Sexual Inversion: the cause of HSTS

Identifying – or self-identifying – a genuinely pre-transsexual HSTS is relatively straightforward. But before we get to the symptoms, let’s look at the cause of all this. It is called Sexual Inversion. There are four basic parameters to consider in diagnosing this: Sex, Sexuality, Gender and Gender Dysphoria.

Sex, of course, is the product of our chromosomes; everyone is either male (XY) or female (XX), apart from a small number who have chromosomal variations, who are usually called ‘intersex’ – but here too, their condition is defined by their chromosomes. Sex can never be changed.

Sexuality describes our basic sexual impulse. We either have male sexuality or female sexuality. Male is sometimes called Active and is the desire to penetrate and female is Passive or the desire to be penetrated. In most people these are aligned but in a small percentage of individuals this is not so. This results in males with female sexuality and females with male sexuality. This is Congenital Sexual Inversion. This is a physiological condition and so forms an aetiology or scale of variation.

books by rod fleming

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Self-medication: the basics for HSTS

The UK is suffering a backlash against transition and HSTS are affected disproportionately. This assault is being orchestrated by TERFs, so called ‘gender-crits’ and justifies itself using the words of individuals like Oren Amitay and Ken Zucker, while conspicuously ignoring the advice of those like Dr Diane Ehrensaft. As a result, a number of worrying developments have taken place recently which may lead to young trans people not being able to access the hormones and treatments they need. Self-medication, while not ideal, must be considered.

We note also, with concern, that various Government bodies in the UK have been deleting links to advice sites on transsexualism, for example Mermaids. We’ll be putting up these links up here so that people can access them.

Many thanks to Transit UK for their information.

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Children in Transition 1

True or homosexual transsexualism, which is usually known as HSTS, is the product of ‘transgender homosexuality’. In this, the individual experiences anomalies in testosterone delivery while still developing in his or her mother’s womb. In girls, too much will cause masculinisation but in boys, too little will cause feminisation. The effects may be observed in children.

The effects of this depend on the severity of the anomaly and the point in foetal development at which it occurred. For example, in boys, the genitalia develop before the brain structures related to sexuality and gender do. So a boy can be born with normal genitalia and, potentially, a sexuality that is so feminised as to be completely female.

The effects of this may be seen soon after birth, when children will begin to display opposite-sex behaviour and play patterns. These are often called ‘Gender Non Conforming’ or GNC but this is misleading, since they are actually sex non-conforming. These may include toy preferences and role preferences in community play. This can begin to be observed as young as age two and parents should be vigilant. If persistent and consistent ‘GNC’, which I will now refer to as ‘sex non-conforming’ or SNC, is being observed in their child then there may well be an issue.

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Sexual Inversion and HSTS: a causative link


Many people have asked for more details about the background to HSTS, homosexual transition desire and the cause of these phenomena. These are legitimate questions. The answer, with a massive amount of supporting evidence and research, appears to be a phenomenon that was discovered over a hundred years ago, called ‘Sexual Inversion’.

Sexual Inversion is the theory that anomalies in sexuality and gender are the result of biological rather than psychological factors. It is well established. There is plenty of evidence to suggest that it is what causes Transgender Homosexuality, which can be either feminine-male or masculine female. This means that it is also the underlying cause of homosexual transition desire, which becomes homosexual Gender Dysphoria in severe cases, and, ultimately, True or Homosexual Transsexualism (HSTS). The striking clustering of physical attributes and behavioural conditions typical of HSTS have always suggested an innate, biological cause and Sexual Inversion is the obvious one. It was identified over a hundred years ago by Karl Ulrichs and expanded on by Havelock Ellis.

Numerous papers have supported this idea and, most recently, Professor Simon Baron-Cohen has extensively studied the phenomenon of hormone delivery issues in utero. While Baron-Cohen’s interest is in other effects of this phenomenon, much of his work, again, supports the Sexual Inversion Theory.

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The future for HSTS

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 and its rich history, we see that perhaps the greatest surprise is its almost complete invisibility in the West, at least until recently. It seems likely that in the future, the levels we see elsewhere will become the norm in the West.

There remain, however, many hurdles and we cannot rest. The future remains uncertain and HSTS are children and young adolescents with little voice and we must speak up for them, against the forces that would destroy them, even today.

