Descriptions from classical mythology, classical history, Renaissance and nineteenth-century history plus cultural anthropology point to the long- standing and widespread pervasiveness of the transsexual phenomenon. These descriptions were generally hidden away in historical or scientific documents, unavailable and of little interest to the general public.
This situation changed in late-1952, however, when transsexual (sex reassignment) surgery burst publicly upon the world. On December 1, 1952, the New York Daily News carried the banner headline, "Ex-GI Becomes Blonde Beauty." For the next few months transsexualism became a household topic as story after story was published. Eventually interest in the subject dwindled and one-time front page stories were lost within the inner pages of the tabloids.
Few articles appeared during the period 1954 to 1976. Those that did seldom rated front-page space. During the summer of 1976, however, the world of professional tennis was disrupted by the controversy surrounding a player who had undergone sex reassignment and subsequently desired to play professional tennis as a woman. The controversy once again sparked the nation's curiosity concerning transsexualism and, during the following months, numerous maga- zine articles, newspaper reports, and television programs dealt with the scientific phenomenon of a "female mind trapped in a male body" or vice versa.
Interest in transsexualism would have dwindled once again, had it not been for a seemingly endless series of newsworthy stories involving transsexuals, such as "Transsexual Wars With The Army" and "Sex Changed Teacher Seeks Job Back." Further, the courts were suddenly alive with transsexual litigation; the common denominator in each being a persistent pattern of severe discrimination.
Systematic medical treatment of transsexualism was initiated in the early- fifties by Harry Benjamin, a prominent New York endocrinologist. The first gender clinics opened during the 1965-67 period at Johns Hopkins Medical Institutions, the University of Minnesota, and UCLA (University of California Los Angeles).
Professionals involved with these clinics realized early in their research that differential diagnosis would be difficult and controversial. Consequently, international symposiums were established to resolve many of the issues surrounding the treatment of transsexualism. International symposiums have since been conducted in London (1969), Denmark (1971), Yugoslavia (1973), Stanford (1975), Norfolk (1977), San Diego (1979), Tahoe (1981), Bordeaux, France (1983), Minneapolis (1985), and Amsterdam (1987).
By 1976 it was clear that transsexualism was no longer seriously questioned as an accepted medical entity. And, in 1979, a professional subspecialty group (The Harry Benjamin International Gender Dysphoria Association) was formed during the Sixth International Interdisciplinary Symposium on Gender Dysphoria, with minimum standards subsequently being established for the treatment and care of gender dysphoria patients.
Today, some 30-plus years since becoming front-page news, gender dysphoria syndrome is described thoroughly in the literature. The literature suggests that: (1) The causes remain unknown; (2) pre-surgical transsexuals as a group are among the most miserable of people, often exhibiting extreme unhappiness which frequently brings them to the verge of suicide or self-mutilation, and (3) a satisfactory outcome to sex reassignment surgery, in terms of improved social and emotional adjustment, is at least 10 times more likely than an unsatisfactory outcome in properly selected patients.
The literature describes the problem of transsexualism as a disturbance of gender identity, where individuals experience a sense of incongruency between their psychological sex and their anatomic sex. Other disturbances described, but frequently confused with transsexualism, include homosexuality and transvestism. They are, however, actually distinct from it. Homosexuals, who are sexually attracted to members of their own sex, and transvestites, who occasionally dress in clothes of the opposite sex, experience conflicts which are only superficially similar to transsexualism. Unlike the transsexual, they do not desire to alter their anatomy. The transsexual, in sharp contrast, feels trapped in a body of the wrong sex and seeks release; either through skilled surgical intervention, or through what ever means--including suicide--available to effectively escape.
The literature indicates a consistent trend towards rejection by both family and friends, harassment and/or discrimination in varying degrees by most of society, and more often than not, a refusal by many in the legal and medical professions to render services; either by reason of questioning the validity of such a diagnosis, or perhaps fear of potential peer and/or community sanctions.
Additionally, it is clear from the literature that the causes of transsexualism are disputed among professionals; most of the controversy focusing on whether the etiology is psychogenic or organic. Money and Ehrhart suggest that a fetal metabolic or hormonal component may predispose a person toward gender confusion. Block and Tessler discuss an endocrine theory which assumes that chromosomal sex and endocrine do not always correspond, and Seyler and associates have demonstrated that the response of female transsexuals to diethylstilbestrol (DES) and luteinizing- releasing hormone (LRH) was intermediate between the female and male patterns, suggestive that a biological component is present.
