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Transsexualism is a condition in which a transsexual person self-identifies as a member of the gender opposite to the one assigned to them at birth. Transsexual people are stereotypically described as "women trapped in male bodies" or vice versa, although some members of the transsexual community, as well as some people outside the community, reject this model. [1]

Transsexualism often manifests itself as an agonizing dysphoria toward one's biological birth sex, as well as difficulty or inability living in its social role. If untreated, it can lead to mental and emotional problems, and sometimes, suicide. Dutch researcher Peggy Cohen-Kettenis estimates that 40% of untreated transsexual people are either institutionalized or die prematurely. However, with proper treatment, transsexual people often become fully functional members of society. [2] The suicide statistics of treated transsexual people (Cohen-Kettenis et al, 1988) do not remarkably differ from non-transsexual populations.

Most transsexual men and women desire to establish a permanent social role as a member of the gender with which they identify. Many transsexual people also desire various types of medical alterations to their bodies. These physical alterations are collectively referred to as sex reassignment therapy and often include hormones and sex reassignment surgery. The entire process of switching from one physical and social gender presentation to the other is often referred to as transition, and usually takes several years.

To obtain sex reassignment therapy, transsexual people are usually required to receive psychological therapy and a diagnosis of gender identity disorder. They must also live as members of their target sex for a period of time, known as the Real-life test, prior to surgery, and meet other requirements specified by protocols known as Standards of Care. These requirements are intended to prevent those individuals who are not genuinely transsexual from transitioning and later regretting doing so; however, they are often criticized as being either ineffective or too strict - while their intention is to prevent "pseudo-transsexual" people from transitioning, they have been claimed to discourage genuine transsexual people from seeking treatment. By most estimates, less than 1% of people who transition ever regret doing so. [3]

Currently, the causes of transsexualism are unknown, and estimates of prevalence vary substantially. One prominent theory suggests that transsexualism is a neurobiological condition which manifests itself as gender dysphoria and in a brain structure known as the Bed nucleus of Stria Terminalis (BSTc).

Definitions

Transsexualism (also known as transsexuality) is a complex condition that is defined differently by different people. Many terms have been proposed through the years to describe transsexual people and the processes they go through. Some of these terms are controversial, among the transsexual community as well as society at large.

Defining transsexualism

The definition of "transsexual" is debated. Many within the trans community feel that a person is transsexual if they personally identify as such. However, some, especially health care providers and some transsexual people, believe there is a certain set of procedures that must always be completed for a person to be called "transsexual". The general public often defines "a transsexual" as someone who has had or plans to have "sex change" surgery, although this term is considered inaccurate by many people who believe that sex cannot really be changed. Additionally, many transsexual people consider "sex change" rude and prefer "sex reassignment" or "gender reassignment" instead. The term currently in widest use for modification of primary sex characteristics is sex reassignment surgery (SRS), a term which reflects the belief that transsexual people do not consider themselves to be changing their sex, but to be correcting their bodies. However, some feel that the term "sex change" is appropriate and that it stresses that transsexual people are not castrated members of their original sex. [4]. In the UK, gender reassignment surgery (GRS) is a prevalent term, but many prefer gender affirmation surgery to be more correct.

It is accepted in the Diagnostic and Statistical Manual of Mental Disorders that expression of desire to be of the opposite sex, or assertion that one is of the sex opposite to the one with which they were identified at birth, constitutes being transsexual. [5] The ICD-10 also states that transsexualism is defined by "the desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment." In contrast, some transgender people often do not identify as being of or desiring to be the opposite sex, but as being of or wanting to be another gender.

Transsexualism has been described as a trait, disease, behavior, desire, mental illness, perversion, paraphilia, political identity, and sin, among other things. Some of these labels are considered offensive by many transsexual people, who usually define their condition as a trait, desire, political identity, or as a medical condition which does not constitute a "disease".

Transsexualism falls under the broader term transgender, which is generally considered an umbrella term for people who do not conform to typical gender roles. However, some in the transsexual community do not identify as transgender, or see transsexualism not as a sub-division of transgender. Some transsexual people find this term insulting as they feel they should not be placed in the same category as transvestites. Often, those people complain that non-transsexual transgender people are somehow "degrading" transsexual people by first describing them as "just tranvestites" (this refers to the assumption, that gender variant people can neatly be divided into "transsexuals" and "transvestites") or "perverts" or similar, and then claiming that this is not what transsexual people are. This is usually accompanied by demanding that medical treatment and legal change of name and legal gender should be reserved only for transsexual people. Some also see the term 'transgender' as subsuming and erasing their identity, rejecting it for themselves because to them it implies a breaking down of gender roles, when in fact they see themselves as fitting a gender role -- just not the one they were assigned at birth. Those contesting this view point out that the idea of a more inclusive "Gender identity disorder" has long replaced the idea of dividing gender variant people into "transsexuals" and "transvestites", that classifying transsexualism as a sub-division of transgender does not automatically erase any transsexual identity, that not all transgender people wish to break down gender barriers, and that any marginalized group trying to gain acceptance of those opposed to them by trying to oppress another group has not only never been successful, it is also ethically questionable according to certain individuals and faiths.

