inanna, being a goddess, was served by women, but not all of these were born so: she was served by transwomen too.ii

The transsexual servants of Inanna self-castrated out of devotion to the Goddess, specifically in order to make themselves complete as women; this was documented not just by the Sumerians but by successor cultures down to Rome and is carried on today in India. They used the complete form of castration, removing scrotum, testicles and penis. This was usually carried out at or soon after puberty, so they would have stopped masculinising at that point and so would appear passable as women.iii

They were the world’s first recorded transsexuals.

Within Sumerian and later Mesopotamian cultures was the tradition of ‘Temple Prostitution’. This existed in many other cultures and we have numerous contemporary accounts of the practice.

Religious prostitution is not, even today, well understood, partly because of centuries of scholarship that sought to erase it and partly because of the generally sex-negative attitude of Anglo-Saxon culture. Women in Sumer did not see the act of sex with a stranger, for money, as demeaning but rather as a religious act that confirmed them as part of the sisterhood of the goddess Inanna.

One of the most famous Mesopotamian texts, the Epic of Gilgamesh, confirms this. In it, Gilgamesh, the king, is frustrated because a wild man by the name of Enkidu, who lives with the animals on the steppe, has been spoiling his traps. Gilgamesh seeks help from the High Priestess of Inanna, who sends a harimsu or temple prostitute to seduce Enkidu and bring him back to the city. This she is to accomplish by finding where he sleeps and lying down naked beside him. When Enkidu awakes, he will be so inflamed with lust that he will have sex with her. So he does and is thereby tamed and brought to the life of the city, where he becomes Gilgamesh’ best friend.

Herodotus, in his description of life in Babylon, a successor to Sumer, wrote

Many women who are rich and proud and disdain to mingle with the rest, drive to the temple in covered carriages drawn by teams, and stand there with a great retinue of attendants. But most sit down in the sacred plot of Aphrodite, with crowns of cord on their heads; there is a great multitude of women coming and going; passages marked by line run every way through the crowd, by which the men pass and make their choice. Once a woman has taken her place there, she does not go away to her home before some stranger has cast money into her lap, and had intercourse with her outside the temple; but while he casts the money, he must say, “I invite you in the name of Mylitta”. It does not matter what sum the money is; the woman will never refuse, for that would be a sin, the money being by this act made sacred. So she follows the first man who casts it and rejects no one.iv

Did transwomen also perform this sacred duty? It’s almost inconceivable that they did not, as it was a requirement for all women. In addition, we have references directly from Sumerian texts that confirm it.

One, from the ‘Hymns to Inanna’ is:

‘”Hail!” to Inanna, First Daughter of the Moon!

The male prostitutes comb their hair before you.

They decorate the napes of their necks with colored scarfs’v

This is clearly referring to transwomen beautifying themselves before performing their religious duties. It suggests that transwomen were accepted in Sumer and were expected to behave as other women did.vi

The modern Indian version of the Sumerian transwomen priestesses are sometimes called ‘hijra’ and amongst them are considerable numbers of HSTS. They too, practise religious prostitution. There is no persuasive argument to suggest that something similar was not also the case in Sumer.


The earliest human civilisations appeared in Sumer, making the fact that transsexualism is described there important. However, the tradition that proceeds through the Middle East and then west and north to Europe and beyond was not the only line of cultural development. At about the same time or slightly later than the Sumerian cities appeared, further east in the Indus valley, similar events were taking place.

Through time, these led to the great Hindu culture of India, which spread south and east across the region. At the core of this culture are texts called the Vedas, which were written between 3000 to 1500 BCE, although the source material might be even older. The Vedas consist of four volumes and have a huge advantage over the Sumerian texts: they are complete. Despite the vagaries of history that India has had to endure, the culture of the Vedas still lives on, in more-or-less unchanged form.

As the culture spread, so did the records of transsexualism.

In his book Tritiya Pakriti, scholar Amara Das Wilhelm has concentrated a huge resource of information which we unashamedly make use of here.

The word kliba or klibaka is the most common third-gender term found in Vedic literature.vii It … often specifically describes those who are effeminate or homosexual by nature. Kliba is frequently used to disparage men considered weak, cowardly, unmanly, effete, of questionable manhood and so on.

In one categoty of kliba, exist ‘Shandha—he has the qualities and behavior of a woman’.

The Sushruta Samhita is an ancient Vedic medical text put into writing sometime around 600 B.C. (It) describes a type of female shandha with the qualities of a man (3.2.43).

Shandha—he has the qualities and behavior of a woman.

The term shandha or shandhaka is also commonly found in Vedic literature. It…often specifically describes male-to-female transgenders. Both the Sushruta Samhita (3.2.42) and Smriti-ratnavali state that the shandha talks, walks, laughs and otherwise behaves like a woman.

Under the category ‘Panda’, he notes ‘ Sevyaka—he is sexually enjoyed by other men’. Clearly, this refers to a homosexual male, though it does not specify his presentation.

Women who are impotent with men are mentioned less frequently in Vedic literature. Nevertheless, several types of nastriya or third-gender women can be found

1) Svairini—she engages in lovemaking with other women. (lesbian)

2) Kamini—she engages in lovemaking with both men and women. (bisexual)

3) Stripumsa—she is masculine in behavior and form. (HSTS)

4) Shandhi—she is averse to men and has no menstruation or breasts.

The word tritiya-prakriti refers to third-gender men and women with various combinations of the two natures described above. It is especially used in the Kama Sutra to describe men and women who are homosexual or transgender by nature. Such people appear as male or female and assume masculine or feminine identities (They have no sexual interest in the opposite sex.)viii

Amara Das notes that:

Because the Dharma Shastra considers the third sex to be an inborn nature rather than an acquired vice, no verses punish third-gender citizens for their characteristic behavior. No laws penalize third-gender men for refusing to marry women or conceive children (quite the contrary) and no laws punish crossdressing, male prostitution, private homosexual behavior, etc.

As you can see, a comprehensive set of what the author calls ‘third gender’ types are here described. Note especially the way that the texts explicitly conflate gender-conforming homosexuality and transsexualism as two forms of the same thing. This was the universal understanding until the 20th century and remains the standard one throughout all of the world except the West.

India today

history hsts hijra
A modern-day hijra, continuing a tradition thousands of years old

In modern India, transsexualism is well known. Indeed, the country recently added a ‘third gender’ category to its Civil Code. There are many forms of transgender/transsexualism in India going by various names in many different languages, such as hijra, thirunangai and others. However, they are all essentially similar.