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.

We still don’t know why this is.

The Future

Until about five years ago I thought the future was rosy indeed for transsexuals the world over, but most of all in the West. Now I’m less sanguine.

We had arrived at a point where medical and psychiatric professionals and other carers were becoming aware of the reality of transition, even if they didn’t fully understand the reasons for it. Remember that as late as 2010, some doctors in the US were still prescribing massive doses of testosterone to ‘cure’ transsexualism. This tone, of ‘curing’ a disorder, was manifest through paper after paper published in the late 20th and early 21st centuries.

Then, a breakthrough seemed to have occurred; now we were to listen to the young people involved and do what they wanted. This appeared to be progress. We had the case of Kim Petras, a young German HSTS, who had her surgery at 16 and is now living a successful life as a woman. There were many others.

Kim Petras

We were naive; a backlash was inevitable. In the West, the narrative had been comprehensively hijacked, not by pretty, smart girls like Petras, but by old men in dresses like Bruce ‘Caitlyn’ Jenner. Nobody seemed to recognise — or be prepared to say — that these were autogynephilic transvestites, fetishistic crossdressing men, who had no relationship whatsoever to True Transsexuals.

To be transsexual, two conditions must apply: you must be same-sex oriented from childhood — that is, homosexual with regard to birth sex; and cross-sex identified. These parameters must be exclusive. You can’t be a bisexual transsexual — but you can certainly be a pseudo-bisexual transvestite. That in itself is not a problem, but when the latter claim the identity of real transsexuals, the ones they harm are those transsexuals.


We have recently seen a huge increase in the number of referrals to gender clinics. In the UK this has been of the order of more than 4000%, over eight years.

As society becomes less intolerant, especially the Anglo-Saxon culture with its relentless hostility towards male femininity and public acceptance of sex while assiduously pursuing clandestine pederasty, (the British way), then we should indeed expect to see many more HSTS come forward. Why would they endure a miserable life as ‘gay men’ when modern techniques can allow them to live complete lives as women?

There is a problem. Historically, there have been at least twice as many Male-to-Feminine (MtF) transitions as Female-to-Masculine (FtM). The new figures more than invert this, with the overwhelming majority being FtM. Further, Homosexual Gender Dysphoria, the clinical cause of HSTS, in its most observed form, sets on in childhood and will be indicated for years both before and after puberty. There is nothing rapid about its appearance.

The forms of Gender Dysphoria

The non-homosexual forms of Gender Dysphoria can appear almost overnight. There is, simply, no similarity between homosexual and non-homosexual Gender Dysphoria, except that both make the subject desire to transition.

The homosexual form is a natural progression of an innate sexuality in which an individual is attracted to members of the same sex and identifies as a member of the opposite one. Universally, they desire to play the opposite-sex role in sexual relationships; that is, males to be penetrated and females to penetrate.

Non-homosexual Gender Dysphoria in males is caused by a condition called Autogynephilia. This is a narcissistic personality disorder that caused the individual to fetishise the idea of himself as a woman. While the female form is less well understood, it is clear that it shares many similarities. It is non-homosexual; it evinces weak self-ideation, of not knowing whom one really is; it sets on rapidly, perhaps almost overnight, with no warning; and, perhaps most worryingly of all, and especially in the female form, it can vanish just as quickly.

This phenomenon has been called ‘Rapid Onset Gender Dysphoria’ or ROGD, which is plausible. The rapidity of its onset, however, it shares with the male form, so perhaps we should just call it ‘female non-homosexual Gender Dyphoria’ although that would yield a less pleasing acronym.

Social contagion

The evidence is that the majority of this uptick in FtM transition, which is occurring in adolescence and early adulthood, is the result of a social contagion. That contagion, in my opinion, is a feminist cult that has taught young girls to believe that ‘gender is a construct invented by men to suppress women’ and that it can therefore, simply be changed. But this is a lie; gender is a function of sexuality and, while that does crystallise over childhood, very soon after puberty, it is fixed. Gender is not a construct; it is the primary interface that humans use to relate to other humans. It cannot be dispensed with or changed.