Transsexualism should not be confused with cross dressing or with the behaviour of drag queens, which can be described as transgender, but usually not transsexual. Also, transvestic fetishism usually has little, if anything, to do with transsexualism. Many transsexual people dress conservatively and modestly, whereas most drag queens and crossdressers dress in a more flamboyant manner.

Gender terminology for transsexual people

Transsexual people are usually referred to by the gender pronouns and terms associated with their target gender. For example, a transsexual man is a person who was identified as female at birth on the basis of his genitals, but who identifies as a man and is transitioning or has transitioned to a male gender role and has or will have a masculine body. Transsexual people are sometimes referred to with "assigned-to-target" gender terms such as "female-to-male" for a transsexual man or "male-to-female" for a transsexual woman. These terms may be abbreviated as "M2F", "F2M", "MTF", "F to M", etc. These terms help to prevent confusion, as some people are oblivious as to whether a "transsexual woman" is a female transitioning to become a male or a male transitioning to become a female. Transsexual men and women are also sometimes referred to as transmen and transwomen.

Transsexual people are often construed as belonging to the LGBT community, and many identify with the community; others do not, or prefer not to use the terms. It should be noted that transsexualism is not associated with or dependent on sexual orientation. Transsexual men and women exhibit a range of sexual orientations just as non-transsexual (cissexual) people do. They almost always use terms for their sexual orientation that relate to their target gender. For example, someone assigned to the male gender at birth but who identifies as a woman, and who is attracted solely to men, will identify as heterosexual, not gay; likewise, someone who was assigned female sex at birth, identifies as a man, and prefers male partners will identify as gay, not heterosexual. Transsexual people, like other people, can be bisexual or asexual as well.

Older medical texts often referred to transpeople as members of their original sex; in other words referring to a male-to-female transsexual as a "male transsexual". They also described sexual orientation in relation to the person's assigned sex, not their gender of identity; in other words, referring to a male-to-female transsexual who is attracted to men as a "homosexual male transsexual." This dwindling usage is considered by many to be scientifically inaccurate and clinically insensitive today, and such a person would now be called and most likely identify herself as a heterosexual transwoman. Some medical textbooks still refer to transsexual people as members of their assigned sex, but many now use "assigned-to-target" terms.

A number of people outside the transsexual community still refer to transsexual people with terms associated with their birth sex (for example calling a male-to-female transsexual "him"). This usage, generally considered insensitive or insultive (especially if intentional), has been (though not exclusively) based on biological arguments such as the unchanged karyotype, which is usually consistent with the sex assigned to the person at birth, or the absence of reproductive capability after transition and sex reassignment surgery. Arguments for this usage have also been based on religious dogma. Conservative groups such as the Traditional Values Coalition are among those to refer to transsexual people as members of their original sex.

Alternative terminology

Among the transsexual community, the short form trans is sometimes used, e.g. TS, trans guy, trans dyke, T-folk, trans folk. Some use the controversial terms tranny and/or trans, though others consider these terms to be offensive. Those who use these terms claim that they are diminishing the power of the term as an insult. Others feel that the terms are insulting or inaccurate regardless of the context. Some feel that such words are problematic because they do not differentiate between "true transsexual people", and people who are merely "playing" with gender.

Some people prefer to spell transexual with one s, in an attempt to divorce the word from the realm of psychiatry and medicine and place it in the realm of identity, but this trend is most common in the United States and, for example, is almost never used in the United Kingdom. [6] Some consider this usage to be silly and/or incorrect.

Some prefer the term transsexed over transsexual, as they believe the term sexual found in transsexual is misleading and implies that transsexualism is a sexual orientation. Another justification made for this preference is that they feel it is more in line with the term intersex, as more transsexual groups are welcoming them because they feel both groups have much in common. It is, by some definitions, possible to be both intersexed and transsexed. Other attempts to avoid the misleading -sexual have been the increasing acceptance of transgender or trans* and in some areas, transidentity.

