Misplaced Pages

Revision as of 05:09, 9 March 2007

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. Transsexualism is considered a taboo subject in many parts of the world. The justifications for negative beliefs about transsexualism may be perceived as being supported by religious beliefs or cultural norms. It has become more widely known in Western nations in the late 20th century due to the sexual revolution, but remains a highly controversial topic.

Gender dysphoria

Transsexualism often manifests itself as a dysphoria toward one's biological birth sex, as well as conflict living in one's 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. The suicide statistics of treated transsexual people do not differ remarkably 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. Under the Harry Benjamin Standards of Care they are also required to live as members of their target sex for at least one year prior to surgery (so-called Real-Life Test or Real-Life Experience), although this time may be longer if the psychotherapist has concerns about the transsexual person's readiness. The intentions of the standard are to prevent people from transitioning when such a transition would be inappropriate (as a dramatic example, a person seeking to transition in order to veil their identity from police), or ill-advised (e.g., a strong crossdresser, who still identifies themselves as their assigned gender). These standards are open to the criticism of being ineffective, or being too strict, discouraging genuinely transsexual people from seeking treatment. Meta-reviews of post-operative transsexuals prior to 1991 reveal a rate of serious regrets of less than 1% for transsexual men and less than 2% for transsexual women, while studies published after 1991 have reported a decrease in the rates for both, likely due to improved psychological and surgical treatments. While such studies lend support for existing protocols concerning care of transsexuals, post-operative follow-up research is considered to be lacking.

Currently, the causes of transsexualism are unknown, and estimates of prevalence vary substantially.

Defining transsexualism

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. As with any terms used by a group, or to refer to a particular group, some of these terms are controversial, or have become controversial, not only to society at large, but even among the transsexual community.

The definition of "transsexuality" is somewhat debated. One common definition is that a transsexual is a person who believes that his or her body does not reflect his or her true 'inner' gender. Another common definition is that a transsexual is a person who has had or plans to have medical or surgical treatments that alter his or her body to better reflect what the individual believes is his or her true gender. The first definition allows greater freedom for individuals to self-identify as a transsexual. The latter defines the term based on actual or planned operative status and makes it more an external label than a term of self-definition.

When surgery is undertaken it is commonly referred to as sex reassignment surgery by health care providers and community members. An older term, sex change surgery may be seen as disrespectful.

The Diagnostic and Statistical Manual of Mental Disorders accepts the expression of desire to be of the opposite sex, or assertion that one is of the sex opposite from the one with which they were assigned at birth, as sufficient for being transsexual. The ICD-10 states in a similar way 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 variously described as a trait, disease, behavior, desire, mental illness, perversion, paraphilia, political identity, lifestyle and sin. The terms perversion and sin are often used in a derogatory manner (especially by Western religions). People may consider the use of such labels offensive whether they are or are not transsexual, or involved with Western religions, themselves.

Transsexualism is often included within the broader term transgender, which is generally considered an umbrella term for people who do not conform to typical accepted gender roles, for example cross-dressers, drag queens, and people who identify as genderqueer. However, some transsexuals object to this inclusion. Historically the reason that transsexuals rejected associations with the transgender or broader LGBT community is largely that the medical community in the 1950s through the late 1980s encouraged (and in many ways required) this rejection of ones queer kin in order to be a 'good transsexual' who would thus be allowed to access medical and surgical care. The animosity that is present today is not still currently fed by this same kind of pressure from the medical community (indeed, today many gender therapists actively encourage their clients to explore support within the broader community.) However the current animosity is reflective of this historical division. (Denny 176.)

Regardless of definition, transsexualism should not be confused with cross dressing or with the behaviour of drag queens and drag kings, which can be described as transgender but not transsexual. Also, transvestic fetishism usually has little, if anything, to do with transsexualism. As a general rule, transsexual people tend to dress and behave in a manner consistent with the gender they identify with, crossdressers tend to dress (and sometimes behave) in a manner consistent with stereotypical ideals of the opposite gender as opposed to the real-life behavior of that gender, and "drag queens" or "drag kings" tend to dress and behave in a flamboyant manner which parodies rather than emulates the opposite gender.