Today, HSTS, always the most innocent and vulnerable in society, face being used as pawns by unscrupulous people who have no interest in them, but in promoting their own political agenda. These include gender-conforming homosexual males, feminists and others. They call themselves the ‘gender-crits’.

A balance has to be struck between protecting the interests of genuinely HSTS children and those of young women who have been hopelessly confused by a sociophagic political cult. HSTS, especially males, need to transition in their teens, in order to maximise their chances of living full lives as women. People with non-homosexual Gender Dysphoria, especially women, should not transition at all.

If these latter are adults, then it is their choice. But neither they, nor the unholy alliance of ‘gender-crits’ have the right to interfere in other people’s lives or to deny them the opportunity to lives as they want to.

We must protect the innocent and that means standing up to gender-crit bullies and insisting that, while non-homosexual transition is indeed questionable, homosexual transsexualism is well-understood. We know what it is, we can identify it and we must support the young people who have it.

It’s not all doom and gloom

Despite the activities of the gender-crits, for whom I have little time, and the concerns of parents, for whom I have the deepest sympathy, I cannot see the clock turning back.

I am lucky enough to observe the development of trans people in Asia. There are no gatekeepers here. Instead there is a support network that sustains young people and passes to them the wisdom of older ones. A young HSTS’ future is explained to him or her by others who have walked the same path.

An equivalent network now exists in the West, through social media and the Internet. This site is a part of that. Through it, young HSTS can find out what and who they really are and learn how to protect themselves from reactionaries. They can protect their future.

I do not believe that the gender-crits will succeed in their aim of denying all transition therapy to young people, but we must remain vigilant and challenge them at every turn. We must reassure parents of boys that it must be preferable for them to have a happy daughter than a miserable ‘gay’ son, and the opposite for girls. We must show them the HSTS success stories. We must show them that their children can have a future, as HSTS.

At the same time, we now have a body of experience, developed amongst HSTS, that would allow them to circumvent the medical profession in order to get the treatment they need. Nobody wants to see them do that, least of all medical professionals, so we must hope that in the future common sense will prevail and young HSTS will be helped, not hindered.

I believe it will.

Rome and transsexualism in the Empire

The history of transsexualism in Rome was intimately tied to that of religion and, paradoxically, sexual libertinism.

In Rome, it was considered the greatest disgrace for a man to be penetrated, but the Romans had no issues with men penetrating. They saw that as just being what men do; and men duly penetrated, with enthusiasm, anyone or anything that would stay still long enough.

Ganymede was a beautiful boy who was raped by Jupiter in the form of an eagle, in Classical mythology. Ganymede is always portrayed as a girl with long flowing hair; transsexualism was part of Roman culture

They had no concept of ‘homosexuality’ as we would understand the term today. Shame, for a man in Rome, was being made into a woman — which was the inevitable result of being penetrated. Numerous tortures were invented by the Romans that involved inserting large objects into the victim’s anus. This was only partly to cause pain; it was much more to cause shame and embarrassment, especially if carried out in public. Male rape was used, by Romans. to demean and dishonour their enemies.

This dynamic pervaded Roman society and is crucial to understanding it. Rome gave its ideas to the successor cultures in Europe, where they were carried on to the modern world and it is from these ideas that the stigma that still attaches to homosexual and transsexual sex derives. Today, men who are known to associate with transwomen are deliberately slighted, especially if their partner is pre-operative, by the assertion that they are the receptive partners in sex. 1

In Rome, however, transwomen were considered perfectly legitimate sexual partners for a man. Indeed, a beautiful transwoman lover would be admired by other men and her owner (since she would almost certainly be a slave) much envied.

Boys become girls: galli

Boys were also considered to be legitimate lovers for men, as they had been in Greece, but the Romans did not have the subtle relationships between the erastes and the erominos, in which the former educated the latter in all the matters of manhood, while also being his sexual lover. In Rome, boy-love was just for fun and so it was normally between free men and slaves. These slaves were called ‘puer delicatus’ or ‘pretty boy’ and either were purchased and served in a master’s household alongside other sexual slaves, or they were bought by pimps and made to work the streets and bath-houses.