Some transsexual people also prefer transgendered over transsexual, because the issue is about gender rather than sexuality. They make a parallel with intergender, whose issue is about being inter (in-between) the genders rather than "intersexual". It is often assumed, particularly by transsexual people, that transsexualism is simply a subset of intersex. "Intersex" previously referred only to those who are genitally intersexed, i.e., with genitals that don't look classically male or female (in spite of the fact that human genitals show an extremely wide variation in general). However, since sex in humans is composed of many different attributes, such as genes, chromosomes, regulatory proteins, hormones, hormone receptors, body morphology, brain sex, and gender identity, any variation among any of those attributes falls under the rubric of "intersex." Transsexualism, in this view, simply becomes neurological intersexuality. (See below for research of physiological causes of transsexualism).

Some people prefer that transsexualism be referred to as Benjamin's syndrome, as it follows the naming conventions of other intersex conditions. [7] This term is named for Harry Benjamin, a pioneer in sex reassignment and research on transsexual people. Many transsexual people who prefer this term argue that scientific research has strongly suggested that their condition is biological rather than psychological in nature. They also feel that 'trans' is misleading, as they believe that their gender was fixed in their brains at birth and that it never changes.

Others object to being referred to as transgender because they feel this links to to other behaviors that they have no connection with. Also, they will point out that they are not changing their gender, which most transsexual people do not consider to be possible. Nor do they feel that they are transcending or transgressing gender but are simply expressing the gender they were born as.

Some people feel that both 'trans' and 'sexual', are misleading. Many feel that people will assume that transsexualism is related to sexual behavior because it contains 'sexual'. A large variety of other terms exist, though almost all of them are somewhat controversial.

Prevalence

There are no reliable statistics on the prevalence of transsexualism. According to the DSM-IV, statistics from smaller European countries have suggested that roughly 1 in 30,000 physical males and 1 in 100,000 physical females seek sex reassignment surgery. [8]. However, it is commonly suggested that many transsexual people do not seek SRS and therefore are not reflected in the statistics. The DSM itself states that no recent epidemiological studies on transsexualism are available. Lynn Conway has suggested that transsexualism is much more prevalent, that 1 in 2500 physical males in the United States has undergone SRS since the 1960s, and that perhaps 1 in 500 individuals experiences gender dysphoria. [9]. The Dutch estimates (Cohen-Kettenis et al, 1988) suggest that the frequency is 1 in 12,000 and is equally common amongst physical males and females, though females seek treatment less often.

Causes of transsexualism

Main article: Etiology of Transsexualism

There is no scientifically proven cause of transsexualism. For many years, many medical and psychological professionals, and the public, assumed that transsexualism was caused by psychological or emotional factors. However, most psychological models of transsexualism could not be successfully applied to significant numbers of transsexual people, and attempts to "cure" the transsexual condition through psychological or psychiatric means were usually ineffective. In recent years, theories have been presented which suggest that the cause of transsexualism has its roots in biology. Because of this, much of the medical profession has slowly come to view transsexualism as a physiological issue, rather than a psychological one. However, at this time (2006), physiological causes of transsexualism have not yet been proven.

Some transsexual people and professionals feel that research into causes of transsexualism assumes a priori the legitimacy of a normative gender identity, and/or that transsexualism is a disease, which they feel is stigmatizing. They usually consider such research to be unnecessary, and possibly causing more harm than good for transsexual people.

Sex reassignment therapy

Most transsexual men and women suffer from psychological and emotional pain due to the conflict between their gender identity and their original gender role and anatomy. They often find that their only recourse is to change their gender role and undergo sex reassignment therapy. This may include hormone therapy to modify their secondary sex characteristics and/or sex reassignment surgery to alter their primary sex characteristics.

Psychological treatment

Psychological techniques that attempt to alter gender identity to one considered appropriate for the person's assigned sex have been shown to be ineffective, as stated above. Therefore, it is generally accepted that the only effective course of treatment for transsexual people is sex reassignment therapy.

The need for physical treatment is emphasized by the high rate of mental health problems, including depression, anxiety, and various addictions, as well as a much higher suicide rate among untreated transsexual people than in the general population. [10] Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role and physical characteristics. [11]

Many transgender and transsexual activists, and many caregivers, point out that these problems usually are not related to the gender identity issues themselves, but to problems that arise from dealing with those issues and social problems related to them. Also, many feel that those problems are much more likely to be diagnosed in transsexual people than in the general population, because transsexual people are usually required to visit a mental health professional to obtain approval for hormones and sex reassignment surgery. These professionals routinely evaluate their patients for mental health problems.

A growing number of transsexual people are resenting or even refusing psychological treatment which is mandated by the Harry Benjamin Standards of Care, because they believe that gender dysphoria itself is untreatable by psychological means, and that they have no other problems that need treatment. This can cause them significant problems when they attempt to obtain physical treatment.