Gender terminology for transsexual people

Transsexual people almost universally prefer to be referred to by the gender pronouns and terms associated with their target gender. For example, a transsexual man is a person who was assigned the female gender at birth on the basis of his genitals, but despite that assignment 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 are particularly helpful in preventing confusion, because to some people the term "transsexual woman" is a female transitioning to become a male, and to others a male transitioning to become a female. When the terms transmen and transwomen are used though, it is typical for them to be used to refer to the gender that the person identifies with, regardless of their appearance or state of transition.

Transsexual people are often considered as part of the LGBT community, and although many do identify with this community, others do not, or prefer not to use the terms at all. Transsexual people typically feel it important for people to understand that transsexualism neither depends upon, nor is related to, sexual orientation. Transsexual men and women exhibit a range of sexual orientations just as non-transsexual (some times referred to as Cisgender) people do, and they will almost always use terms for their sexual orientation that relate to the gender with which they identify. For example, someone assigned 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 the female gender 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 transsexual people as members of their original sex by 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 usage is considered by many to be scientifically inaccurate and clinically insensitive today. As such someone who would have been referred to as a "homosexual male transsexual" would now be called and most likely identify herself as a heterosexual transsexual woman. Although this usage is dwindling, some medical textbooks still refer to transsexual people as members of their assigned sex, but now many use "assigned-to-target" terms.

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

Alternative terminology

The transsexual community typically use the short form "trans", or simply "T" as a substitution for the full word "transsexual", e.g. TS, trans guy, trans dyke, T-folk, trans folk. Some may even use term that have become controversial to some, such as tranny and/or trans, despite others considering these terms to be offensive. Those who do use these terms claim that they are diminishing the power of the term as an insult, just as some members of the gay and African-American communities have embraced slurs directed at them. 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 transsexual people, and people who are merely "playing" with gender.

Some people may prefer to spell transsexual with only one s, thus writing transexual. They will typically assert that they are attempting to divorce the word from the realm of psychiatry and medicine and place it in the realm of identity. This trend is most common in the United States, and is almost never used in the United Kingdom. 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 more closely parallels with the term intersex, which is considered by them to be important 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 may 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 between (inter) the genders rather than "intersexual". It is often assumed, particularly by transsexual people, that transsexualism is 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. (Despite the fact that human genitals show an extremely wide variation in general, intersexed people typically have quite obviously ambiguous genitalia that frustrate attempts to assign them within a binary sex system.) 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 could fall under the rubric of "intersex." Transsexualism, in this view, simply becomes a form of being neurologically intersexed. (See below for research of physiological causes of transsexualism).

Harry Benjamin agreed with German sexologist Magnus Hirschfeld that transsexuals were a form of neurological intersex. Hirschfeld coined the term "Transvestite" in his seminal work on the matter, Die Transvestitien. In this work, he describes what is now known as transvestic fetishism as well as transsexuals. In 1930, he supervised the first known sex reassignment surgery on Lili Elbe of Denmark.

The term "Transsexual" was coined by Harry Benjamin during his work of the 50's and 60's, which culminated in The Transsexual Phenomenon in 1966. This term continues to be used by the public and medical profession alike. It was included for the first time in the DSM-III in 1980 and again in the DSM-III-R in 1987, where it was located under Disorders Usually First Evident in Infancy, Childhood or Adolescence.

The term "Gender Dysphoria" and "Gender Identity Disorder" were not used until the 1970s when Laub and Fisk published several works on transsexualism using these terms. "Transsexualism" was replaced in the DSM-IV by "Gender Identity Disorder in Adolescents and Adults".

Some people prefer that transsexualism be referred to as Harry Benjamin's Syndrome as it follows the naming conventions of intersex conditions. This term is named for Harry Benjamin, a pioneer in sex reassignment and research on transsexual people. Many transsexual people who prefer this term assert 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, and has never changed. Thus that nothing about their steps in correcting themselves is actually "trans" at all, but rather they are simply taking steps to assert what they feel that they are already. A small number of people who are post operative and living in their chosen role prefer to call themselves either a neo-woman or neo-man, thus omitting references in the term 'transsexual' to sexuality or being inbetween (trans).

While the above gives a fairly comprehensive view of terminology, it's important to note that some people may feel that both 'trans' and 'sexual', are misleading, and others may take objections to terminology that are unique to their perspective. While a large variety of other terms exist from those presented here, they have not been excluded with bias, although almost all of them are somewhat controversial.