These boys were called ‘galli’, which means ‘Celt’ or ‘Gaul’ because the prettiest were fair-skinned boys who came from Gaul, modern France. The Romans hated the adult Gauls but apparently not their boys. It was widely reputed that Gaulish boys were introduced to being the sexual partners of men, long before they arrived in Rome and so were skilled lovers. Such boys invariably presented as girls.

Many were castrated, especially if they were retained in a household, as this caused them to retain their youthful femininity for far longer. They lived as women, with the other female slaves. However, once they grew older and outlived their usefulness in their master’s household, they would face an uncertain future, although many became household managers. If they were not so lucky, they too might become transsexual prostitutes.

Cybele; Phrygian Goddess of Transsexuals

Transsexual priestess of Cybele

After the Punic Wars, the cult of Cybele, the Phrygian Great Mother, was imported to Rome and so were the rituals surrounding her. Phrygia was in Anatolia, part of what we now call Turkey and is one of the cradles of human culture. The Phrygians had three  qualities that impressed Roman authors: their abilities as horse-soldiers; their ferociousness; and the prominence of transsexualism in their culture.

Cybele’s cult was a derivative of the older Sumerian and Akkadian cults of Inanna and Ishtar, with similar rituals. Cybele herself was cognate to the Sumerian/Akkadian Ereshkigal, to the Egyptian Nephthys and to the Hindu Kalli amongst many others. She is the Goddess in Dark aspect.

An older transsexual arch-priestess of Cybele

In devotion to her, just as they had in previous cultures, boys would work themselves into a trance, using incense, alcohol, other narcotics, music and dance —  and then self-castrate, to become priestesses and temple prostitutes. These boys are often also referred to as ‘galli’ both by Roman writers and later ones, but this is a conflation with the Gaulish ones. However, while the true galli were invariably slaves, self-castration in the cult of Cybele became popular amongst free-born boys of good families.


Other forms of transsexualism existed, which reflected the multi-cultural nature of the Roman Empire. For example, 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.”

Again, this refers to the removal of the male genitalia, a ‘complete transformation’ in which both testes and penis were removed. This differs from the more commonplace form of castration in which the testes only were removed.


Limited castration, in which only the testes were removed, was performed on slaves. It was especially popular in Egypt, less so in Rome itself. These individuals usually lived as men and the function of castration was to make them less aggressive and more docile. Full castration was more dangerous, took much longer to recover from and could lead to problems with urination and the risk of urinary tract infections.

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. It made no difference whether the castration was enforced, as it was for slaves, or voluntary, as it was for free-born boys.


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 Elagabalus (203-222) is fascinating. 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.


Sporus (see link to separate article) was a slave-boy who served as a prostitute in the household of the Emperor Nero. She bore a striking resemblance to Nero’s wife, which is probably why she had been purchased; slave boys could be more compliant in sex than free-born women. After Nero killed his wife in a fit of rage, he married Sporus and had her castrated in order to be a ‘complete woman’. Sadly, after Nero was deposed, she became the plaything of his successors and eventually committed suicide.

Christianity in Rome

Hermaphrodite always fascinated Greek and Roman men. Frequently she was portrayed in poses like this one — which, amazingly, has survived intact.

Various Emperors, notably Augustus, the first Emperor, made attempts to limit the libertine proclivities of the Roman population, and not just the men. But for hundreds of years after Augustus’ reign, prostitution, including that of boys and transsexuals, persisted and indeed, became a feature of Roman life. As long as cults like that of Cybele and that of Isis, which had been imported from Egypt, along with numerous other goddess cults all vying for popularity and wealth existed, transsexualism remained protected; and as long as Roman men believed that sex with anyone was a laudable act, as long as they were the one penetrating, so the pueri delicati would remain popular sexual partners; the delightful sweetmeats without which no orgy would be complete. But when Rome adopted Christianity as the official State religion, all of that changed.

Although Christianity, in its Roman form, made huge concessions to goddess culture, the avatars of the Goddess that were venerated were those of the Virgin and the Mother, and not those of the Harlot, the temple prostitute, or the transsexual street-prostitutes that were commonplace. Christianity had an absolute injunction against any form of homosexual sex which it applied firmly. It also had a horror of anal penetration, which, after all, in the millennia before modern surgery, was the only way an HSTS transwoman could enjoy sex.