Therapists' records reveal that many transsexual people do not believe they need psychological counseling, but acquiesce to legal and medical demands in order to gain rights which are granted through the medical/psychological hierarchy. (Brown 103) Legal needs such as a change of sex on legal documents, and medical needs, such as sex reassignment surgery, are usually impossible to obtain without a doctor's and/or therapist's approval. Because of this, many transsexual people feel coerced into confirming pre-ordained symptoms of self-loathing, impotence, and sexual-preference, in order to see simple legal and medical hurdles overcome. (Brown 107) Transsexual people who do not submit to this medical hierarchy likely face the option of remaining invisible, with no legal rights and possibly, identification documents incongruent with gender presentation.

Diagnosing transsexualism

Transsexual people who present themselves for psychological treatment are usually diagnosed with gender identity disorder; the diagnosis of "transsexualism" having fallen out of favour in recent years. This diagnostic label is often necessary to obtain sex reassignment therapy. However, some people diagnosed with gender identity disorder have no desire for sex reassignment therapy, particularly not genital reassignment surgery, and/or are not appropriate candidates for such treatment. While some feel that formal diagnosis helps to destigmatize transsexualism, others feel that it adds stigma. (Brown 105)

Some people who desire sex reassignment therapy do not have gender identity disorder, as the term is usually defined, and desire to transition for other reasons. This includes homosexual people who are unable to accept their homosexuality (or which were, up until the 1970s, encouraged by caretakers to change their gender role, including SRS), cross-dressers who feel more comfortable dressed as members of the opposite gender and may become confused (although many transsexual women do go through a phase where they identify as cross-dressers), and people with certain psychiatric disorders, such as schizophrenia, borderline personality disorder, dissociative identity disorder, and Munchausen syndrome. (Brown 106-107) Most professionals believe that sex reassignment therapy is not appropriate for such individuals. (Brown 107) If SRS is performed in such cases, the result is usually expected to be very negative for the individual, since it, unlike with patients with GID, does not help them, but leaves them with a body undesirable to them. [12].

However, some transsexual people suffer from co-morbid psychiatric conditions unrelated to their gender dysphoria. The DSM-IV itself states that in rare instances, gender identity disorder may co-exist with schizophrenia. Psychiatric disorders generally are not considered contraindications to sex reassignment therapy, unless they are the primary cause of the patient's gender dysphoria. (Brown 108) However, the process of psychological treatment is usually much more complicated for transsexual people with co-morbid psychiatric conditions.

Some transsexual people have pressured the American Psychiatric Association to remove Gender Identity Disorder from the DSM. Many of these people feel that mental health professionals are being insensitive by labeling transsexualism as "a disease", rather than as a trait. [13] Furthermore, many people feel that psychologists and psychiatrists have developed specific models of transsexualism which exclude many transsexual people, such as Ray Blanchard's model. Some who feel that transsexualism is a physical rather than a mental condition have proposed the diagnosis of Benjamin's Syndrome to replace GID. Andrea James has proposed the terms interest in feminization and interest in masculinization to refer to desire for sex reassignment therapy, regardless of whether the person with the desire is transsexual. [14] Some people believe that all forms of body modification, including sex reassignment therapy, should be offered on demand. (Brown 103) However, some who feel that transsexualism is an inborn trait believe that defining it as an "interest" places emphasis on the hypothesis that transsexualism is a "lifestyle choice".

Additionally, the rules or requirements for diagnosis are almost always determined by non-transsexual medical gatekeepers, who have the power to allow or deny a transsexual person's need to transition based on their own perceptions of how a transsexual person should act and/or appear, which are sometimes prejudiced or based largely on cultural stereotypes. For example, they may reject the hair of a transsexual man as being "too long", even though many non-transsexual men like to wear long hair.

Requirements for sex reassignment therapy

Main article: Standards of Care for Gender Identity Disorders

The requirements for hormone replacement therapy vary greatly. Often, a minimum time period of psychological counseling, or a time period spent living in the desired gender role is required. This time period of "cross-living" is usually known as the Real-Life-Test (RLT) or Real-Life-Experience (RLE). This is not always possible; transsexual men frequently cannot "pass" this period without hormones. Transsexual women may also require hormones to pass as women in society. Most transwomen also require facial hair removal, voice training or voice surgery, and sometimes, facial feminization surgery, to be passable as females; these treatments are usually provided upon request with no requirements for psychotherapy or "cross-living". The most recent revision of the HBIGDA Standards of Care recognizes this limitation for some transgender people. Therefore, the SOC state that patients may be approved for hormone treatment after either a period of successful cross-living or a period of diagnostic psychotherapy - generally at least three months. Some doctors are willing to prescribe hormones to any patient who requests them; however, most physicians are reluctant to do so, especially for transmen. In transmen, some hormonally-induced changes may become virtually irreversible within weeks, whereas transwomen usually have to take hormones for many months before any irreversible changes will result. Some transsexual men and women are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves.