The practice of self-castration may have been introduced, paradoxically, by Muslim invaders of the subcontinent. Today it is carried on across India but many groups of trans people do not do this and instead live their lives intact. The great difficulty that they formerly endured, the relentless masculinisation caused by testosterone, can now be controlled with proprietary hormones.

A recent census suggested that there were around half a million transwomen in India, but workers in the field consider that an underestimation. They point out that transwomen are deeply suspicious of the authorities and, in any case, most are illiterate and could not read a survey form. The official census figures should be seen as a lower bound, therefore.

Into the West

From Ancient times, through classical antiquity and up to the Christianisation of Rome, transsexualism was widely reported and commented on. In Mesopotamia, from the times of Sumer, transsexuals served in the temples of the various goddesses, as we have discussed. This tradition carried on through the Akkadian period, for many centuries.

To the west and north of Mesopotamia, in what is now Turkey and then was called Phrygia, an extremely potent form of the Goddess, called Cybele, was revered. Again, here, young males would work themselves into a trance, possibly with the aid of narcotics. They would tie a blessed cord around their genitalia, so tight that it cut off the blood supply and then, with one upward stroke of a knife, remove them. They would then collapse and be laid down to recover. If they survived this ordeal they were ‘reborn’ as women and able to serve the Goddess.


Hermaphrodite was a Greek deity who had the physical characteristics of a woman but also had a penis. She was originally the son of Hermes and Aphrodite, and was, according to the myth, uncommonly beautiful. A nymph called Salmacis fell in love with him and prayed to be united with him forever; the gods merged the two into one, in answer to her. They did this by making Hermaphrodite fall into the pool in which Salmacis lived. Hermaphrodite/Salmacis had the beauty of a woman with the phallus of a man. Salmacis’ pool for ever after retained the power of feminising and softening men, making them like women.

history hsts hermaphrodite
Reclining Hermaphrodite

The art depicting Hermaphrodite was unambiguous: she appeared to be a woman, with breasts, beautiful face, feminine hips and so on, and always dressed as a woman, but with a penis.

Statues and depictions of Hermaphrodite were made in quantity in Greece and, especially, Rome. We don’t fully understand the purpose of these, but since many were large, we can be sure that they were expensive ornaments. The famous ‘Sleeping Hermaphrodite’ appears as a completely unremarkable woman from one side, but when you look from the other, you see that she has a penis.

Even if the figure itself is a kind of ribald conversation piece — Rome was a culture where sex was everywhere and humour was robust — it still leaves open a door. Why was this considered amusing? Was it possible that men were seduced by real transwomen, even fooled by them? There are remarkable parallels between this and some modern depictions of transwomen, especially in Thailand, where many do work in the sex trade. There is a pervasive male fear of being ‘trapped’ by a transwoman so passable that she is undetectable and those who — allegedly — are ‘fooled’ become the butt of male humour. Or perhaps the exoticism of the image, conflating both female and male sexual qualities in one, stimulated the Roman viewer, just as so many men are stimulated today, by images of pre-operative transwomen.

Many of the homes of wealthy Romans had ‘sex rooms’ which were decorated lavishly with every form of erotic imagery; perhaps the recumbent Aphrodite was a centrepiece for such spaces. Given the famous propensity for sexual adventure demonstrated by Romans, it would be rash to suggest that a beautiful transwomen would not have been a prized courtesan.


A common misconception is that Romans had an aversion to sex between two males. They did not. There was a strict interdiction against adult free men being penetrated, but they could penetrate other males, as long as they in turn were not adult free men. This was legally codified as the Lex Scantinia. Usually men would choose slaves to penetrate, since they were not protected by this.

One class of Roman that seems likely to have been HSTS was the puer delicatus or catamite.ix These began as beautiful boy-slaves.

hostory hsts puer delicatus
Artist’s impression of a Roman orgy with a puer delicatus entertaining a man

A puer delicatus was no ordinary slave boy, however. They were specifically chosen for their feminine beauty, girlish comportment and natures. These are all classic characteristics of young HSTS. They were often castrated before puberty and gr

ew up as girls, wearing their hair long, using make-up and dressing in feminine clothing. They learned to dance and to play musical instruments. They were groomed to play the role of exotic courtesans and some even became wives.

Naturally, being castrated, they never masculinised. Indeed, we can surmise, from the history of the castrati of the 17th and 18th centuries, that they might grow breasts and have womanly faces and feminised bodies. But the life of a puer delicatus hung on the thread of time itself; once they lost their youth and beauty, their futures became uncertain. Some might have joined or even become the chief of the household staff, but most were simply replaced and disposed of.

Emperor Nero married just such a puer delicatus called Sporus,

history hsts sporus
Bust of Sporus/Sabina

whom he renamed Sabina, after the wife he had beaten to death in a rage. Nero then paraded her around Rome wearing the formal robes of an Empress.

Sabina remained a transwoman even after Nero’s death. She was taken to wife by one Nymphidius Sabinus, a member of Nero’s guard who wished to taste the delights of Imperial life. He was assassinated by rivals. Sabina was then married to the first husband of the original Sabina, who was called Otho. He became, for a short period, Emperor, before being defeated by Vitellius. Otho committed suicide. Inheriting her as a spoil of victory, Vitellius planned to humiliate Sabina, for being the wife of his rival, by having her publicly raped and killed in the role of Proserpina. Sabina, only 19, thwarted him by killing herself. The tragedy of Sporus/Sabina’s life must touch the coldest heart; to end it was perhaps the only voluntary decision she ever took.

The Romans were coy about relations between men and these transwomen, but Sabina’s high-profile history turns a searchlight on sexual practice and convention in Rome. HSTS — which is what a puer delicatus was, whether by choice or not — were seen as legitimate sexual partners for even noble men in Rome. Keeping a puer delicatus as a concubine was a widespread practice that might even have conferred status, since the most beautiful would command high prices; showing off a beautiful young transwoman would be like arriving in a new Ferrari. And this was nothing new, in Nero’s day. The practice was one the Romans had inherited, like so much else, from the Greeks and its origins are lost in the mists of time.

One somewhat mysterious class of feminine, homosexual male in Roman culture was the cinaedus. This name was borrowed from the Greek kinaidos. It refers to an effeminate male who is enthusiastically receptive in sex. These are mentioned many times by Greek and Roman authors and are described as being ‘brazenly effeminate’. Others were referred to as ‘sons of Cybele’, a clear suggestion that some might have been self-castrated transwomen. Some, however, appear to have been bisexual, engaging in sex with men (where they were passive) and women. Most notably perhaps, they were a class of performer who danced, sang and played music. This places them in a tradition comparable to those found in India, Japan and elsewhere, of trans entertainers.

