A transsexual (sometimes transexual) person establishes a permanent identity with the opposite gender to their assigned (usually at birth) sex. Transsexual men and women make or desire to make a transition from their birth sex to that of the opposite sex, with some type of medical alteration (gender reassignment therapy) to their body. The stereotypical explanation is of a "woman trapped in a man's body" or vice versa, although many in the transsexual community reject this formulation. For the exact wording of formal diagnoses, see gender identity disorder.
The minimum requirements for a person to be considered transsexual are debated. Some feel that hormonally induced changes, without surgical changes, are sufficient to qualify for the label transsexual. Others, especially health care providers, believe there is a certain set of procedures that must always be completed. The general public often defines "a transsexual" as someone who has "sex change" surgery. The current term in widest use for modification of 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, it is also often accepted (and is also evident in the Diagnostic and Statistical Manual) that to express desire to be of the opposite sex, or to assert that one is of the sex opposite to the one with which they were identified at birth, constitutes being transsexual. In contrast, some transgendered people, on the other hand, often do not identify as being of or wanting to be the opposite sex, but as being of or wanting to be another gender.
Transsexuality (also known as transsexualism) is one of a number of behaviours or states collectively referred to as transgender, which is generally considered an umbrella term for people who do not conform to typical gender roles. However, many in the transsexual community do not identify as transgendered. Some see transgender as subsuming and erasing their identity, rejecting the term 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.
Transsexual people are often construed as belonging to the LGBT or the Queer community, and many identify with the community; others do not, or prefer not to use the term. It should be noted that transsexuality is not associated with or dependent on sexual orientation. Transsexual men and women exhibit a range of sexual orientations just as non-transsexuals (cissexuals) 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; and someone who was assigned female sex at birth and prefers male partners will identify as gay, not heterosexual.
(As stated above, older medical texts often 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." Again, this dwindling usage is considered scientifically inaccurate and clinically insensitive today, and such a person would now be called and most likely identify herself as a heterosexual transwoman.)
Transsexuality should not be confused with cross dressing or the behaviour of drag queens, who can be described as transgender, but usually not transsexual. Also, transvestic fetishism has usually little, if anything, to do with transsexuality.
Gender terms used to describe transsexual people always relate to the target. For example, a transsexual man is someone who was identified as female at birth owing to his genitals, but identifies as a man and who is transitioning, or has transitioned, to a male social gender role and a male-identified body (an alternative term is female-to-male transsexual or transman; compare also transwoman).
One common abbreviation used to clarify involves versions of "assigned-to-target", i.e. female-to-male, or male-to-female. This helps avoid confusion caused by outdated medical terminology. These terms are abbreviated with several variants, so female-to-male might be expressed as F to M, FtM, F2M, F-M, F>M, etc.
Those researching the topic should be aware that older medical texts often referred to the person's original sex; in other words, referring to a M2F transsexual as a "transsexual male." This usage is now sharply deprecated and little-used.
Among the transsexual community, the short form trans is more commonly used, e.g. trans guy, trans dyke, trans folk. Some also use the somewhat more controversial term tranny, e.g. tranny boy. Both abbreviated forms are also used by non-transsexual transgendered people, although "tranny" is often considered offensive if used by those outside the community.
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.
Some people prefer the term transsexed over transsexual, as they believe the term sexual found in transsexual is misleading. 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 also 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.
Causes of transsexualism
There is no scientifically proven cause of transsexualism. However, many theories have been proposed which suggest that the cause of transsexualism has its roots in biology.
Proposed psychological causes
In the past, many reasons for transsexualism have been proposed. Those reasons have usually been psychological; including "overbearing mothers and absent fathers", "parents who wanted a child of the other sex", "repressed homosexuality", "sexual abuse" or a variety of sexual perversions.
None of these theories however was able to be applied successfully to a majority of transsexual people, usually not even to a significant minority. Many theories also were developed in order to describe transsexual women, and when applied to transmen, they usually work even less. Many of these theories had also previously been applied to homosexuals, where they did not work out, either. This led to theories which consider physical reasons for transsexualism.
Experience with individuals who were surgically reassigned at birth (in order to correct deformities such as those caused by accidental castration) suggests strongly that the mental gender identification is determined at birth - individuals born male but raised as female show the same symptoms of gender dysphoria as transsexuals.
Psychological treatments aimed at "curing" transsexuality are historically known to be unsuccessful, and there is anecdotal evidence that this may increase the suicide rate among transsexuals. A number of treatments were frequently attempted in the past that are now considered ineffective and in some cases barbaric, including aversion therapy, psychoactive medications, electroconvulsive therapy, hormone treatments consistent with the birth gender, and psychotherapy alone.
Many transsexual (and also many other transgendered) people have assumed that there is a physical cause of their transsexualism, because they claim to have had the feeling of being a girl or a boy for as long as they can remember. However, until recently, no physical cause could, with any certainty, be proposed or established.