Some surgeons who perform sex reassignment surgeries may require their patients to live as members of their target gender in as many ways as possible for a specified period of time, prior to any surgery. However, some surgeons recognize that this so-called real-life test for transmen, without breast removal and/or chest reconstruction, may be difficult. Therefore, many surgeons are willing to perform some or all elements of sex reassignment surgery without a real-life test. This is especially common amongst surgeons who practice in Asia. However, almost all surgeons practicing in North America and Europe who perform genital reassignment surgery require letters of approval from two psychotherapists; most Standards of Care recommend and most therapists require a one-year real-life test prior to genital reassignement surgery, though some therapists are willing to waive this requirement for certain patients. A recent study done on transwomen has shown that a real-life test of less than one year, or no real-life test at all, does not increase the likelihood that a patient will regret genital reassignment surgery. [15] Many transsexual people opt for a real-life experience longer than is officially required, to remove any doubts they may have of whether they should undergo surgery.

Hormone replacement therapy

Main article: Hormone replacement therapy (trans)

For transsexual men and women, hormone replacement therapy (HRT) causes the development of many of the secondary sexual characteristics of their desired gender. However, many of the existing primary and secondary sexual characteristics cannot be reversed by HRT. For example, breasts will grow in transsexual women but they will not regress in transsexual men. Facial hair will grow in transsexual men, but will not regress in transsexual women. However, some characteristics, such distribution of body fat and muscle, as well as menstruation in transsexual men, may be reversed by hormonal treatment. Generally, those traits that are easily reversible will also revert on cessation of hormonal treatment, unless chemical or surgical castration has occurred. For many transsexual people, surgery is required to obtain satisfactory physical characteristics.

Several health risks are associated with hormone replacement therapy, especially when higher doses are taken, as is common for pre-operative transsexual patients. Therefore, it is generally inadvisable for transsexual people to take hormones without a physician's supervision.

Some transsexual women use herbal phytoestrogens as alternatives to pharmaceutical estrogens. However, little research has been done on the safety or effectiveness of such products, and anecdotal evidence suggests that their effects, if noticeable at all, are very subtle when compared to conventional hormone therapy.

Sex reassignment surgery

Main article: Sex reassignment surgery

Sex reassignment surgery consists of procedures which transsexual women and men undergo in order to match their anatomical sex to their gender identity. While genital reassignment surgery (GRS) refers only to surgeries that correct genital anatomy, sex reassignment surgery (SRS) may refer to all surgical procedures undergone by transsexual patients.

SRS tends to be expensive and is not always covered by public or private health insurance. In many countries with comprehensive nationalized health care, such as Canada and most European countries, SRS is covered under these plans. However, requirements for obtaining SRS and other transsexual services under these plans are sometimes more stringent than the requirements laid out in the Harry Benjamin Standards of Care, and in Europe, many local Standards of Care exist. In other countries, such as the United States, no national health plan exists and the majority of private insurance companies do not cover SRS. There are also significant medical risks associated with SRS that should be considered by those who are contemplating the surgery.

Prior to surgery, transsexual men and women are often referred to as pre-operative (pre-op); those who have already had the surgery may be referred to as post-operative (post-op) or simply identified as members of the sex to which they have transitioned. Not all transsexual people undergo sexual reassignment surgery (either because of the high cost of such surgery, medical reasons, or other reasons), although they live constantly in their preferred gender role; these people are often called non-operative (non-op).

A more modern idea suggests that the focus on surgery status is misplaced, and therefore, an increasing number of people are refusing to define themselves in terms of operative status, often defining themselves based on their social presentation instead. Many transsexual people believe that SRS is only a small part of a complete transition.

Many Western societies, nowadays, have procedures whereby an individual can change their name, and sometimes, their legal gender, to reflect their gender identity (see Legal aspects of transsexualism).

Medical treatment for transsexual and transgender people is also available in most Western countries. However, transsexual and transgender people challenge the "normative" gender roles of many cultures and often face considerable hatred and prejudice. The film Boys Don't Cry chronicles the case of Brandon Teena, a transsexual man who was raped and murdered after his status was discovered. The project Remembering Our Dead, founded by Gwendolyn Ann Smith, archives numerous cases of transsexual and transgender people being murdered. [16] In the United States, November 20 has been set aside as the "Day of Remembrance" for all murdered transgender people.