Prevalence

There are no reliable statistics on the prevalence of transsexualism. The DSM-IV (1994) quotes prevalence of roughly 1 in 30,000 assigned males and 1 in 100,000 assigned females seek sex reassignment surgery in the USA. The most reliable population based estimate of the incidence occurrence is from the Amsterdam Gender Dysphoria Clinic The data, spanning more than four decades in which the clinic has treated roughly 95% of Dutch transsexuals, gives figures of 1:10,000 assigned males and 1:30,000 assigned females. Other bodies report figures of between 1:1000 or even 1:500. No consensus has been agreed and pressure groups maintain this is probably because of various governments' unwillingness to fund treatment accordingly.

Causes of transsexualism

Many psychological causes for transsexualism have been proposed, while research has been presented to suggest that the cause of transsexualism has its roots in biology. There remains no agreement, however, as to the cause of transsexualism.

Some transsexual people and professionals feel that research into causes of transsexualism assumes at face value the legitimacy of a normative gender identity, and/or that transsexualism is contrary to normal development, and could be considered a disease, or syndrome, which a transsexual may feel is stigmatizing. They usually consider such research to be unnecessary, and wonder if such studies might possibly be causing more harm than good for transsexual people.

Meanwhile, other transsexual individuals and professionals believe that transsexualism is, in fact, a syndrome with a physiological basis as a form of intersexuality. Those with this viewpoint generally support research as to the cause, believing that it will verify the theory of a biological origin and thereby reduce social stigma by demonstrating that it is not a delusion, a political statement, or a paraphilia. There is presently no test available that can prove a biological cause of transsexuality, but this may change with the advancement of science.

Sex reassignment therapy

It has been suggested that this article be merged into Sex reassignment therapy. (Discuss) Proposed since March 2007.

Most transsexual men and women suffer from psychological and emotional distress due to the conflict between their gender identity and their assigned gender role and/or anatomy. They often find that their only recourse is to change their gender role and possibly 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.

A 1998 clinical review found that MTF sex reassignment surgery had positive effects on psychiatric morbidity, and that surgery may have reduced healthcare costs. The authors noted, however, that few controlled clinical trials existed, as evidence was limited.

Psychological treatment

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

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

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. Thus exposing the transsexual community to a higher level of evaluation for mental health issues than the general populace.

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. Unfortunately, this can often cause them significant problems when they attempt to obtain physical treatment as health professionals expect such therapy to be occurring concurrently with physical treatment.

Therapists' records reveal that many transsexual people do not believe they need psychological counseling, but rather they will acquiesce to legal and medical expectations in order to gain rights which are thusly 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 and/or therapist's approval. Because of this, many transsexual people feel coerced into affirming pre-ordained symptoms of self-loathing, impotence, and sexual-preference, in order to overcome simple legal and medical hurdles. (Brown 107) Transsexual people who do not submit to this medical hierarchy typically face the option of remaining invisible, with no legal rights and possibly with identification documents incongruent with gender presentation.

Diagnosing transsexualism

The current diagnosis for transsexual people who present themselves for psychological treatment is "gender identity disorder". As the DSM has changed its terminology, the diagnosis of "transsexualism" has become unused 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 at all, 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 only adds stigma, essentially feeling that such a diagnosis is equivalent to saying something really is wrong with them. (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 can include 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, it may be important to realize that many transsexual women do go through a period where they self-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, typically does not alleviate issues for them, but rather leaves them with an intolerable body..

However, some transsexual people may 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, and that psychiatric disorders are generally not considered contraindications to sex reassignment therapy, that is unless they are the primary cause of the patient's gender dysphoria. (Brown 108) Despite this permissiveness, 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 at least some mental health professionals are being insensitive by labeling transsexualism as "a disease", rather than as an inborn trait. Furthermore, many people express that some psychologists and psychiatrists in viewing transsexualism as "a disease" have sought to develop specific models of transsexualism, which they feel exclude many transsexual people, such as Ray Blanchard's model.