There has been preliminary evidence to suggest that the brains of transsexual people are wired in alignment with their perceived gender identity: transsexual women have a female brain, transsexual men have a male brain. This evidence concerns the central subdivision of the bed nucleus of the stria terminalis (known as BSTc, a part of the Striatum). Males have a larger BSTc than females; in a study of six male-to-female transsexuals' brains, it was found that all had a female-sized BSTc.  (http://www.symposion.com/ijt/ijtc0106.htm)  (http://jcem.endojournals.org/cgi/content/full/85/5/2034?ijkey=3b96d2a5b484008ddb217db0011974bc17e940d6&keytype2=tf_ipsecsha) Likewise, it has been found that a transsexual male (a person identified as female at birth but who identified as a man) had a male-sized BSTc region.  (http://www.jneurosci.org/cgi/content/full/22/3/1027?ijkey=9eaf15ba349455e4b788509d3c3c1e2d8ccd6dd8&keytype2=tf_ipsecsha) A 1997 paper (http://www.genderpsychology.org/psychology/BSTc.html) by Zhou, Hofman, Gooren and Swaab discussed the high accuracy and applicability of the male-to-female results despite the small size of the study.
The general structure (for example the size and hemispheric differences) of transsexual peoples' brains is not significantly different from that of other members of their birth sex. It should be noted, however, that brain size correlates to body size.
However, extending the study is difficult, because currently, the only way to establish the size of the BST is through an autopsy, which limits the number of available subjects.
Objections against reseach of causes
Scholars of gender theory, gender professionals and transsexual rights activists contest the very rationale of looking for a "cause" to transsexualism. The basic assumption behind this quest for "causes" is that gender dimorphism (the idea that there are only two discrete, well defined and dichotomous genders) is an established fact. The critics cite, among other things, historiographic and anthropological findings pointing to the fact that different cultures had diverse concepts of gender, some of them including three or more genders.
The main argument against the search for a "cause" to transsexualism is that it assumes a priori the legitimacy of normative gender identity, i.e. gender identity congruent with the external genitalia. This, affirm the critics, is an unproved contention. Historical research shows that the relation of genitals and gender identity changed across cultures. Assuming a priori that variant gender identity is anomalous (and therefore its "causes" should be investigated) distorts science's view of gender and contributes to the stigmatization of gender non-conformant people.
Individuals may begin to come to terms with their gender identity at many different stages in their life. In most cases, the transsexual condition becomes apparent at some time in childhood, sometimes in very early childhood, where the child may be expressing behaviour incongruent with, and dissatisfaction related to, their assigned gender.
Most of the time, though, these children try to hide being different as soon as they experience rejection resulting from their differences.
Since transsexualism is still not widely accepted in many countries, transsexual youth may feel they need to remain in the closet until they feel that there is a time appropriate to reveal to their parents their gender identity -- understandably so, as parents have a great deal of influence in their children's lives, some parents can react negatively towards such news. Other parents can be very supportive, initially, or after such news has been broken to them.
Ensuring the child's security
Only in recent years have some transsexual or transgendered children received both appropriate counselling and in some rare cases also medical treatment, as well as the possibility to change their social role.
Families with a young child, who may identify already as a member of "the other" sex, and who chooses to change their gender roles through dress and behaviors, may decide to relocate this child and home to another area in order to afford the young person the best opportunity to live in the desired gender role among a novel set of peers and community.
Choosing to remain and live within an intolerant society where the local community has had previous experience of the child's assigned sex may raise many challenging issues. Gwen Araujo of Newark, California was a young person who had attempted to cross-live as a female, a gender opposite to the male gender assigned her at birth. She became the victim of violent crimes that resulted in her death after she attended a party where her birth sex was revealed.
The film Ma Vie En Rose (http://www.sonypictures.com/classics/mavieenrose/) (1997), by Alain Berliner, depicts a similar scenario: Ludovic is a young child who is assigned male but who identifies as a girl and tries to make others agree with this identification. Ludovic's gender play incurs conflict within the family and prejudice from the neighbours; in the end the family has to relocate to a new community.
The 1999 documentary film Creature directed by Parris Patton, tells the story of Stacey "Hollywood" Dean, a young transsexual woman who grew up in rural North Carolina. It follows her through four years and includes interviews with her conservative Christian parents.
The necessity to relocate, however, depends very much on the social environment and the handling of the situation by caretakers and other adults. There are also several cases where this was not necessary, particularly in Western Europe.
Gender reassignment therapy
Most transsexual men and women suffer from great psychological and emotional pain due to the conflict between their gender identity and their original gender role and anatomy. They find their only recourse is to change their gender role and undergo gender reassignment therapy. This may include taking hormones or having sex reassignment surgery to modify their primary and secondary sexual characteristics.
Mental health approaches that attempt to change the gender identity to one considered appropriate for their assigned sex have universally been shown to be ineffective. It is generally accepted, therefore, that the only effective course of treatment for transsexuals is gender reassignment therapy.