The Scythians were a nomadic people who wandered an enormous territory in central Asia, reaching from the north of the Black Sea as far east as the Hindu Kush. Scythian soldiers were said to have pillaged the temple of Venus at Ascalon in ancient times. Herodotus wrote that Aphrodite cursed them by making them effeminate:

“…most of the Scythians passed by and did no harm, but a few remained behind and plundered the temple of Heavenly Aphrodite… But the Scythians who pillaged the temple, and all their descendants after them, were afflicted by the goddess with the “female” sickness: and so the Scythians say that they are afflicted as a consequence of this and also that those who visit Scythian territory see among them the condition of those whom the Scythians call “Hermaphrodites”. x

Hippocrates mentions Scythian tribes in which ‘enarees’ (men without manhood), ‘effeminates’ or ‘eunuchs’, dressed as women, spoke like women, and did women’s work. They also performed a vital role in society as diviners or prophets.

Helen Savage observed:

The Roman poet Ovid, who was exiled to the borders of the Scythian steppe in the first century BC, provides a tantalising hint of the practice there of drinking mare’s urine, a substance so high in oestrogens that it is still used as the source of a proprietary drug, ‘premarin’, widely used still for hormone replacement therapy – and to feminise male-to- female transsexuals. ‘ Taylor observes that the practise of drinking animal urine is still not unusual among pastoralist peoples, and suggests that if the Scythians drank this potent liquid it is hardly surprising that they experienced some very disturbing effects from it.

… as the feminising effect of drinking hormone-rich urine was known and as there seems to be no evidence that anyone was forced to take it against their will, some measure of willing compliance in a process of feminisation, for whatever reason, seems at least plausible.xi

After the Punic Wars, the cult of Cybele was imported to Rome and so were the rituals surrounding her. Here the young males were referred to as ‘galli’xii. The cult — with the accompanying practice of self-castration — became popular amongst boys of good families.

Egypt had become a Roman vassal in the first century CE as a result of the Roman assumption of the former Greek territories, which were established by Alexander the Great. Philo of Judea (30 BCE to 40 CE) the Jewish philosopher of Alexandria, wrote of a section of the populace,

“Expending every possible care on their outward adornment, they are not ashamed even to employ every device to change artificially their nature as men into women … . Some of them … craving a complete transformation into women, they have amputated their generative members.”

In all these cases, it must be emphasised, those who underwent the procedure subsequently lived as woman. While slaves were often castrated, especially in Egypt, the procedure used was different in that only the testes were removed. These individuals usually lived as men and the function of castration was to make them less aggressive and more docile. Where the whole external genitalia were completely removed, the purpose was for the individual, born male, to live as a woman. It was, clearly, transsexualism.

Ovid (43 BCE to 18 CE) was a prolific Roman poet and writer. In modern parlance he would have been described perhaps as a journalist, as he, like many Romans of letters, wrote copiously about the things he observed in the world around him. One of his most famous works is a play titled Metamorphoses. In it, Teresias — a male — becomes Teresa when he hit two copulating snakes with a piece of wood. She was transformed back into a male by the same process. Once again, it is clear that the theme of transsexualism was popular.

The Emperor Elegabalus (203-222) presents a fascinating history. His brief reign occurred in the years 218-222, at the end of which he was killed.

Elagabalus was born in what is now Homs in Syria and inducted to the hereditary priesthood of the solar deity El Gabal, who was worshipped in the city as the supreme deity. In a different approach to the Greeks and Romans who erected statues of their deities in their temples, El Gabal was worshipped in the form of a meteoric black stone. Elaborate ceremonies would mark this stone’s entry to Rome.

Sun worship had increased in popularity in Rome and Elagabalus saw an opportunity to set up El Gabal as the greatest deity in the Empire, stronger even than Jupiter. On his coronation as Emperor, Elagabalus danced, in women’s robes, around the meteoric stone that was the totem of El Gabal. Many sources commented on her beauty and femininity. Throughout a short life, he frequently bemoaned his male genitalia and even promised ‘half the Empire’ to any doctor who could make for him a vagina. He was famously attracted to men.

Elagabalus was only 19 when he was assassinated. His behaviour, as well as his support for women, which brought him into conflict with major powers in Rome, suggests that he was HSTS.

If so, Elagabalus was a sad and lonely transgirl in a world that simply did not understand her and could not accept her transsexualism. While this was, paradoxically, acceptable amongst priestesses to the goddess, in an Emperor, in the strongly masculine Roman Empire, it was anathema. She paid the ultimate price for being whatever she really was.

Into Europe

The imposition of Christianity as the Roman state religion caused huge changes. In the first place, the temples to the various goddesses who had previously had transsexual priestesses were all closed. Although Jews were — somewhat warily — tolerated by the new Christian Roman authorities, the old — now considered unfashionable, ‘pagan’ — religions, were suppressed. Along with them, of course, went the opportunity for transsexual priestesses.

At the same time, male homosexuality and transsexualism came under extreme levels of religious persecution both form the Catholic church and later, the Protestant ones. It is absolutely certain that transsexuals would have borne the brunt of this savagery.

Male homosexuality, however, because it is innate, persisted despite the danger and violence, which meant that HSTS, which is the natural end-point of male homosexuality, also did, albeit covertly and latently. But there were still examples.

Gregory of Tours (538 to 594 CE) wrote a story about a man who had worn women’s clothing as a child and had continued into adulthood by dressing as a nun and living in a convent.

The Chevalier d’Eon (1728 to 1810) was a male French diplomat and mistress to King Louis XV. He spent the second half of his life as a woman. Eonism, a term referring to cross-gendered behaviour, was derived from d’Eon’s name. It was first used by Havelock Ellis, but the term is no longer in wide use. (This individual was more likely an autogynephile rather than HSTS.)


One fascinating example of how HSTS was able to persist in Europe was the mollies. These were young homosexual males who dressed as women and sought sex with men. They are best known through the ‘molly houses’ of England, which were public houses that specifically catered to them. These might have had rooms available for the consummation of sex, although often, too, this was performed outside. Full ‘weddings’ were often arranged, with faux priest overseeing, after which the happy couple would consummate their — albeit temporary — union on a bed set up in the same space; meantime the assembled company followed suit. The molly-houses were dens of extreme licentiousness that rival the bars of Pattaya today.