Virtually countless theories abound, with research failing to wholly support any one position. The result is that most professionals accept the theory that best corresponds with their own personal background, education and clinical experience.

Adding to the controversy is a lack of standardized criteria to determine the presentation of true transsexualism; the diagnostic process being one of inference and the ruling out of other disorders. Definitive diagnostic tools such as standardized physical or psychological tests are simply non-existent.
On the other hand, there is considerable indication that experienced practitioners are finding methods to accurately differentiate primary from secondary transsexualism and predict outcomes. Extensive patient histories, psychometric testing and psychiatric evaluations program intake, mid- transition (following initiation of hormone therapy and full-time living in the gender-role of reassignment), and just prior to surgery are used to monitor patient progress and adjustment/suitability for sex reassignment surgery. Coupled with this evaluative process is the real-life test, extending from one- to two-years, supplemented by private or group therapy to resolve non-gender related emotional problems, etc. and develop realistic patient expectations prior to surgery. Despite the controversy about transsexualism, the literature on the subject does reflect some recurrent themes. First, each individual's gender identity is well established by early childhood. Second, transsexualism usually manifests before puberty, and once the pattern is established, it is highly resistant, if not impossible, to change. Third, true transsexuals do not respond to psychotherapy, rejecting this mode of treatment because they see their problem as physical and the solution as surgical, not psychiatric. Consequently, therapy aimed at other than sex reassignment has consistently failed, rendering self-castration or suicide a real risk. Fourth, transsexuals suffer from a distinct gender disorder of unknown etiology that is capable of amelioration, if not cure, uniquely through sex reassignment. Fifth, as might be expected, surgical complications are more frequent when individual surgeons or surgical teams are making their initial attempts at vaginal construction. As experience of each group develops, the complications may be largely reduced eliminated. Sixth, sex reassignment, while often treated as cosmetic in the literature, has consistently been deemed non-cosmetic and, in the majority of cases, medically necessary by the courts.
Despite the generally favorable non-cosmetic and medically necessary judicial decisions, the American judicial system has failed to keep pace with medical and scientific advances, particularly in the area of gender dysphoria syndrome and transsexualism. This failure is aptly demonstrated by a diversity of decisions, rendering the transsexual vulnerable to discrimination in a variety of socio-economic contexts, especially in the areas of civil rights and health care. This vulnerability was clearly described in a recent article by Tim Alger, wherein it was stated that "[t]here [are few] provisions for transsexuals under the law. They're kind of left out there, hanging in space. Each time they go into court, depending on the empathy of the judge, it is unknown how they will be treated."
There can be little doubt about the complexity of the socio-legal problems surrounding the transsexual. The newness and limited size of this field makes research difficult. Furthermore, more often than not, the professional may find that once a body of information has been accumulated, it may well fail to provide an answer to the question which motivated the research. On the other hand, few fields of endeavor offer more challenge.
Lawyers, legislators, and judges need to better understand the human condition as it relates to gender dysphoria syndrome, in particular transsexualism. For only through this group of professionals can the advancement of equal rights and equal protection under color of law be attained.
Every member of society, regardless of race, national origin, religious belief, sex, sexual orientation, or sexual status (transsexual, hermaphrodite, etc.) should be entitled to be judged and to live under a government of laws, free of prejudice and the weakness of a government of men or women acting without laws to regulate their treatment.

During pre-discharge procedures, the Army elimination board found that plaintiff's husband, Kristian Von Hoffburg, was a psychological female-to- male transsexual but biological female. The board further opined that the intent of AR 635-200 is to define the sex of a person in the biological sense. As such, the board recommended that the plaintiff be discharged from the service because of homosexual tendencies. Plaintiff was subsequently discharged.
Plaintiff filed suit just prior to her discharge, seeking a declaratory judgment, injunctive relief and monetary damages. The United States District Court for the Middle District of Alabama dismissed the complaint without prejudice because plaintiff had failed to exhaust her administrative remedies.
Upon appeal the 5th Circuit Court of Appeal held that: 1) The plaintiff must exhaust her administrative remedies prior to seeking judicial review of her honorable discharge from the Army; and 2) Plaintiff's claim for monetary damages cannot be satisfied by the available administrative remedies; she must resort to the courts for that form of relief. Finally, the Appellate Court remanded the case back to the district court with directions to vacate the order of dismissal of the claim for monetary damages, but hold the claim in abeyance pending the administrative resolution of plaintiff's remaining claims.