Some people who have switched their gender role enter into traditional social institutions such as marriage and the role of parenting. They sometimes adopt or provide foster care for children, as complete sex reassignment therapy inevitably results in infertility. Sometimes, they adopt children who are also transsexual or transgender and help them live according to their gender identity.[citation needed] Some transsexual people have children from before transition. Some of these children continue living with their transitioning/transitioned parent, or retain close contact with them. A recent study shows that this does not harm the development of these children in any way.[17]

The style guides of many media outlets prescribe that a journalist who writes about a transsexual person should use the name and pronouns used by that person. Family members and friends, who are often confused about pronoun usage or the definitions of sex, are frequently instructed in proper pronoun usage, either by the transsexual person or by professionals or other persons familiar with pronoun usage as it relates to transsexual people. Sometimes, transsexual people have to correct their friends and family members many times before they begin to use the proper pronouns consistently.

Coming out

Employment issues

Transsexual people have historically had difficulty maintaining employment. Most transsexual people find it necessary to remain employed during transition in order to cover the costs of living and transition. However, employment discrimination against trans people is rampant and many of them are fired when they come out or are involuntarily outed at work. [18] Transsexual people must decide whether to transition on-the-job, or to find a new job when they make their social transition. The transsexual community usually regards this as a personal decision, though those who are fired during transition will have to find new jobs. Finding employment is often a challenge, especially for those in mid-transition.

Legal policies regarding name and gender changes in many countries make it difficult for pre-op transsexual people to conceal their trans status from their employers. [19] Because the Harry Benjamin Standards of Care require a one year RLT prior to SRS, some feel this creates a Catch 22 situation which makes it difficult for transpeople to remain employed or obtain SRS.

In many countries, laws are providing increasing protection to transpeople from workplace discrimination, and an increasing number of companies are including "gender identity" in their non-discrimination policies. [20] However, these laws and policies often have gaps, and they are not always fully implemented and enforced.

Stealth

After transsexual men and women are living full-time as members of their target gender, they may wish to blend in with other members of their new sex, and will avoid revealing their past. They do this believing that it will provide greater peace and security on the other side of a stressful and potentially dangerous transition, and/or because they wish to be seen only as members of their target sex, not as transsexuals.

This behaviour, known as stealth, is recognized by most people in the transsexual community as an individual decision that one must make. Some, however, within and outside the transsexual community, feel that one should be upfront about his or her past, and that stealth living is somehow dishonest. Some draw a parallel with a perceived need for lesbian and gay people to "come out", and may perceive a failure to do so as betrayal of a greater community, seeing hope for advancement of civil rights and public image in the visibility of greater numbers. However, most people within the community understand that revealing one's transsexual history is a deeply personal choice. Moreover, this is part of an individual's medical history, and as such should be his or hers alone to disclose.

The equation with "coming out", whereby a lesbian or gay person, or a transsexual person who has hidden their true gender identity while maintaining their originally assigned gender role, feels they reveal their true self, has been countered by the explanation that, in contrast, because of prejudice, sensationalism, and how it can trigger unconscious personal feelings and emotions, knowledge of someone's transsexual past can prevent the average person from being able see the transitioned person's true self.

The decision to live completely stealth is believed to present its own psychological difficulties. Many believe that post-transition transsexual people who have no one in which to confide may have tendencies towards anxiety and depression. The term deep stealth is sometimes used for those who have completely isolated themselves from their past, their birth families, the medical professionals directly involved in their treatment process, and from the support structures that may have helped them through transition. Several examples exist of people who have gone deep stealth whose status was only discovered at their death. For example, the jazz musician Billy Tipton was deep stealth and his status was unknown, even by his wife and (adopted) children. Tipton's death illustrates one of the dangers of going deep stealth. This fear of discovery as being transsexual may often keep people from seeking needed medical care. Tipton bled to death from an ulcer that could have been readily treated at the time had he been able to seek medical care without fear of discovery.

However, many believe that fear of discovery, as mentioned above, is justifiable. Several examples also exist of people who have been denied medical treatment upon discovery of their trans status, whether it was revealed by the patient or inadvertently discovered by the doctors. For example, Leslie Feinberg was once turned away from a hospital emergency room where s/he had sought treatment for encephalitis. (Feinberg 2) Like Tipton, Feinberg was presenting as a man but had female genital anatomy. S/he nearly died after being denied treatment. Feinberg's case demonstrates one of the many dangers of actually being discovered. Additionally, Tyra Hunter died after being denied care by paramedics and emergency room physicians after she was injured in an automobile accident.

The majority of the transsexual and transgender community has learned to accept that people choose, for many reasons, including political beliefs, religion, family responsibilities, career, perception of how well they will be accepted by others, and personal psychology, to live at a certain place on the spectrum from 'out and proud' to 'deep stealth'. By this view, Billy Tipton's decision to live deep stealth was no more or less valid than Jamison Green's decision to be out and politically active, as detailed in his book 'Becoming a Visible Man'. There are risks and benefits associated with every point on the spectrum and the decision is widely considered a personal one.