The mollies’ partners were fascinating. We know little about them, because of the universal disapproval of their lifestyle. However, they seem to have been older males who also affected effeminate modes of presentation and were called ‘queenies’. It is possible that these were older mollies whose youthful beauty had passed them by, but they might also have been transvestite autogynephiles. Even today, in the West, AGP males are known to be attracted to younger HSTS and it’s unlikely that this is a recent phenomenon.

By the 19th century HSTS in northern Europe had largely been driven underground by massive social intolerance of male effeminacy and the draconian penalties that were in place. These had been at their most extreme in Europe’s Protestant nations, with the Dutch being particularly vicious. Thousands of homosexual and transsexual people were judicially murdered in the most horrific manner over a period of centuries. Homosexual males remained, of course, but the legal penalties for discovery meant that their activities had to be covert. Appearing to be masculine, a technique that has persisted to this day, was their primary line of defence. There was little opportunity now for HSTS expressions, at least in MtF.

By the beginning of the 19th century a new wind of some tolerance began to blow. After the revolution of 1789, France abolished its anti-homosexuality laws, but the UK had to wait until 1967!

Despite this, homosexuality was an ongoing element of the English ‘Public School’ system, as the excellent Quentin Crisp, who later identified as transsexual, wrote in his book ‘The Naked Civil Servant’.xiii

South East Asia

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Trans pageant in the Philippines. Pic Rod Fleming

Today, southeast Asia is known for the large numbers of transwomen apparent there. While these are by no means all HSTS, many are. But are they a new phenomenon? No.

In his book ‘The Third Sex: Kathoey: Thailand’s Ladyboys’, Richard Totman discussed the background to Thailand’s transwomen, often called ‘kathoey’. This term in actual fact covers a range of presentations including gay men, but the author concentrated on the transwomen who make up the best known part of the group.xiv

He documents kathoey being recorded in Thai culture for hundreds of years. Thailand’s religious culture is called Theravedic Buddhism. The name ‘Theravedic’ is important as it means ‘derived from the Vedas’. In other words, this is a culture that understands exactly the same classifications that we’ve already seen in Indian Vedic culture, and transsexualism is a part of that.

Totman cites examples of kathoey being observed at traditional weddings in Thailand hundreds of years ago, and also performing other roles, as entertainers and so on. These are very similar to the roles they play today. Theravedic Buddhism has been the basis of Thai culture for at least 2000 years and there is no reason to suppose that kathoey have not been a longstanding part of this.

The Philippines, an extensive archipelago that forms the Pacific barrier of the southeast Asian subcontinent, were colonised by the Spanish after Magellan’s ‘discovery’ of the islands in 1521. Prior to this, the islands had already been exposed to Islam, but the underlying culture was animist. This is a belief in nature spirits and deities. The Spanish brought with them, and eventually enforced, Roman Catholicism, which is now the religion of 95% of Filipinos.

Despite this, transsexualism has a long history in the Philippines too. We know this because the Spanish conquistadores were accompanied by priests. Their job was not just to minister to the unfortunate people who found themselves under the heel of the military invaders, but to report back, to the Pope, everything that was discovered. This was so that the Papacy would receive its due share of the spoils! Nevertheless, they also reported on cultural and other phenomena they found interesting. Amongst these was an understanding of gender that was much different from their own.

At least one insurrection was led against the Spanish by ‘men dressed as women’ and there were tribes where more than two genders were normal. These seem to have been similar to the present-day Bugis people of Indonesia, who claim five genders. In fact, however, these devolve to two, masculine and feminine. They are: man born male, man born female, woman born female, woman born male and all at once. These last are the priests in the culture, which is animist.

Research conducted on the Philippines’ island of Negros in the 1950s and 60s by anthropologist Donn Hart reveals a longstanding presence of homosexual and transgender individuals in the region, from the slightly effeminate dalopapa or binabaye to the fully transgender bayot. Similar third-gender subcultures can be found throughout the country’s many islands, each with its own set of local categories and terms. xv

Today, there are huge numbers of transwomen in the Philippines. While these are of both types, HSTS and AGP, the former are conspicuous. Every town seems to have a population of them.

In Indonesia, transwomen are called ‘Waria’ which means. roughly, ‘man-woman’. This is a predominantly Muslim nation yet the Waria tradition is tolerated. In non-Muslim areas such as Bali, there are considerable numbers of transwomen much more like those found in Thailand.

Quite why southeast Asia has so many trans people is not fully understood. Clearly, there is a cultural input. This area has traditionally been far more relaxed about male homosexuality than almost any other in the world. At the same time, homosexuality and trans are seen as the same thing and gender-conforming homosexual males are somewhat looked down on by others.


The modern history of Japan’s transwomen, commonly known in the West as ‘newhalf’ dates back to 1965, when police raided a bar in Tokyo’s Akasaka district and arrested 10 women on charges of prostitution, according to historian Junko Mitsuhashi.

However, three of these women were male on paper, but had undergone GRS to remove their external male genitalia. We do not know if this amounted to full vaginoplasty or rather, was simply a complete castration. Japan’s prostitution law meant that the police could not charge them with prostitution, as only women could be charged for this. xvi

In the early years of the 20th century, newhalf became better known outside Japan, often performing in porn movies. Inside the country, many work as prostitutes but these constitute only a part of the broader trans scene. We don’t know the relative proportions of HSTS and autogynephilic transvestite forms, but we do know that both exist. No research has been done that might inform us as to the total numbers or the breakdown.

The phenomenon is much older than this, though. Kabuki theatre first appeared in Japan in the early 17th century, at which time it was performed entirely by women, who played both male and female roles. However, in 1629, the authorities banned this, which immediately promoted another form of kabuki, in which males played all the parts. Those who played women in the theatre were called ‘onnagata’ and were seen not as actors playing women, but as real women.

This association of transwomen with theatre and entertainment persisted right up to the modern era. However, kabuki itself is related to an even older tradition of entertainment, geisha. This had already appeared by the 13th century. While geisha became open to women in the 17th century, prior to this, all geishas were male, called taikomochi. These still exist within contemporary geisha, though there are few left. Taikomochi have traditionally appeared to be, and lived as, women.

Westerners usually think that geishas are a form of courtesan, that is, essentially, very glamorous sex workers. But this is not exactly the case. Geishas are primarily entertainers, not prostitutes. On the other hand, sex work itself is a form of entertainment, principally for men, and there has always been a link between geisha and sex, however much it might be denied. While today’s newhalf of Japan may work in sex and in porn, this is an extension of their role in entertainment. So their connection to the earliest forms of geisha and kabuki is clear.