Current Title VII case law involving effeminate males and/or transsexuals includes: Smith v. Liberty Mutual Insurance Co., Voyles v. Ralph K. Davies Medical Center, Holloway v. Arthur B. Andersen & Co., Powell v. Read's Inc., Audra Sommers v. Budget Marketing, Sommers v. Iowa Civil Rights Commission, Kirkpatrick v. Seligman & Latz, Ulane v. Eastern Airlines, and Doe v. U. S. Postal Service.
In Smith the court held that Title VII did not forbid employment discrimination based on "affectional or sexual preference" of the job applicant, despite the fact that the plaintiff was not characterized as a homosexual person but "effeminate."
The Voyles court expanded the non-applicability view to include both transsexuals and bisexuals. Voyles, a medical technician, was dismissed when she informed her employer that she intended to undergo sex reassignment from male-to-female. She was dismissed on the ground that such a change might have a potentially adverse effect on coworkers and patients. She sued under the Civil Rights Act of 1964 for injunctive and monetary relief on the grounds that the dismissal constituted sex discrimination under the Act. The District Court granted the defendant's motion to dismiss, stating that "[s]ituations involving transsexuals, homosexuals, or bisexuals were simply not considered [by Congress in passing the Act], and from this void the Court is not permitted to fashion its own judicial interdictions." The dismissal was upheld on appeal by plaintiff to the Ninth Circuit Court of Appeal.
The Court reached a similar decision in Holloway, wherein plaintiff, employed as a multilith operator, was dismissed after having informed her supervisor that she was undergoing treatment in preparation for sex reassignment from male-to-female. The Court granted the employer's motion to dismiss the suit, ruling again that Title VII did not embrace transsexual discrimination. Again, the decision was affirmed on appeal. The Court did, however, go on to rule that "a transsexual who claimed discrimination because of his or her sex, male or female, could state a cause of action under Title VII.
In Powell, plaintiff was engaged in the required trial living venture prior to sex reassignment surgery. On her first day of employment as a waitress in a new job, plaintiff was dismissed by her supervisor who had been informed by a customer that plaintiff had been a man. The court followed the Voyles and Holloway decisions, stating that Title VII did not embrace sex reassignment.
The Eight Circuit Court of Appeals followed the reasoning of previous courts in Sommers. Miss Sommers was fired by her employer, Budget Marketing, after having told them she had the anatomy of a woman and working two days. The company said she was fired because its office routine was disrupted because female employees threatened to quit if Miss Sommers were allowed to use their restroom.
While the Court was not unmindful of the problem Sommers faces, they recognized the problem Budget faced in protecting the privacy interests of its female employees. An appropriate remedy was not immediately apparent to the Court. "Should Budget allow Sommers to use the female restroom, the male restroom, or one for Sommer's own use?" The issue before the court, unfortunately, was not whether such an accommodation could be reached but, rather, whether Congress intended Title VII of the Civil Rights Act to protect transsexuals from discrimination. The court held with the other Circuits that such discrimination is not within the ambit of the Act.
Sommers, having failed in the federal court system, next brought suit against the Iowa Civil Rights Commission. The Iowa Supreme Court held, however, that an Iowa statute prohibiting discharge of an employee because of that employee's sex or disability did not proscribe employment discrimination based on transsexuality.
The Kirkpatrick court found that a preoperative male-to-female transsexual terminated from employment for not dressing and acting as a man while at work, failed to state a cause of action under 42 U.S.C. Section 1985(3). Under color of law, "plaintiff must allege that defendants' refusal to allow her to continue work while dressing and acting as a woman denied her equal protection, or equal privileges and equal immunities, and where there was no allegation that any other employees who were biologically men, were protected, privileged, or immune so as to have a right to work while dressed and acting as women (or vice versa)." Further, the court went on to find that transsexuals "are not (a) suspect class for purposes of equal protection analysis and (b) clearly there was rational basis for employer's requiring its employees who dealt with public to dress and act as persons of their biological sex since allowing employees to do otherwise would disturb customers and cause them to take their business elsewhere." The decision was affirmed, on appeal, by the Fifth Circuit.
