Most of us are perfectly comfortable with the fact that we are male or female. In fact we normally never give it a thought. But there are a very few people who feel they were born with the wrong body – men who feel they should have been born women and vice versa. These people suffer from a recognised medical condition known as gender dysphoria and are generally referred to as transsexual.
Because transsexual people are born with bodies that seem perfectly normal to other people, we may suspect that the source of these deep seated feelings about the body arises from the brain. A report from the Netherlands Institute for Brain Research confirms this theory. In examining the brains of many individuals, including homosexual men, heterosexual men and women and six male-to-female transsexuals, they found that a tiny region known as the central region of the bed nucleus of the stria terininalis (BSTc), which is believed to be responsible for gender identity, was larger in men than in women. The BSTc of the six transsexuals was as small as that of women, thus the brains of the transsexuals seem to coincide with their conviction that they are women.
The rate of occurrence of transsexuality is not accurately known. Because of the social stigma attached to being transsexual, arising from a widespread lack of awareness of the true nature of the condition, it is something that is often kept hidden. Therefore it is only possible to collect statistics on the numbers of declared transsexuals and such figures undoubtedly represent only a proportion of those affected. Not very long ago estimates of the rate of occurrence of male-to-female transsexuality might have been around 1 in 100,000 of the male population. Today, with the greater awareness and openness that exists, some estimates now put the figure at greater than 1 in 10,000. It is known that other chromosomal or intersexed conditions can have rates of occurrence of, or approaching, 1 in 1,000 of the population and it may well be that this is the true order of magnitude of transsexuality.
Rates of occurrence of known female-to-male transsexuals are significantly lower, typically being around 1/3 to 1/4 of the rate for male-to-female transsexuals. However, this rate has varied somewhat with time and between different parts of the world. This suggests that varying cultural factors might play a role in the decision to be open about the condition.
The currently accepted and effective model of treatment for the condition of transsexuality utilises hormone therapy and surgical reconstruction and may include counselling and other psychotherapeutic approaches. Speech therapy and facial surgery may be appropriate for some male to females, and most will need electrolysis to remove beard growth and other body hair. In all cases, the length and kind of treatment provided will depend on the individual needs of the patient. The male to female will take a course of female hormones (oestrogen) similar to those used in the contraceptive pill and HRT, the female to male will take the male hormone testosterone.
At this time they will also be required to carry out the Real Life Test, during which they will be required to legally change their name and all documents to show their new gender identity. All documents including passport, driving licence, medical card, etc can be changed, but at present it is not possible for UK citizens to change their birth certificate. During the Real Life Test they will also be expected to live, work and socialise full time in the new gender role, to deal with any problems which may arise for example at work or within the family, and generally become familiar with the reality of living this way. After a minimum of a year (two years if being treated via the NHS) if the Real Life Test has been successful and the psychiatrist is satisfied with the person’s progress, they can be referred for surgery. After surgery the person will continue to take hormones for the rest of their life, but probably at a reduced dosage.
Because the BSTc is so small none of the non-invasive imaging techniques currently available can measure it, it cannot be detected through scans, X-rays of blood tests. Diagnosis is carried out through lengthy and in-depth assessment by a specialist consultant psychiatrist, however it is important to understand that gender dysphoria is not a psychiatric condition, nor is it a mental disorder.
In a male to female transsexual person, the effects of feminising hormones vary greatly from patient to patient but most patients experience noticeable changes within 2-3 months, with irreversible effects after as little as 6 months.
The main effects of feminising hormones are as follows:
1) Fertility and ‘male’ sex drive drop rapidly, erections become infrequent or unobtainable and this may become permanent after a few months.
2) Breasts develop, the nipples expand and the areolae darken to some extent, but typical final breast size is usually somewhat smaller than that of close female relatives.
3) Body and facial fat is redistributed. The face becomes more typically feminine, with fuller cheeks and less angularity. In the longer term, fat tends to migrate away from the waist and be re-deposited at the hips and buttocks, giving a more feminine figure.