When we think of ‘sex work’ we in the West immediately think of the physical act, but it is much broader than that. Geisha culture fits into a ‘hostess’ tradition found all over Asia. In this, women are retained by bars and clubs to entertain male clients, often just by sitting talking to them. The man buys the woman ‘lady drinks’ which are more expensive than ordinary ones, and she takes the difference. In addition, tipping generously is encouraged, with big tippers becoming ‘celebrities’ constantly surrounded by women or transwomen, depending on the venue and his tastes. Whether or not the relationship extends to actual sex is between the customer and the hostess; in many cases it does not.

Ray Blanchard noted the propensity of HSTS to be involved in sex work and, while this is absolutely not true of all, many are. More importantly, perhaps, they enjoy it and feel affirmed by it. After all, what stronger reassurance could a person have that she is a beautiful woman, than that a man would pay to be with her? It is easy to see the parallel between the satisfaction of stage entertainment, the rapturous applause of the audience, and being showered with gifts, money and even offers of marriage by men. Every society has niches where transwomen can feel fulfilled and have good lives and this is one of them; it fits into a global pattern of similar lifestyles.



The Pacific is full of transwomen.

The British explorer Captain Bligh famously sailed HMS Bounty to Tahiti in 1789. A crewman, James Hamilton, noted that:

the mahu (male-to-female transgenders) of Tahiti were “like the eunuchs in India.” He described how they lived and dressed as women, sang and danced along with them and excelled in all their tasks. Upon hearing that the mahu were hermaphrodites, Bounty commander Captain Bligh asked one of the Polynesian “eunuchs” to remove his loincloth. Bligh’s report noted that the native’s “yard” [penis] was not absent or deformed but very soft and small, having been customarily tied up against the groin. He also observed how the native women treated and respected the mahu as one of their own.

In the Hawaiian Islands, whose inhabitants are believed to have originated from Tahiti, the mahu were also present along with the aikane—sexually related or “friendly” men that were essentially masculine-type homosexuals and bisexuals. In Tuvalu, the word pinapinaaine substitutes for mahu, as does the word fa’afafine (“like a woman”) in Samoa and fakafefine in Tonga.xvii

All of these various terms refer to the same thing: males who appear to be and live as women.


Ethnologist Eva Meyerowitz, stationed in Ghana during the 1920s-1940s, observed that among the Ashanti and Akan, “men who dressed as women and engaged in homosexual relations with other men were not stigmatized, but accepted.”

“In Burkina Faso of the Upper Volta River, Frenchman Louis Tauxier reported sorone within the Mossi tribes during an expedition in 1912. The sorone were beautiful boys, aged seven to fifteen, that dressed like women and served as pages and sexual partners to the village chiefs. They were often entrusted with state secrets and forbidden to be sexually intimate with women. Among the Dagara tribes of southern Burkina Faso, homosexual and transgender people served as shamans and were considered special gatekeepers who straddled both worlds in order to help sustain the universe.’ xviii

The huge continent of Africa is today noted for some of the most strident anti-homosexual voices in the world. Most of these come from the Anglican religious community, which was introduced by the British and has, wherever it set itself up, been a harbinger of extreme intolerance for all things homosexual and transsexual. It is a bizarre irony that the Church of England, the mother of all of this, is now quite relaxed and has an open attitude to both; but the wider Anglican community, often egged on and funded by extremist US American fundamentalists, remains as intolerant as ever.

Both homosexual and transsexual behaviour were noted across the continent in pre-colonial days. Once again, the two were not seen as separate, with transsexualism being seen as a natural conclusion to homosexuality. We refer the reader to Amara Das Wilhelm’s book (name) which gives far more detail than we have room for here.

South America

The principal colonial power in Latin America was, again, Spain and as in the Philippines, the Pope’s embedded reporters, the Catholic priests, travelled with the conquistadores, noting and enumerating all that they encountered.

Again we turn to the research of Amara Das Wilhelm, who has collated a great deal of information.

After his exploration of the Veracruz region of eastern Mexico, conquistador Hernando Cortes (1485-1547) informed King Carlos V of Spain: “…in each important temple or house of worship, they have a man or two, or more, depending on the idol, who go dressed in women’s attire from the time they are children, and speak like them, and in manner, dress, and everything else they imitate women. With them especially the chiefs and headmen have … intercourse on feast days and holidays, almost like a religious rite and ceremony.” Similar reports of “hermaphrodite” natives among the indigenous tribes of Mexico, South America, Florida and the West Indies evoked great curiosity back in Spain. Eager to investigate, Spanish writer and traveler Francisco Coreal set out for Florida in 1669. Once there, he discovered a class of effeminate boys who lived with the women, made their same handiworks, wore particular feathers and served the native tribesmen in various ways that included (sex). Coreal wrote: “I believe that these hermaphrodites are none other than the effeminate boys, that in a sense truly are hermaphrodites.”xix

Once again, homosexuality and transsexualism are seen as related.

In modern times, Latin America’s trans community, usually called ‘travesti’ have become internationally famous for their great beauty. Supermodel Lea T (b. 1981, alias Leandra Medeiros Cerezo) is a Brazilian transwoman and she is very far from being alone. The transwomen of Latin America should be seen, like transwomen elsewhere, as having deep cultural roots.

Probably the most thorough and at the same time, readable, work on the modern Brazilian travesti is the eponymous book by Professor Don Kulick. He spent a year living in a ‘travesti house’ in Bahia in northern Brazil and his work should be regarded as required reading.xx

North America

During the 20th century, extensive data were gathered on traditional practices among several tribes of North American Indians. “In nearly every part of the continent there seem to have been, since ancient times, men dressing themselves in the clothes and performing the functions of women … .”

These individuals were and are still known by several translations meaning ‘Two Spirit’ by the people themselves. In the past they were called ‘berdache’, an Arabic epithet imported via French, by whites. Not all expressions of this were the same, but seemed most visible where gender roles and appearance between men and women were most marked. This probably is simply because of the lessened gender differences, meaning the Two-Spirit people were still there, they were just less obvious to Western observers. The phenomenon was, however, widely noted.

two-spirit traditions have been documented (and in somecases, photographed) in nearly 150 indigenous North American tribes and societies. In roughly half of these, female counterparts were also reported that lived and dressed as men. Included among the tribes were the Seminole, Navajo, Mohave, Crow, Zuni, Pueblo, Hopi, Kutenai, Blackfeet, Hidatsa, Cheyenne, western Algonquian and nearly half of the thirty-five tribes living along the Pacific Northwest. Two-spirit natives comprised a distinct social class within most of these tribal communities; for example, among the Hidatsa of the northern Plains, two-spirits were observed at no less than fifteen to twenty a village and typically pitched their tipis together in a group.xxi

In North America, mores established across Anglo-Saxon culture applied. These generally prohibited any expression of effeminacy and, indeed, often punished it.

