Gender identity, gender dysphoria, and transgender have been in the news recently which has been heightened by the president’s ban on transgender military service, a change from the previous presidential policy. In our conversation with people in general, there are a number of misconceptions about gender dysphoria with transitioning to the opposite gender. Even physicians, frequently don’t understand the major changes of the genital-urinary system in males and in the genital-urinary-reproductive system in the female. My primary initiation and observation concerned a patient about a decade ago.

Let me call him Lawrence. He appeared as a squatty, bearded, middle aged, hairy chested man who came in for a complete evaluation. Although he had mild lung disease, he came in without a referral. His wife had briefed us that he was a schizophrenic. However, he was alert, oriented with good fluent speech. As we went through his medical history and came to his urogenital system, he indicated no urinary problems, did not have a prostate and said he was really a female. In fact, he’d had three pregnancies and three children.  He decided in his 30’s that he felt more like a male. He went through the Stanford Dysphoria clinic and after psychiatric evaluation it was determined that he met the criteria of dysphoria and would qualify for their transgender program. He had bilateral mastectomies, vaginectomy, hysterectomy with bilateral oophorectomy (both ovaries were excised). He was started on testosterone, began growing a beard and hair on his legs and chest.

On physical examination he had large scars over both sides of his chest; his clitoris was about 3 cm. But there was no glans penis—perhaps the entire enlarged clitoris, which he said was sensuous, would be the equivalent of the glans penis. But there was no urethra in the enlarged clitoris. He informed me that he still had to urinate sitting down as he always had when he was a female. He had two aluminum testicles in a surgically designed scrotum beneath the phallus (prior clitoris) but just above his urethra. He thus continued to void sitting down with his urinary stream coming from behind his aluminum testicles which were encased in a smooth scrotum. He was unable to stand at the male urinals to empty his bladder as the other males did and always had to use the enclosed toilet stalls. He tried not to go into a busy restroom so he could slip into a stall without being obvious and escape before arousing curiosity about such a short bowel movement time.

He (formerly she) had divorced her husband, went through the trans program, and married a woman with three children. There was no restroom problem since he appeared as a male and would cause screams if he went to the restroom of his original gender. He stated sexual intercourse was somewhat modified since he had minimal ability for intromission but since his entire clitoris was sensuous, they could both reach a climax.

He returned for several follow up visits. His demeanor was very much like a woman who liked to be touched and to touch. His demeanor seemed to be similar to my homosexual patients who liked boys better than girls. When he was a female, he liked girls better than boys. His wife made an unannounced visit to the office and elatedly reported that his new psychiatrist said he was not schizophrenic. He made the diagnosis of bipolar disorder. He declined further evaluation of his sexual identity. He further ordered me to never send his records out to any doctor or insurance company.  It seemed as if I was the only physician he totally confided in.

Had he been in the Army, he would have had difficulty hiding his transgender status, whether in the barracks, in camp, in the latrine or in the battle field. The prejudice would have been overwhelming. The soldiers may have been overtly belligerent or worse. President Trump seems to understand how this would interfere with military readiness. Therefore, the ban seems appropriate.

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