Andrea James in an article rejecting terminology and disease-models of transsexuality, has proposed the terms "interest in feminization" and "interest in masculinization" to refer to a desire for sex reassignment therapy, regardless of whether the person with the desire is transsexual. Although she herself admitted that there are numerous difficulties and issues with this terminology that she herself could easily list, she hasn't advanced this terminology as a finalized terminology, but rather a start towards finding terminology that avoids the traditional issues surrounding transsexuality which describe it as a "disease" or a "deviant" condition. Critics of her terminology would point out that she has swung the pendulum too far in the other direction, now equating transsexuality to a "life-style choice", which often offends those transsexuals who feel that their condition has a biological origin. Andrea herself agreed with this position that transsexuality is not a choice, but she was rather strong in rejecting any assertion that it should be classified as a disease rather than a part of typical human variance.

Other people, under the position that transsexual is a physical condition and not a psychological issue, assert that sex reassignment therapy should be given if requested, and may even align with those who feel that all body modification should be offered on demand. (Brown 103)

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 will 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

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 reassignment 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. 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

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 as 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 revert upon cessation of hormonal treatment, unless chemical or surgical castration has occurred, though for many transsexual people, surgery is required to obtain satisfactory physical characteristics.

As with all medical activities, health risks are associated with hormone replacement therapy, especially when higher doses are taken, as is common for pre-operative transsexual patients. It is always best advised that all changes in therapeutic hormonal treatment should be done with a physician's supervision, as starting, stopping or even changing doses can have physical and psychological health risks.

Although some transsexual women use herbal phytoestrogens as alternatives to pharmaceutical estrogens, little research has been done on the safety or effectiveness of such products, with the best evidence being anecdotal that the best results appear to be minimal and very subtle when compared to conventional hormone therapy; that is, if any noticeable changes happen at all.

Sex reassignment surgery

The surgical and medical procedures undertaken to align transsexual individuals' physical appearance and genital anatomy with their gender identity are sometimes known collectively as Sex Reassignment Surgery (SRS). Other proposed terms for SRS include Gender Confirmation Surgery, Gender Realignment Surgery, Gender Reassignment Surgery, and Transsexual Surgery. The aforementioned terms may also specifically refer to genital surgeries like vaginoplasty and phalloplasty, even though more specific terms exist to refer exclusively to genital surgery, the most common of which is Genital Reassignment Surgery (GRS). Another term beginning to be used in the medical community is Genital Correction Surgery, which emphasizes that the procedure is merely correcting the genitals to match the inner sense of gender.

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. It is to be noted though, that the government of Iran pays for such surgery because it is believed to be valid under Islamic Sharia.

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.

Legal and social aspects

Many Western societies have procedures whereby an individual can change their name, and sometimes, their legal gender, to reflect their gender identity (see Legal aspects of transsexualism). Laws regarding changes to the legal status of transsexuals are different from country to country. Within the US, some state jurisdictions do allow amendments or complete replacement of the original birth certificates. Some jurisdictions may even seal earlier records against all but court orders in order to protect the transsexual's privacy.

In many other countries, it is still not possible to change birth records or other legal documents relating to ones gender status. Since many governments are revising the legal status of post-operative transsexuals, there are many individuals pioneering changes to these laws, such as Estelle Asmodelle whose book documents her struggle to change the Australian birth certificate and passport laws, although there are other individuals who are were instrumental in changing laws and thus attaining more acceptance for transsexual people in general.

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. 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. 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.

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. 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. 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 from workplace discrimination to transpeople, and an increasing number of companies are including "gender identity" in their non-discrimination policies. However, these laws and policies often have gaps, and they are not always fully implemented and enforced. California has strigent anti-discrimination laws to protect transsexual persons in the workplace and specifically prohibits employers from terminating or refusing to hire persons who are discovered to be transsexual. Member states of the European Union provide employment protection as part of gender discrimination protections following the European Court of Justice decisions in P v S and Cornwall County Council

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 ones 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 equating of "coming out" (whereby a transsexual person who has hidden their true gender identity while maintaining their originally assigned gender role, reveals their true self) with honesty or social activism has been countered by the explanation that, because of prejudice, sensationalism, and the triggering of unconscious personal feelings and emotions, knowledge of someone's transsexual past can prevent the average person from being able to 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 and whose status was discovered only 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 he had sought treatment for encephalitis. (Feinberg 2) Like Tipton, Feinberg was presenting as a man but had female genital anatomy. 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.