In Male Sex Work from Ancient Times to the Near Present, Mack Freedman discusses the situation in the USA in the late 19th century:

‘at the Golden Rule Pleasure Club on West Third Street, (New York)… one was “buzzed” into a room with a table, two chairs, and a young man dressed as, and identifying as, a woman.’

This rise of trans sex work in the USA was noted in an 1894 medical report cited by Freedman:

In many large cities the subjects of contrary sexual impulse form a class by themselves and are recognized by the police . . . They adopt the names of women, and affect a feminine speech and manner, “falling in love” with each other, and writing amatory and obscene letters. In New York City alone there are no less than one hundred of these, who make a profession of male prostitution, soliciting upon the streets and in parks when they get the opportunity.

However, with regard to the UK at the same time, he notes:

…the situation in Britain … meant sticking with one’s biological gender…Transgender people, in fact, were arrested simply for cross-dressing, charged with male prostitution, and often convicted on conjecture. This fit into the subliminal mores of fin de siècle Britain, which punished biological males presumed to be “inverts,” people who acted effeminate or otherwise eschewed their biological gender role.xxii

In other words, feminine behaviour on the part of men was actively persecuted in Britain, conforming to the then extremely phobic attitude of the Anglican Church, which was dominant. This led to many transwomen hiding by appearing to be gender conforming, at least in public. It is certainly the case that many homosexual males there, who would today likely transition, were unable to do so for fear of violence, in earlier times; indeed, many appear not to have so suppressed their own natures that they did not recognise themselves for what they were.

The English author Quentin Crisp wrote several remarkable books about the life of a highly feminine homosexual male in England. Late in life he said that, after a life of perplexity, he at last knew what he really was — a transsexual. Sadly, he went to his grave without being able to live the life he perhaps should have, as a woman. His words are a damning testament to the cruelty and intolerance of the culture he grew up in.

However, in other parts of Europe, things were less grim. In Germany up to the time the Nazis took over in 1933, a moderately tolerant culture was prepared to give out special ID cards to trans people. These did not change their birth sex attribution or name, but did form an official recognition of the fact that they habitually appeared to be of the opposite sex, through clothing and make-up. This protected them to some extent from police harassment. The sexologist Magnus Hirschfeld, whose practice was in Berlin was prepared to give letters of support. Hirschfeld was later involved in the celebrated case of Lilli Elbe, before moving to the USA to flee the Nazis.

hsts history christer stromholm
Pic by Christer Stromholm

After the war, in the 1950s, Paris became the home of a community of transsexuals living on and around the Place Blanche. Many of them worked in cabaret, others in the sex business. They were photographed, in one of the most remarkable collections of photojournalism, by the Swedish photographer Christer Stromhölm over ten years up to the late 1960s.xxiii Some of these went on to have GRS and two actually attended Stromhölm’s funeral 40 years later, testifying to the bond he had built up with them.

One of the best-known French transsexuals, who was one of the mothers of modern Western transsexualism, was Jacqueline Charlotte ‘Coccinelle’ Dufresnoy (1931-2006). While still a teenager, the young Coccinelle began performing in a Paris cabaret that specialised in female impersonators. Unlike the other stars, however, Coccinelle lived full time as a woman. After a chance meeting with Marie-André Schwindenhammer (1909-81), Coccinelle was introduced to the use of hormones by the older transwoman. Some time later, on tour in Nice, she met a younger transwoman, who later told her about Dr Georges Burou, who ran a maternity clinic in Casablanca. He also performed GRS, since the French legal ban on castration did not apply in Morocco. Coccinelle had her surgery there in 1958.

history hsts coccinelle

The West today.

The above represents only an overview of the evidence we have. It is not a comprehensive analysis of it by any means, but only highlights the most important parts. Each regional history is so diverse and rich that it requires an article of its own and I’ll address this through time. Africa, for example, remains somewhat unstudied, but from what we do know, has a colourful HSTS history, and I have not even addressed Russia, China or many other nations and cultures. At the same time I apologise for having glossed over the massive literature from the ancient world, which again could fill a book. Given the widespread prevalence of HSTS elsewhere and its long history, which I have only skimmed the surface of, there is no doubt that we will find much more to discuss.

It’s always important to remember that historical evidence is subject to interpretation and we have to beware seeing other cultures through eyes conditioned by our own. However, there is enough detailed information to tell us that HSTS has been a part of human society for a very long time. It is not a function of modern culture. Its presence in non-sedentary tribal cultures, not exposed to Western ones, tells us that it is not a uniquely Western phenomenon. It appears to be a universal constant, a normal and intrinsic part of human sexual variation.

I have not attempted to tease out which examples above are HSTS and which are transvestite autogynephile because there is usually insufficient information to make this assessment. Some, like Elagabalus, are clearly HSTS, while the Chevalier d’Eon was just as clearly AGP. In all other cases I have assumed that both types were present, since that is what we find today; however, the evidence for the presence of HSTS is clearly stronger than that for AGP.

Frequently people ask ‘why are there so many transsexuals, in southeast Asia, for example, or Latin America?’ But this is to ask the question from a minority viewpoint. The real question is ‘why are there so few in the West?’ When we look at the global prevalence of HSTS, we see that perhaps the greatest surprise is its almost complete invisibility in the West, at least until recently.

With the high-profile surgical transition of Coccinelle and later Christine Jurgensen (USA) and April Ashley (UK), it might have been thought that, by the mid-1960s, a veritable HSTS explosion would have taken place. Cross-sex hormones were by then readily available. The first, PreMarIn, had been launched in 1941, and the female contraceptive pill, then containing high dosages of oestrogen, was becoming popular. But this explosion did not happen. It would not be for another 50 years that HSTS prevalence in the West would begin to rise to levels comparable to those found elsewhere and even now, at time of writing, it is far lower than in say, southeast Asia.