Under the new order, transsexuals were ruthlessly persecuted, both because of their desire to be the male-born lovers of men and their association with ‘pagan’ goddess cults . Rome’s lasting contribution to the history of transsexualism — which had become a commonplace within its culture — would be to drive it underground.

April Ashley MBE: Fame and notoriety

In the UK, by far the most famous of the HSTS transwomen who were aided by Dr Burou was April Ashley. Unfortunately, her fame was perhaps less welcome than she might have desired.

Born George Jamison in 1935, April was a classic HSTS. She was bullied in her youth for her femininity and, according to her autobiography, never fully masculinised. Fully homosexual, she joined the Merchant Navy, where she was preyed on and raped.

In the late 1950s she moved to Paris and joined the cast at the Carousel Theatre, where she met Coccinelle. SHe took her name, ‘Ashley’ from the character in the film ‘Gone With the Wind’.

In 1960 she took £3000 in savings – a fortune in those days – and went to Casablanca. She became the first British person to have Genital Reconstruction Surgery (GRS) at Dr George Burou’s clinic there.

April Ashley with Arthur Corbett

Returning to London, she hit the celebrity glamour circuit, working as a model and dating film and theatre stars. In 1961, however, she was publicly outed by the Sunday People, a now-defunct tabloid that specialised in the salacious. With much of her career in tatters and many doors closed to her, in 1963 she met Arthur Corbett, who was married and had four children. He was Eton-educated and the heir of Lord Rowallan, as well as which, he was known to be an autogynephilic transvestite. (Today, it is well known that autogynephiles or AGPs are strongly attracted to HSTS transwomen.)

As is so often the case, though, having divorced his wife to marry April, this marriage also foundered in short order and a hugely notorious court case ensued, as April attempted to secure a financial settlement. The court decided that her husband owed her none, because, since she was legally male, they had never been legally married.

After the trial, April Ashley returned to occasional modelling, writing and public speaking. Although a life long activist for trans rights, she otherwise lived a quiet life and, at time of writing, was still doing so, in Fulham, West London.

April Ashley was able, finally, to legally change her gender marker in 2004, after the UK Government passed the Gender Recognition Act. In 2012 she was awarded the MBE for services to Transgender equality. She always maintained a friendship with Labour Politician John Prescott, whom she had met in the Merchant Navy.

In later life, April suffered considerably from osteoporosis, because she was not prescribed a maintenance dose of oestrogen HRT to keep this at bay.

Sporus: The bride of Emperor Nero

Transsexualism, in the form of HSTS or, as the DSM-V has it, ‘Early Onset Gender Dysphoria’ has been around for a very long time. However, it was not until recently that we have begun to know something of the lives of HSTS. In antiquity, many were known of but few had their lives documented or recorded. Indeed the only one we are aware of was a slave called Sporus, who became the wife of the Roman Emperor Nero.

Sporus was what was known as a ‘puer delicatus’ or ‘pretty boy’. In Rome, these were almost always slaves, because the sexual role they played, of recipient in anal sex, was considered taboo for a Free man. It was normal for these boys to be castrated in order to preserve their feminine appearance longer. This was probably what is now called an ‘orchiectomy’ or ‘orchidectomy’, which involves the removal of the testes but not the penis.

Sporus had caught the attention of Nero because he closely resembled the Emperor’s wife. After Nero killed the poor woman in a fit of temper, he selected Sporus as her replacement. She was duly castrated and formally married. Nero paraded her around the city as Rome’s First Lady.

Unfortunately for Sporus, Nero was deposed and killed and his successor took her as his wife, as a part of his spoils. Calamity followed calamity when this husband was also killed and the new Emperor again took Sporus to wife; but this one had no intention of feting her. Rather, in order to humiliate her and thereby to humiliate the memory of his late predecessors, her former husbands, he planned for her to be gang-raped and then torn apart in the Circus as a treat for the people.

Sporus killed herself. Hers was a sad life, but one that should be remembered.

Although there are records of transgender individuals appearing in the pages of history between Sporus’ time and ours, these are rare and most appear to relate to autogynephilic transvestites rather than HSTS. One such, for example, the Chevalier d’Eon, lived ‘half his life as a man and half as a woman’. Clearly he was a classic Western AGP.

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.