4) Body hair growth often reduces and body hair may lighten in both texture and colour. There is seldom any major effect on facial hair, although if the patient is undergoing electrolysis, hormone treatment does noticeably reduce the strength and amount of re-growth. Scalp hair often improves in texture and thickness, and male pattern baldness generally stops progressing.
5) Many people report sensory and emotional changes: heightened senses of touch and smell are common, along with generally feeling more ’emotional’. Mood swings are common for a while following commencement of hormone therapy or any change in the regime.
In the female to male transsexual, where biological females are prescribed androgens, changes include:
1) A permanent deepening of the voice, this usually occurs within four months and is irreversible.
2) Permanent clitoral enlargement occurs.
3) Some breast atrophy, but at this stage it is usual to bind the breasts.
4) There is cessation of menstruation within three to six months
5) Increased strength and weight gain particularly around the waist and upper body with decreased hip fat. With exercise this can take the form of muscular development. Testosterone will not alter height or bone structure.
6) Growth of facial and body hair is likely to follow the pattern of hair growth inherent in the family, for example if other male members of the patient’s family have a tendency to baldness or if they do not have a great deal of body hair this is what can be expected with hormone treatment.
7) Increased social and sexual interest and arousability may occur and there may also be heightened feelings of aggression.
The most frequent form of surgery for male to female patients is known as penile inversion. When carried out by a skilled and experienced gender surgeon the results look almost indistinguishable from the external genitals of a natal woman. The transsexual women, however, does not have ovaries and a womb, is not able to conceive and does not have monthly periods. During the operation tissue and skin from the penis and scrotum is relocated to form a vagina and clitoris. Following surgery the patient will need to keep the newly formed vagina from closing up by performing regular dilation.
In the female to male, surgery is often carried out in stages, and the first stage is usually removal of the breasts with a bilateral mastectomy during which the nipples are preserved but may need to be reduced in size. The next stage is usually hysterectomy and oophorectomy to remove uterus and ovaries. Both these stages are commonly performed operations and can be carried out by any competent surgeon who does not necessarily need experience of gender reassignment surgery. Further stages are more specialised and involve metaidoioplasty for construction of a microphallus by surgically releasing the enlarged clitoris, or possibly phalloplasty which is construction of a penis. There are various techniques in use for phalloplasty, but as yet there is no method which can produce a totally realistic and fully functioning penis. Scrotoplasty may be carried out at the same time, or separately, to create a scrotum from the labia and silicone implants.
There is no evidence of any genetic link to the condition of gender dysphoria and therefore it is not something that is known to be passed down through generations of the same family. Nobody knows exactly what causes the condition, although there are various theories that consider a possible link between hormone disturbance in the mother during the first weeks of pregnancy or other interruptions to the normal course of pregnancy while the foetus is at a critical point of development.Is this Person a Man or a Woman?
In this example let us look at the male to female transsexual person. Gender dysphoria occurs when the person believes themselves to be a woman, their brain knows them to be a woman, even though their physical body may be that of a man. The only ‘cure’ for gender dysphoria is to change the body to match the brain. Therefore after surgery both brain and body are those of a woman. This person is in all respects a woman, even her passport will show this. It is therefore extremely painful for such a person to be addressed as ‘him’ or ‘Mr’. Having gone through so much to find a sense of inner peace in their true gender role, they should rightly expect to be treated as the woman they know themselves to be.
Even after hormone treatment and surgery, a transsexual male to female, may still retain certain male physical characteristics. These may include a voice that is unusually deep for a woman, or they may be very tall, or have large, hands and feet and heavy bones, particularly in the jaw and brow area of the face. They may have a receding hairline and need to wear a wig. When you meet this person for the first time you may feel shocked, uncomfortable or uncertain how to treat them. Hopefully you will understand that this is a medical condition for which the person is receiving treatment from highly qualified doctors and consultants, that they have been carefully assessed and diagnosed, and in many cases their treatment has been carried out under the National Health Service. If you think of it in this way you will find it easier to accept that this is a genuine and serious situation. If you are willing to accept this person for who they are, you will be helping them to adjust to a very difficult life challenge, and you may find you are making a very good and loyal friend.
What is the Difference Between Transvestite and Transsexual?