The reasons for this are complex and we will deal with them in another article.



i Inanna is one representation in a line that goes back into prehistory. She later became Ishtar, Astarte (Biblical Ashtaroth), Asherah, Aset (Isis), Eostre and many others.

ii A eunuch is a castrated male and this has allowed some to suggest that Inanna’s servants were a type of man. But there are two different forms of castration: one in which only the testes are removed, and the other in which the complete external genitalia are. Castration when carried out by force on slaves, for example, as happened in Arabic culture, only involved the removal of testes, whereas in the Sumerian and later voluntary acts, the entire external male genitalia is removed. This is associated with transsexualism.

iii That one effect of peri-pubertal castration is to render a male subject feminine is confirmed by the case of the Italian Castrati, many of whom dressed and performed as women.

iv Herodotus, The Histories 1.199, tr A.D. Godley (1920)

v Kramer S N & Wolkstein, D Inanna, Queen of Heaven and Earth: Her Stories and Hymns from Sumer 1983 Harper Perennial

vi Some writers have suggested that Sumer was a ‘non-binary’ culture. This is incorrect. Sumerian society was strictly divided into masculine and feminine gender roles, it was just that transsexuals were accepted as members of their desired gender.

vii While we respect greatly Amara Das Wilhelm’s scholarship and diligence, we do not agree with his idea of ‘third gender’. There are only two sexes, male and female and two genders, masculine and feminine. The former is an unmodified binary and the latter is a modifiable one; in other words, the first is an either/or switch and the second is a sliding scale. Male-to-feminine transsexuals have male sex but feminine gender and vice versa for Female-to-masculine. However, their expression of gender may vary from almost conforming to extremely non-conforming, at the extreme ends of the gender scale.

viii Amara Das Wilhelm Tritiya-Prakriti: People of the Third Sex:Understanding Homosexuality, Transgender Identity, and Intersex Conditions Through Hinduism.2008. XLibris

ix ‘Catamite’ is a corruption of ‘Ganymede’, who was a beautiful boy taken by the god Zeus as courtesan and given eternal youth and beauty, but Zeus’ wife Hera took exception to the competition. It is usually taken to mean an effeminate, submissive homosexual male but this ignores the extent to which they were feminised. They were castrated and lived as women; they were transsexuals.

x Herodotus. The Histories, book I, chapter 105

xi Savage, Helen (2006) Changing sex?:transsexuality and Christian theology. Durham University. http://etheses.dur.ac.uk/3364/

xii ‘Galli’ is a pejorative; it is certain that the individuals themselves did not use it. The same is true of the feminine version ‘gallae’, which is preferred by some modern authors but was not used in antiquity. The word ‘galli’ actually means ‘Celt’ and comes from the same root as ‘Gaul’ and ‘gallic’ etc. Its use as an epithet, as here, was due to the intense Roman hatred of the Celts for their sacking of Rome in 390 BCE. This led the Romans, typically, to accuse them of homosexuality and effeminacy and the word became used as an insult like ‘faggot’ (US) or ‘poof’ (UK).

xiii Crisp, Q. The Naked Civil Servant.1997. Penguin Classics

xiv Totman, R. The Third Sex: Kathoey: Thailand’s Ladyboys 2004 Souvenir Press

xv Amara Das Wilhelm

xvisource: https://www.buzzfeed.com/lesterfeder/transgender-in-japan?utm_term=.fhBXBvOWoe#.afmpWkxLy3

xvii Amara Das Wilhelm

xviii ibid

xix ibid

xx Kulick, D. Travesti: Sex, Gender, and Culture among Brazilian Transgendered Prostitutes 1998 University of Chicago Press

xxi Amara Das Wilhelm

xxii Freedman, M Male Sex Work from Ancient Times to the Near Present, http://harringtonparkpress.com/wp-content/uploads/2015/07/MaleSexWork_Chapter-1.pdf

xxiii Stromhölm, C Les Amies De Place Blanche 1983; republished 2013 Aman Iman Editions

What is HSTS?

HSTS stands for ‘homosexual transsexual’. This describes a set of people with very specific characteristics.

The most significant of these is unique attraction to the same sex, from childhood. This applies equally to those born male and those born female. This characteristic is marked and always present.

This does not mean that HSTS are ‘gay men’. They’re not. But their transsexualism is directly linked to their sexuality, which causes them to be romantically and sexually attracted to members the same sex — typically, HSTS transwomen will like classic, masculine, strong men, often older, and HSTS transmen will like conventionally beautiful women.

There are a number of secondary characteristics that emphasise the way that HSTS are physically and behaviourally shifted towards the norms for the opposite, rather than their own, sex. Although there is quite a lot of variation in these, broadly speaking they will be present to at least some degree. These include having same-sex crushes, cross-dressing as children identification with female (if male) role models and so on. These behaviours are known as ‘gender non-conforming’ or GNC.

Some characteristics are different for those born male and those born female. These are propensities and are not absolute, nor are they present in all cases. They will be present in most, however.

For males, they include: a tendency towards slightness of build and lightness overall for height, when compared to related males; fine bones and features; a tendency towards facial neoteny, otherwise known as ‘baby-face’; tendencies towards strongly feminine behaviours and comportment; a dislike for rough-and-tumble contact sports, although they may enjoy other sports — volleyball rather than basketball, for example. They may be small as well as slight, although this is not always so. As children and teenagers they may enjoy dancing, art, music, and more typically feminine recreations.

For females, characteristics include: heaviness of build and increased natural muscularity; a preference for contact sports and games; possible masculinity in their features; a propensity to enjoy more typically masculine sports and play.

Note that just because you or your child exhibit some of the above, that absolutely does not mean that this must be a case of HSTS. Plenty of boys like sewing, as legions of tailors and leather-workers will attest and art schools are full of women sculptors. This holds across the array of secondary characteristics.

To reiterate, ALL HSTS are strongly homosexual in their sexual and romantic orientation and without that, there is no indication of HSTS, irrespective of any of the other characteristics. However, not all homosexuals will transition to full HSTS.

The determination as to whether a person is or is not HSTS can only be made by the individual over a long period of time.

Whether or not a person should transition depends on a range of factors, most notably which gender they feel most discomfort in. This discomfort is called Gender Dysphoria. (See below.) Where it is most intense and, in HSTS this is usually associated with strong secondary characteristics, the individual may struggle to cope with living in the sex-conforming gender. If these feelings of discomfort or distress outweigh any feelings of rejection or exclusion by the culture around them, the individual will probably do better by transitioning.

‘Transition’ can be be social-only or surgical.

In social transition, the person lives as a member of the opposite sex, takes cross-gender hormone replacement and may seek cosmetic surgeries but not Genital Reconstruction (GRS) or transition surgery. In surgical transition, this last is specified, as well as the others. Again, this is on a scale of intensity and it’s affected by culture. More HSTS are likely to surgically transition in a society where this is made available and is affordable, than in others. Both social and surgical transitions are valid and this is not a hierarchy. Both socially and surgically transitioned HSTS are HSTS.