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.

Although the incidence of regret is not known, there are many documented cases of regret. Evidence suggests 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. 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. He runs a website on which he has posted some stories of regretful trans patients. Among notable regretful trans patients are Renee Richards and Danielle Bunten Berry.

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*-organizations 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. 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.

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. Addams has appeared in numerous movies and television shows, including the 2005 movie Transamerica, in which Felicity Huffman portrays a pre-op transsexual woman.

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. 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.

Thomas Harris' Silence of the Lambs included a serial killer who considered himself a transexual. After being turned down for sex reassignment surgery due to not meeting necessary psychological evaluations, he then harvested female bodies to make a feminine suit. While the movie and novel initially sparked more intolerance toward transexuals, it has since diminished from public criticism of transsexuality.

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.

Transsexual people are gaining acceptance in much of Latin America, and gender reassignment surgeries are on the rise in Mexico, Argentina and Brazil.

Transgender-related issues remain largely taboo in much of Africa and in developing countries around the world.

Harry Benjamin Syndrome, HTTP://www.harrybenjaminsyndrome-info.org/defines the affirmation of body sex to brain gender - an intersex condition.

Bibliography

• Brown, Mildred L. (1996). True Selves: Understanding Transsexualism - For Families, Friends, Coworkers, and Helping Professionals. Jossey-Bass. ISBN 978-0787967024. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
• Feinberg, Leslie (1999). Trans Liberation : Beyond Pink or Blue. Beacon Press. ISBN 978-0807079515.
• Standards of Care for Gender Identity Disorders, Sixth Version. - World Professional Association for Transgender Health (2001)
• Kruijver, Frank P. M. (2000). "Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus". Journal of Clinical Endocrinology & Metabolism. 85 (5): 2034–2041. doi:10.1126. Retrieved 2007-02-25. {{cite journal}}: Check |doi= value (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
• Schneider, Harald J. (2006). "Typical female 2nd-4th finger length (2D:4D) ratios in male-to-female transsexuals-possible implications for prenatal androgen exposure". International Society of Psychoneuroendocrinology. 31 (2). Elsevier, Oxford, UK: 265–269. ISSN 0306-4530 PMID 16140461. Retrieved 2007-02-25. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
• 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
• Rathus, Spencer A. (2002). Human Sexuality in a World of Diversity. Allyn & Bacon. ISBN 978-0205406159. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
• Denny, Dallas, (2006); Transgender Communities in Transgender Rights.

See also

• List of transgender-related topics
• List of transgender-rights organizations
• List of LGBT-related organizations
• List of transgendered people

External links

• Basic TG/TS/IS Information - including Successful Transwomen and Successful Transmen
• FTM International - Female To Male International: practical and medical information
• FTM Australia - Comprehensive information for all men identified female at birth in Australia.
• Hudson's FTM Resource Guide - Comprehensive information for female to male trans men and allies - USA-based
• Gender.org - The home of Gender Education & Advocacy, a nonprofit corporation using the web to provide education and advocacy for transsexual and transgender issues.
• Definition and Synopsis of the Etiology of Adult Gender Identity Disorder and Transsexualism - prepared by 24 internationally recognized experts, published by the Gender Identity Research and Education Society (GIRES)(See: http://www.gires.org.uk)
• How to Respect a Transsexual Person
• The International Journal of Transgenderism - The Official Journal of the World Professional Association for Transgender Health (formerly HBIGDA)
• Transsexuality - Jennifer Diane Reitz's Help & Support Site. Home of the COGIATI gender test, a controversial assessment of gender identity and transsexuality.
• Lynn Conway - her goal is to "illuminate and normalize the issues of gender identity and the processes of gender transition."
• Dr Becky's Website - List of therapists, physicians, medical info, etc.
• TransParentcy - Organization to support transgender parents and their advocates (lawyers, mental health professionals, friends, family) by providing information and resources to diffuse and/or disspell the myths about any adverse impact being transgendered/transsexual might have on ones children.
• Transsexual Road Map - practical and medical information