Transsexual youth

Main article: Transgender youth

Different individuals come to terms with their gender identity during many different stages of life. In most cases, the transsexual condition becomes apparent at some time in childhood, when the child may express behaviour incongruent with, and dissatisfaction related to, their assigned gender. However, many of these children hide their differences from an early age; therefore, acquaintances, friends, and even parents of these children may be unaware of their differences. Many of these children fear coming out, often justifiably. Some, but not all, parents react negatively when they learn that their child is transsexual. Because most children and adolescents are dependent on their parents, coming out has potential consequences.

According to the DSM-IV, the majority of children diagnosed with gender identity disorder establish a gender identity congruent with their physical sex by adulthood, and often in adolescence. Puberty is agonizing for most transsexual adolescents, as the physical androgyny of childhood is lost and these teenagers experience bodily changes with which they are uncomfortable. However, in recent years, more parents have come to accept transsexual children, and more doctors are willing to offer them medical treatment, though most are still reluctant to do so.

Regrets and detransitions

After transitioning, transsexual people sometimes regret their transition, or even choose to detransition to their original sex. However, every recent study done on the number of detransitions states that their number is well below 1%, and that the reasons for detransitioning are very diverse.[21] The majority, but not all transsexual people who detransition consider themselves regretful.

Although the incidence of regret is not known, there are many documented cases of regret. Evidence suggests [citation needed] that regret is more common among self-identified autogynephiles, transsexual people with co-existing psychiatric problems, patients with surgical complications, and patients having religious views that their transition was "wrong". In a 2001 study of 232 MTF patients who underwent GRS with Dr. Toby Meltzer, none of the patients reported complete regret and only 6% reported partial or occasional regrets. [22] Jerry Leach, a Christian minister who claims to have backed out of SRS a few weeks before his scheduled surgery date, and reverted to living as a man, also claims that he is contacted by many post-op transsexual people with stories of regret. There are some recent claims that examination of his own personal story of transition reveals some inconsistencies and implausibilities. [citation needed] He runs a website on which he has posted some stories of regretful trans patients. [23]. Among notable regretful trans patients are Renee Richards and Danielle Bunten Berry. [24]

These cases are often cited as reasons for the lengthy triadic process outlined in the Standards of Care, which specifies a treatment process combining psychological, hormonal, and surgical care. While many have criticized this process as being too slow for some, it is argued that without the safeguards within the Standards of Care, the incidence of unsuccessful surgical transitions would be much higher. This is also questioned by many critics, especially with regard to particular demands of some caregivers. The article above states that in some of these cases, transitioning could have been prevented if some demands made by caregivers, or demands perceived as coming from the caregivers, had been less rigid; particularly, if the patients had not felt that talking about any problems or doubts would jeopardize their further treatment. An unwavering demand for medical treatment and the absolute conviction of "doing the right thing" is often seen as a necessity for the diagnosis of transsexualism, and therefore the prerequisite for any further treatment; consequently, further treatment has been denied to people who uttered any doubts or even questions.

Critics claim that when patients cannot talk about problems or doubts, but have to present themselves as having neither, the patients, anxious to get treatment they perceive at this point to be absolutely necessary, will face these problems or doubts after transitioning, when dealing with them may be much more difficult, and this will often lead to social problems, depression, anxiety, or other problems. They believe that, in some cases, this may lead to a retransitioning. While there is no scientific study on the question, many trans*-organisations and groups claim that patients who feel less pressure to conform to any particular stereotype will have more satisfactory outcomes after transition. This does not preclude any screening for mental problems which might lead to pseudo-transsexualism, nor supportive psychological therapy, if necessary.

Additionally, some people detransition after SRS because their desire was to undergo SRS and continue living in the gender role assigned to them at birth. [25] However, they transition temporarily in order to satisfy the requirement of a real-life test.

Depictions of transsexualism in the media

Although many transsexual people are modest about their bodies, and are found in all walks of life and professions, transsexual women are commonly featured in pornographic works. When depicted without having undergone vaginoplasty, they are usually referred to as "shemales". While some pre-operative transwomen call themselves and others like them "shemales," the term is regarded as offensive by many transsexual people. [26]

Films depicting transgender issues include The World According to Garp and The Crying Game. The film Different for Girls is notable for its depiction of a transsexual woman who meets up with, and forms a romantic relationship with, her former best friend from her all-male boarding school. Ma Vie en Rose portrays a six-year-old child who is gender variant.

Two notable films depict transphobic violence based on true events: Soldier's Girl (about the relationship between Barry Winchell and Calpernia Addams, and Winchell's subsequent murder) and Boys Don't Cry (about Brandon Teena's murder).