What initially appeared to be a landmark decision occurred during the trial court phase of Ulane v. Eastern Airlines. Ulane, an Eastern Airlines pilot, fired after undergoing sex reassignment surgery, was reinstated with back pay by U.S. District Judge John Grady, who found Eastern guilty of sex discrimination. Judge Grady ruled that Ulane was fired not because of any legitimate safety reasons, but because Eastern officials were concerned about the image of having a transsexual flying their planes. Grady attacked Eastern's "ostrich-like" motives, comparing the airline's position to that of opponents of civil-rights legislation. "Ignorance, prejudice, discrimination and hatred have throughout history been justified by, 'I don't know. We can't take a chance,'" he wrote. Grady ruled that Eastern's medical witnesses "are in my view contemptuous of transsexuals, with an intolerance and prejudice that's culpable." He then went on to reject Eastern's claims that Ulane, as a transsexual, was not entitled to protection under the federal Title VII law prohibiting sex discrimination. The decision, however, was overturned by the Seventh Circuit, with the Supreme Court denying certiorari. In handing down its decision, the Seventh Circuit wrote: "Ulane is entitled to any personal belief about her sexual identity she desires. After the surgery, hormones, appearance changes, and a new Illinois birth certificate and FAA pilot's certificate, it may be that society, as the trial judge found, considers Ulane to be female. But even if one believes that a woman can be so easily created from what remains of a man, that does not decide this case."
Current case law clearly indicates that transsexuals cannot bring suit under Title VII. However, a recent case involving the U.S. Postal Service, has opened the door to possible claims and protection under the Rehabilitation Act of 1973.
In Doe v. United States Postal Service, the court found that Doe had: (1) failed to state a claim under Title VII, (2) succeeded in her claim based on denial of equal protection, since no court has held either that all governmental discrimination against transsexuals rationally based or that it is somehow outside the scope of equal protection, insofar as applicants for U. S. Government employment are entitled to protection against arbitrary or discriminatory treatment, (3) succeeded in her claim under the Rehabilitation Act of 1973, in that her transsexualism is an impairment that substantially limited at least her major life activity of working.

There are few alternatives for transsexuals who find themselves incarcerated. The right to treatment in the area of mental health has been given such unconstitutional underpinning that during an involuntary civil commitment the right requires adequate treatment or release. Prison officials are charged with the protection and safety of the inmates in their care and with seeing to the inmate's physical and mental health. Thus, the preoperative transsexual, who has been receiving medical treatment for his or her transsexualism prior to incarceration, may have grounds for continued treatment. On the other hand, the individual who has not been diagnosed and treated for their transsexualism prior to incarceration is at the mercy of prison authorities and associated medical personnel as to whether he or she will have an opportunity to be diagnosed and treated.
Prisoners are normally admitted to prison facilities in accordance with their physical anatomy at the time of incarceration. Thus, the untreated preoperative male-to-female is assigned to the men's facility, and the untreated preoperative female-to-male is assigned to the women's facility.
The decision of which facility to assign a preoperative transsexual in mid- transition is complicated. There are few administrative decisions or case law to rely on. Common sense, however, should tell the transsexual facing incarceration that it is impossible to undergo hormone therapy and visibly feminize or masculinize one's body while institutionalized without problems. The physical changes associated with hormonal sex reassignment have caused serious problems in relations with both prison staff and other inmates.
The news media has carried a number of articles concerning preoperative transsexuals incarcerated at mid-transition. Each of these stories has detailed sexual abuse, beatings by both inmates and prison guards, extended solitary confinements. For example, in Farmer, district Judge William Nealon dismissed a transsexual inmates civil rights suit against the Federal Bureau of Prisons because it lacked merit.
The inmate, identified only as Farmer, a diagnosed transsexual serving a sentence for theft and forgery, claimed FCI Lewisburg officials were deliberately indifferent to [her] serious medical condition by refusing to continue [her] estrogen treatment, subjected [her] to cruel and unusual punishment and violated [her] rights to due process and equal protection by isolating [her] in administrative detention during [her] Lewisburg stay.
In denying Farmer the medication Premarin, a brand of conjugated estrogens, based on informed medical opinion and not an indifference to [her] medical needs, Judge Nealon stated the court would not second-guess three doctors who agreed the proper treatment for people "who feel that nature has assigned them the wrong sexual characteristics remains firmly in the providence of psychotherapy, not in hormonal or surgical manipulation."