Template:Sexual Identities

1. Lynn Conway - TS Successes
2. Kuiper, Bram (October 1988). "Sex reassignment surgery: A study of 141 Dutch transsexuals". Archives of Sexual Behavior. 17 (5): 439–457. doi:10.1007/BF01542484. ISSN 0004-0002 PMID 3219066. Retrieved 2007-02-25. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
3. ^ Kuiper, A.J (September 1998). "Gender Role Reversal among Postoperative Transsexuals". International Journal of Transgenderism. 2 (3). Retrieved 2007-02-25. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
4. BehaveNet - Gender Identity Disorder
5. Transexual, transsexual, and restricted Google searches - Language Log
6. Detail of conversation between Benjamin and Hirschfeld re. neurological intersex
7. ^ Pauly MD, Ira B. (28 May 1993). "Terminology and Classification of Gender Identity Disorders". Journal of Psychology & Human Sexuality. 5 (4): 1–12. ISSN 0890-7064. Retrieved 2007-02-26.
8. Laub, D. R. (April 1974). "A rehabilitation program for gender dysphoria syndrome by surgical sex change". Plast Reconstr Surg. 53 (4): 388–403. PMID 4592953. Retrieved 2007-02-26. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
9. Fisk, N. (1974). "Gender Dysphoria Syndrome. In D. Laub & P. Gandy (Eds.)". Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria Syndrome: 7–14.
10. Harry Benjamin's Syndrome - definition and aetiology - HBS group
11. van Kesteren, Paul J. M (1997). "Mortality and morbidity in transsexual subjects treated with cross-sex hormones". J. Clin. endocrinol. 47 (3). Blackwell, Oxford, UK: 337–343. doi:10.1046/j.1365-2265.1997.2601068.x. PMID 9373456. Retrieved 2007-02-25. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
12. The Wessex Institute for Health Research and Development. Surgical gender reassignment for male to female transsexual people (Structured abstract) 1998:25. Southampton: Wessex Institute for Health Research and Development
13. Seattle and King County Health - Transgender Health
14. The International Transsexual Sisterhood - Study On Transsexuality
15. What can I do about this? Is there hope for me? - transsexual.org
16. ^ A defining moment in our history - TS Road Map
17. SRS After Less Than a One-Year Real-Life Test : Absence of Regrets - Anne A. Lawrence, M.D
18. Remembering Our Dead - a memorial to transgender people who have been murdered
19. Green, MD JD FRCPsych, Richard (December 1998). "Transsexuals´ Children". International Journal of Transgenderism. 2 (4). Retrieved 2007-02-25.
20. Work transition for transsexual women - TS Road Map
21. Weiss, Jillian Todd (2001). "The Gender Caste System: Identity, Privacy and Heteronormativity" (PDF). Tulane Law School. Retrieved 2007-02-25. {{cite journal}}: Cite journal requires |journal= (help)
22. Workplace Discrimination: Gender Identity or Expression - Human Rights Campaign Foundation
23. Judgment of the Court of 30 April 1996. - P v S and Cornwall County Council. - Reference for a preliminary ruling: Industrial Tribunal, Truro - United Kingdom. - Equal treatment for men and women - Dismissal of a transsexual. - Case C-13/94 - European Court reports 1996 Page I-02143
24. Factors Associated with Satisfaction or Regret Following Male-to-Female SRS - Anne Lawrence, M.D., Ph.D
25. Reality Resources Publications
26. A Warning for Those Considering MtF SRS - Lynn Conway
27. Potential complications of vaginoplasty - TS Road Map
28. What's Offensive - discussion of offensive transsexual terminology
29. CSI: Crime Scene Investigation / Ch-Ch-Changes at IMDb
30. Calpernia Addams at IMDb
31. Transamerica at IMDb
32. TransGeneration at IMDb
33. Beautiful Daughters - LOGO (TV channel) Documentary
34. Silence of the Lambs at IMDb
35. Mukasa, Juliet V. (2006-10-23). Transgender Human Rights Issues in Africa. World International Lesbian and Gay Association (ILGA) PANEL AT 2ND UNCHR SESSION. Retrieved 2006-12-24. {{cite conference}}: Check date values in: |date= (help); Cite has empty unknown parameter: |booktitle= (help)CS1 maint: location (link)

• Articles to be merged from March 2007
• Gender
• LGBT
• Transgender people and behavior
• Transgender