(We do not use the older definition of ‘transsexual’ that was applied only to those who had surgically transitioned. We apply it to both socially and surgically transitioned HSTS.)

For MtF transition surgery today is an extremely successful procedure both cosmetically and functionally and most candidates, once recovered, need no further intervention. Still, it is a major decision that must be taken with care.

Many HSTS live full and happy lives; transition is not a failure, but a natural end-point that is appropriate for some individuals, though not others. As such, those who are successful in it should be lauded. Neither transition nor non-transition are ‘better outcomes’ in any general sense, because the better outcome is the right one for a particular individual and everyone is different. Only the individual can make that decision. From the point of view of individual, family, and professionals, the objective should be that he or she lives a full and happy life and can achieve their romantic and other desires, irrespective of the gender they present in.

Nature or Nurture?

There is evidence that HSTS is not a mental, but a physical condition, possibly the result of abnormal hormone delivery in the womb. While this is not yet confirmed, the clustering of physical and behavioural characteristics in HSTS individuals tends to support the idea. Brain scans using MRI imaging techniques have shown that in some areas of the brain, HSTS are different from heterosexual males. While correlation is not causation, this is another straw in the wind pointing to an innate cause for HSTS. In addition, there is no solid evidence to suggest that homosexuality itself can be ‘conditioned’ into a child and so it must be innate.

HSTS can, though, suffer some co-morbid mental disorders such as anxiety and depression as a result of the difficulties their condition presents and it is important not to ignore these as part of a balanced treatment pathway.

The decision to transition, either socially or surgically, may be influenced by social pressure, professional counsellors and so on, but the extent to which this is effective is unknown. However, those around a GNC child who shows signs of being HSTS should take great care to ensure that the child’s desires and well-being, and not their own or the broader society’s, are the focus of any intervention.

In many ways, although we call this homosexual transsexualism (HSTS), the inverse is more appropriate: transsexual homosexuality. This makes its relationship to gender-conforming homosexuality much more clear: they are both points on a scale of development with HSTS being at the extreme end. For individuals in this group, transition can be an appropriate, even vital, life-choice.

Gender Dysphoria in HSTS

One of the terms you will hear often is ‘gender dysphoria’ (GD). This refers to an intense feeling of discomfort at publicly presenting in the gender that normally would conform to your birth sex. If you are not trans and are male, imagine for a moment how you would feel if you were to go into work tomorrow wearing a mini-skirt, heels, stockings, a wig and make-up. It is likely that this would make you feel quite uncomfortable (unless you are actually trans). Gender Dysphoria or GD is presented as something like that, but worse.

A diagnosis of Gender Dysphoria is required for cross-sex treatment under the WPATH (explain) guidelines. Two psychological assessments confirming this and stating that the indicated treatment is surgery, are required under the same rules, for GRS. While calling yourself ‘transgender’ has become a fashion option in recent years (one reason why we don’t use the term) the diagnosis of GD remains the basis of clinical treatment.

We believe that a proper and complete understanding of the exact nature of the HSTS condition is essential to ensure that the person receives the correct advice, treatment and guidance before, during and after any transition. While transgender is by and large a meaningless term, transsexual is by no means fully descriptive of all those who experience GD.

This fashion for ‘transgender’, which is socio-political and not psychological or sexual, harms HSTS directly. HSTS are genuinely transsexual and while not all, by any means, need surgery, nearly all require HRT and possibly other therapies including cosmetic surgery. The idea that a person can be any ‘gender’ they claim just by saying so, and without any observable or measurable symptoms, undermines and erases the real issues that HSTS face, which are not a matter of fad or fashion.

Even worse, the relentless conflation of two totally different phenomena, HSTS and non-homosexual trans, causes yet more difficulty, with, once again, HSTS suffering.

Non-homosexual or autogynephilic MtF trans people can have various types of body dysmorphia. This is a result of Anatomical Autogynephilia, where the subject not only desires the body parts of a woman but also is repulsed by his own sexual organs. This can be so intense that he desires to have them reshaped into a cosmetic vagina. Many will never use this for sex with a man, because they are heterosexual and attracted only to women. Some will; these are called pseudo-bisexuals. However, the point is the extreme feelings of revulsion for particular body parts, which give rise to the feelings of discomfort or dysphoria. Markedly, this rarely has anything to do with other people’s feelings towards them and tends to focus on their own feelings about their own bodies.

HSTS appear to experience dysphoria differently. For them it is far less fixated on body parts and much more on social role. They want to live complete lives, as women, without fear of discovery. Hiding male genitalia in women’s clothing can be quite the feat, especially if the person is well-endowed. Most would like, for example, to wear a bikini to the beach, without fear of anything ‘popping out’. Many are terrified of what might happen if they were involved in an accident and first responders accidentally found their genitalia were male. (There have been cases where accident victims have actually died because of this, when the responders refused to give necessary help). Many HSTS, especially in the West, live in ‘deep stealth’ where nobody at all knows their history or background. They may have built solid, good lives and relationships not just with partners but with friends and colleagues, which would be completely destroyed if they were discovered to be transsexual. All of these possibilities tend to push the individual towards electing for GRS and we might call them ‘social imperatives’.

In addition, HSTS often state that they wish to have sex without the encumbrance of an organ that just gets in the way and which they will never use. They will usually express this in terms of partnerships and so this too has a social or interpersonal element. Their desire for GRS is not just about appearance: an HSTS transwoman will invariably use her vagina for sex with male partners!

It appears, then, that GD for a non-homosexual trans person is introspective and has to do with the subject’s relationship to his own body, while for an HSTS it is extrospective and has to do with her relationships to the people around her and her position in society, as well as sex. This is an area which is much in need of more research.

Professionals and HSTS

The difference between these two forms, unfortunately, is often ignored by even those professionals who do recognise the central importance of GD. This may lead to inappropriate treatment strategies for HSTS, if they are presumed to have a form of GD that they do not.

Unfortunately, non-homosexual trans have been successful in dominating the debate and it is a fact that many, if not most, professionals who assist HSTS as part of their jobs, do not understand the nature of HSTS. This ignorance is also found in well-meaning support organisations like GIRES in the UK, which does not even, apparently, realise that there are two different forms of MtF trans, despite the high-sounding title it has given itself.

In brief, this situation is scandalous and should never have occurred. It is our purpose to provide a resource which will provide accurate and evidence-based information to HSTS, their parents, carers, professionals and volunteers.