The differences are very distinct between a person who cross dresses and someone whose brain is telling them they belong to the opposite gender role. The transvestite may just cross dress occasionally, or may enjoy dressing regularly either in the privacy of their own home or to socialise. Some live full time in female clothes, but they always retain their core identity of themselves as male and will not want to consider gender surgery. Generally TVs who are “out” are sociable and may attract a lot of attention, they may enjoy wearing outrageous or fetish outfits and spend a lot of time involved with their clothes and appearance. It has often been observed that TVs tend to be heterosexual males while drag queens and female impersonators are often gay men. Although transsexual people are often very concerned about their dress and appearance, this is not the driving force behind their cross dressing. For the transsexual person clothes are an expression of their core female identity and many strive to blend in by studying how women of their age and background dress and learning how to tailor their appearance and mannerisms to attract as little attention as possible.
The above is a general guideline, but this is far from being a black and white issue and most cross dressers would place themselves somewhere on a gradient between the outrageous female impersonator at one extreme and the totally integrated post operative transsexual at the other. Many people who later go on to complete full gender reassignment begin the search for their true identity within the transvestite community, perhaps this is the only obvious and safe place where they feel they can cross dress. Also there are very few social groups where transsexual people meet, so those who enjoy socialising may be attracted to transvestite clubs. Many individuals feel very confused about their true gender identity, so how can an outsider be expected to judge whether a person is TV or TS when that person themselves does not know – or cannot accept – where their true identity lies and is therefore not giving out any clear signals about themself.
Long before they begin medical treatment, in fact often long before they even realise what is happening within them, most transsexual people will already show signs of thinking and behaving in ways more usual to the sex opposite to that of their physical appearance. They will frequently recall knowing from childhood that they were in some way “different” and it is usual for a transsexual woman to remember dressing in the clothes of a mother or sister, having a dislike for traditional boys’ toys and games, and feeling more comfortable in the company of girls.
Because of social pressures, particularly on young men, many transsexual people enter a period of denial in their late teens, in which they try to suppress any thoughts or feelings to do with their gender identity. For example it is common for a male to female to take up a typically male profession such as the armed forces, police, engineering, lorry driving, and also to marry and have children. They tell themselves that this proves they cannot possibly be a woman. At this time of their life they may also absorb themselves totally in a career – often becoming very successful – or in some form of sport or hobby which occupies all their spare time. Some may continue to cross dress.
But in time the stress begins to build until the person no longer feels able to keep this thing hidden and they need to seek help and medical treatment. When the gender dysphoria has been suppressed in this way for many years, the person may have developed other problems such as severe depression or a dependence on alcohol or drugs, and this will also need to be dealt with, along with any commitments to family responsibilities. There may be a break with wife, children and siblings, a change of career, loss of home, money and security, so the road to gender transition is an extremely difficult and often painful one.
Transsexual people often reveal themselves to be extremely isolated individuals, some people never make it through transition. Those who do have to find a lot of inner strength and determination to keep going. During transition these people need the support and understanding of friends and family as well as work colleagues and society in general. After surgery it is common for many people to melt away into society, living a normal life and often nobody guesses what they have been through. However the scars created by the pain of living with gender dysphoria for many years may remain and make it difficult for them to settle into an ordinary lifestyle.
Transsexual people are just ordinary people who experience all the challenges and problems that everyone has to deal with. Some are optimistic and cheerful, some slip easily into depression, some are determined, some are fragile, some make friends easily, some find socialising difficult. They are people like everyone else – they also suffer from a condition called gender dysphoria.
Understand what is happening, and accept the person for who they truly are – this is often all a transsexual person wants from you. Try to offer encouragement and support. Imagine how you would feel if it was you – take a moment to try and imagine how you would feel if you woke up tomorrow morning to find your body had become the opposite gender.
After all it could easily have been you who was born with this medical condition, nobody knows exactly what causes it but the dysphoria is believed to occur in an unborn baby during the first three months of the mother’s pregnancy. Someone who has already been through so much does not need to be victimised and taunted, humorous remarks, clever comments and other subtle ways of intimidation can cause intense pain. Also remember it is now against the law to discriminate against someone because they are transsexual.
Gender Trust – 2003