On the other hand, the Supreme Court has refused to review a ruling by the 7th U.S. Circuit Court of Appeals, which ordered a lower court to take up Lavarita Meriwether's suit against Indiana prison officials.
Meriwether, 28, a preoperative transsexual, alleged in her complaint, filed in 1983, that she has been denied all treatment, including estrogen therapy for her gender dysphoria, that she has been the victim of violence and sexual assault while housed in the general prison population, and that she had been segregated for up to five months while being sexually and emotionally abused by guards.
U. S. District Judge James E. Noland threw out Meriwether's suit, ruling that no "serious" medical need was involved. His decision was reversed and the suit reinstated by the 7th U. S. Circuit Court of Appeals. The Appellate Court, in sending the case back for further review, found evidence of deliberate indifference to the medical needs of Meriwether, and that she has a right to some kind of medical treatment, but stressed "it might not take the form of estrogen therapy." Under similar circumstances, U.S. District Judge Raul Ramirez, granted a preliminary injunction to Anna Marie Mostyn, a preoperative transsexual, stating that "although prison officials classified her as a man, because the sex change has not been completed, evidence is overwhelming in every respect that Mostyn has predominantly female characteristics and is a true transsexual."
Judge Ramirez ordered that she be kept out of the general male population of any prison, and that medical treatment be continued because the inmate "could have severe psychological effects" if they were stopped. He refused, however, to grant her request to be allowed to wear feminine clothing and cosmetics while in prison.
The course of action, therefore, for the preoperative transsexual undergoing treatment should be quite obvious--avoid compromising situations which could lead to incarceration.

Divorce Individuals who have entered into marriage and are later diagnosed as gender- conflicted should seek legal assistance if they decide to pursue sex reassignment surgery. This is especially important when children are involved, should the transsexual parent desire to maintain custody and/or visitation.
With the exception of perhaps the Randall, In Re Welfare of N. H. and In Re Custody of T. J. cases, discussed in the preceding section, parental custody and/or visitation rights have generally been denied the gender-conflicted parent; the Daly decision being typical of the many uncited custody/visitation rights battles.
Divorce is traumatic enough on children. The situation is complicated even further when one parent is sufficiently gender-conflicted to seek sex reassignment, and the other parent is hostile, seeking to deny parental rights to the other altogether. The real losers are the children of such a union/custody and visitation rights battle.
Love sometimes means letting go . . . particularly when the long-term emotional health of the children are at stake. The gender-conflicted parent, faced with a hostile spouse in a divorce action, should consider very carefully the long-term effects on their children of a prolonged custody battle.
Finally, it should be noted that few physicians will provide hormone therapy, and even fewer surgeons will perform sex reassignment surgery prior to a divorce action being completed because of the threat of a malpractice suit by the gender-conflicted's spouse. Marriage
Marriages between gender-conflicted and non-gender-conflicted fall into three categories: (1) Marriages between two persons of the same sex (preoperative marriage); (2) Marriages between a person of one sex and a person of the opposite sex who was formerly of the same sex (postoperative marriage); and (3) marriages between two persons of the opposite sex, one of whom subsequently became a member of the same sex.
Preoperative Marriage: Marriage contracted by preoperative gender-conflicted individuals are clearly considered invalid: the law making no provision for a marriage between persons of the same sex. The reported cases have unanimously rejected claims by parties involved in same sex marriages.
In Baker v. Nelson, the Minnesota Supreme Court denied efforts by two males to obtain a marriage license, reasoning in part that "[t]he institution of marriage as a union of man and woman, uniquely involving procreation and rearing of children within a family, is as old as the book of Genesis." Further, the Court ruled that such denial did not violate the plaintiffs' First amendment right to freedom of religion, their Eighth amendment right not to be cruelly and unusually punished, their Ninth amendment right to privacy, nor their Fourteenth amendment right to equal protection and due process. The same issues were subsequently raised and rejected by other courts in Jones v. Hallihan and Singer v. Hara.
In Anonymous v. Anonymous, a marriage contract was entered into by two males, one of whom thought the other was female. Upon attempting to consummate the marriage, the unsuspecting male discovered the true sex of the other. Shortly thereafter he was transferred overseas. In the meantime, the second male underwent sex reassignment. The first male sued for a declaration as to the status of the marriage. The New York Supreme Court declared that the marriage ceremony had not in fact created a valid marriage, noting that "[w]hat happened to the [second male] after the marriage ceremony is irrelevant, since the parties never lived together."