Transsexual people have also been depicted in some popular television shows. In Just Shoot Me, David Spade's character meets up with his childhood male friend, who has transitioned to living as a woman. After initially being frightened, he eventually forms sexual attraction to his friend, but is scorned, as he is 'not her type'. In a 1980s episode of The Love Boat, McKenzie Phillips portrays a transwoman who is eventually accepted as a friend by her old high school classmate, series regular Fred Grandy.

The series' Law & Order and Nip/Tuck have had transsexual characters, but they were played by non-transsexual women or professional cross-dressers. The series Without a Trace featured an episode in which a transsexual woman went missing and is almost killed by her ex-wife's husband after visiting her family, which she abandoned before transtioning. CSI: Crime Scene Investigation had an episode dealing with a transsexual victim, Ch-Ch-Changes. Many transsexual actresses and extras appeared on the episode, including Marci Bowers and Calpernia Addams. The transwoman victim, Wendy, was played by Sarah Buxton, a cisgender woman. [27] Addams has appeared in numerous movies and television shows, including the 2005 comedy Transamerica, in which Felicity Huffman portrays a pre-op transsexual woman. [28]

In fall 2005, the Sundance Channel aired a documentary series known as Transgeneration. This series focused on four transsexual college students, including two transwomen and two transmen, in various stages of transition. [29] In February 2006, LOGO aired Beautiful Daughters, a documentary film about the first all-trans cast of The Vagina Monologues, which included Addams, Lynn Conway, Andrea James, and Leslie Townsend. [30]

Transsexualism in non-Western cultures

Transsexual people enjoy varying degrees of acceptance in non-Western societies.

Before the Islamic Revolution in 1979, the issue of transsexualism in Iran had never been officially addressed by the government. Beginning in the mid-1980s, however, transgendered individuals have been officially recognized by the government and allowed to undergo sex reassignment surgery. (See Transsexuality in Iran)

This stance might be considered liberal from an American or European viewpoint, but some Iranian clerics use the stance to stress heteronormativity on the part of Iranian and Islamic society. Homosexuality is still forbidden and punishable by death in Iran, and the viewpoint is that males who are attracted to other males should become women. Furthermore, in many societies where homosexuality is poorly accepted, social acceptance of transsexual people is high, and many societies which accept homosexuality are not tolerant of transsexual people.

This heteronormative stance is also seen in countries such as Brazil and Thailand. Thailand is thought to have the highest prevalence of transsexualism in the world. In Thailand, kathoey (who are often, but not always, transsexual) are accepted to a greater extent than in most countries, but are not completely free of societal stigma. Feminine transsexual kathoey are much more accepted than gay male kathoey; this may be seen as an example of heteronormativity. Due to the relative prevalence and acceptance of transsexualism in Thailand, there are many accomplished Thai surgeons who are specialized in sex reassignment surgery. Thai surgeons are a popular option for Western transpeople seeking surgery, largely due to the lower cost of surgery in Thailand.

See also Transgender in non-Western contexts.

References

  • Brown, Mildred L. and Rounsley, Chloe Ann (1996); True Selves; Jossey-Bass.
  • Feinberg, Leslie (1998); Trans Liberation; Beacon Press.
  • Harry Benjamin International Gender Dysphoria Association (2001); Standards of Care for Gender Identity Disorders, Sixth Version. [31]
  • Kruijver, Frank P. M. Zhou, Jiang-Ning Pool, Chris W. Hofman, Michel A. Gooren, Louis J. G. and Swaab, Dick F., (2000); Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic nucleus; J. Clin. Endocrinol. Metab., May 2000; 85: 2034 - 2041.
  • Schneider, Harald J. Pickel, Johanna and Stalla, Gunter K., (2005); Typical female 2nd-4th finger length (2D:4D) ratios in male-to-female transsexuals--possible implications for prenatal androgen exposure; Psychoneuroendocrinology, In Press, Available online 2 September 2005. [32]
  • Xavier, J., & Simmons, R. (2000). The Washington transgender needs assessment survey, Washington, DC: The Administration for HIV and AIDS of the District of Columbia Government. [33]

See also

that supports the concept backed by indicative research that Harry Benjamin Syndrome (aka transsexualism), should be classified as an intersex medical condition.

  • From Within - Online book based on real events aimed at younger transitioners. Follows the story of Vicky and her young transition in England.
  • Saving Throw - Brenda Make's Saving Throw / Genderrain Project is a full-length autobiography, which also touches on bisexuality, abuse, recovery, drug abuse, gender ethics, and politics.
  • FTM International - Female To Male International: practical and medical information
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