Postoperative Marriage: The issue of whether a marriage is legal when one of the parties has changed his or her when one of the parties has changed his or her sex before the marriage ceremony appears to present more of a problem for the courts. The validity of a postoperative marriage hinges on many factors, as do all marriages; for example, fraud and absence of consummation.
Early case law (pre-1975) clearly considered all transsexual marriages to be invalid. In Francis B. v. Mark B., the husband had undergone operations for mastectomy and hysterectomy, and was undergoing hormonal therapy at the time of the marriage. During attempted consummation the wife discovered that the husband was without a penis and could not perform sexually. The wife brought suit for an annulment on the ground that the husband was a female, wherein the husband brought a cross-suit for divorce. The court ruled that the husband could not succeed on a suit for divorce because there had been no valid marriage to begin with. "While the inability to consummate the marriage would have been enough to justify the annulment, the defendant was in fact a woman," thus invalidating the marriage.
On the other hand, in M. T. v. J. T., the New Jersey Appellate Division unanimously declared in 1976 that an individual who changes sex through surgery is entitled to all the legal rights enjoyed by others of the same sex, including marriage. The court rejected previous decisions in this country and abroad, in which a person's sex was determined solely by his or her chromosomes or designated sex at birth. The court ruled that "[i]f the anatomical or genital features of a genuine transsexual are made to conform to the person's gender, psyche, or psychological sex, then identity must be governed by the congruence of these standards." Therefore, at least in New Jersey, a marriage between a postoperative transsexual and a person of the opposite sex is valid as long as the transsexual tells the partner in advance about his or her sex reassignment.
The controversy continues, however. In In re Ladrach, reported upon by Jan Elliot, a postoperative male-to-female transsexual sought to marry a genetic male. Noting [incorrectly] that only Arizona, Louisiana, and Illinois statutorily permit changing sex on a birth certificate, although another twelve permit such change without statute, the court held that it could not alter the birth certificate of the transsexual without statutory authority and accordingly the transsexual could not lawfully marry a man.

Judicial Response
A search for cases involving transsexuals and health insurance related issues was conducted in May, 1988, utilizing both LEXIS and WESTLAW. The search produced less than a dozen cases despite the fact there are clear indications that more have come to trial. The majority are either settled out of court or never go beyond the trial court level.
One fact became increasingly clear during the above case search; that is the inability of the American judicial system to keep pace with scientific and medical advances of the past 30+ years. The judicial decisions rendered by the courts represent a broad-spectrum of societal concerns--i.e. Change of name, correction of birth certificates, criminal issues, civil rights, marriage, and health insurance. These decisions have been, in general, nothing more than a succession of confused and inconsistent legal pronouncements as the system attempts to reconcile medical and biological facts with legal and social concepts of sex and gender. The system's diverse opinions are aptly illustrated in Richards v. United States Tennis Ass'n and Ulane v. Eastern Airlines.
The first medical necessity case to come before the court was Denise R. v. Lavine. Denise R., a male-to-female transsexual, having lived fully as a female for 18 years, was denied medical assistance for sex reassignment surgery by the New York City and State Department of Social Services. Neither the City or the State questioned the diagnosis, but determined that there was insufficient evidence to find medical necessity.
The New York Appellate Court ruled in favor of plaintiff, holding the state commissioner's denial of services as arbitrary and capricious. On appeal, the Court of Appeals reversed the appellate court decision, concluding that "[w]here an administrator adopts one of several conflicting opinions," the court could not "assume the role of either social agency or legislative body."
On facts similar to those in Denise R., Doe, an adult male-to-female transsexual, appealed from a decision by the Minnesota State Welfare Department denying medical assistance benefits for sex reassignment surgery. The trial court affirmed the Welfare Department's decision; however, on appeal, the Minnesota Supreme Court reversed the decision. The Supreme Court held that: "(1) The total exclusion of transsexual surgery from eligibility for medical assistance payments was void; (2) The standard of medical necessity requiring applicant for benefits to prove by conclusive evidence that requested medical treatment will eliminate disability and render applicant self-supporting was invalid; and (3) The Welfare Department's determination to deny medical assistance benefits was arbitrary and unreasonable."