The need for physical treatment is emphasized by the high rate of mental health problems, including depression, various addictions, and a suicide rate among untreated transsexual people many times the rate in the general population (some estimates are as high as between thirty and seventy percent); many of these problems in the majority of cases disappear or decrease significantly after a change of gender role..
Transgender and transsexual activists, but also many caretakers, however, point out that these problems are usually not related to the gender identity issue as such, but to problems that arise from dealing with those issues and social problems related to them. Also, those problems are much more likely to be diagnosed than similar problems in the general population, since for both medical treatments and letters of recommendation contacting a healthcare professional is needed, where the patients are routinely screened for these and similar problems.
A growing number of transsexual and transgender people therefore resent or even refuse often mandatory psychological treatment, since gender dysphoria itself is untreatable by psychological means, and they have no other problems that need treatment. This however can cause significant problems when they try to obtain physical treatment.
Therapists' records reveal most transsexuals do not believe they need psychological counseling, but acquiesce to legal demands in order to gain rights which are granted through the medical/psychological hierarchy. Legal issues such as a name change, and sex reassignment surgery itself are usually impossible to obtain without a doctor's approval. This leads to the inevitability that transsexuals feel coerced into confirming pre-ordained symptoms of self-loathing, impotence, and sexual-preference in order to see simple legal hurdles granted. Transsexuals face the unattractive option of remaining invisible with no legal rights and possibly incongruent identification, or submitting to a medical hierarchy which alone has the ability to grant legal gender status.
Requirements for gender reassignment treatment
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 is required, and a minimum time spent living in the desired gender role in order to ensure they can function psychologically in that role. This is not always possible; transsexual men especially often cannot "pass" this period without hormones. This time period is usually called the Real Life Test (RLT).
Generally speaking, physicians who perform sex-reassignment surgery require the patient to live as the opposite gender in all possible ways for at least a year (this is termed "cross-living") prior to the start of surgery. The RLT is usually part of a battery of requirements. Other frequent requirements are regular psychological counseling and letters of recommendation for surgery.
Hormone replacement therapy
Main article: Hormone replacement therapy (trans)
For both transsexual men and women hormone replacement therapy (HRT) causes the development of the secondary sexual characteristics of their desired gender. The already existing primary and secondary sexual characteristics are not undone by HRT; surgery is required to remove them or change their appearance; transsexual women also require epilation to remove unwanted facial hair and, if necessary, body hair.
Sex reassignment surgery
Main article: Sex reassignment surgery
Sex reassignment surgery consists of processes transsexual women and men take in order to match their anatomical sex to their gender identity; however, surgery to correct genitalia (SRS) is also very expensive and not covered by public or private health insurance everywhere.
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 by the sex and sexual status they have chosen. 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 chosen gender role; these people are often called non-operative.
A more modern idea suggests the notion that the focus on surgery status is misplaced, and therefore more and more people are refusing to define themselves in terms of operative status.
Legal and social aspects
Main article: Legal aspects of transsexualism
Many Western societies today have some sort of procedure whereby an individual can change their name, and sometimes also their legal gender, to reflect their gender identity. Medical procedures for transsexual and transgender people are also available in most Western countries. However, transsexual and transgender people make strong challenges to the prevalence of gender roles in many cultures and often face considerable prejudice. The film Boys Don't Cry chronicles such a case.
Some people who have undergone a change of gender role will adopt or provide foster care for children, often for children who are also transsexual or transgender so they can live according to their gender identity. Societies are in some instances challenged to assimilate these men and women into their social institutions such as marriage and the role of parenting. Often children exist from the time before transition. Many of these children stay with their transitioning/transitioned parent. Recent research 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 should use the pronoun and name used by that person. Family members and friends, who are often confused about pronoun usage or the definitions of sex, are frequently corrected by either the transsexual or the professionals who assist them as they approach that point at which they begin to "pass" as a member of the sex they wish to adopt.
After this level of transition and development has been achieved, many transsexual men and women may wish to blend back in with other members of their new sex and will avoid revealing their past preferring the relative peace and security they find on the other side of a stressful and potentially dangerous transition.
This behaviour is known as stealth, and is somewhat a contentious issue. Some people, including some transsexual people, feel that they should be upfront about their past, and that stealth living is somehow dishonest; however, others claim that transsexual men and women should be able to live in their true gender role in a normal way and be in control of whom they reveal their past to.
The choice to live completely in stealth is known to present its own psychological difficulties - while its desirable for the transsexual male or female to assimilate fully into the new gender role, without someone in which to confide there are often tendencies towards anxiety and depression. The term deep stealth is sometimes used for these individuals, referring to those that have completely isolated themselves from their past and from the support structures that may have helped them through transition, and who now are only known as transsexual to the medical professionals directly involved in their treatment process.
As with every transition, in children and in adults, "experts" often raise the spectre of transitions gone wrong, that is people transitioning back to their original sex. These cases do in fact exist, however, every recent study done on the number of these cases states that their number is well below 1%, and that the reasons for retransitioning are very diverse. See this article in the International Journal of Transgenderism (http://www.symposion.com/ijt/ijtc0502.htm) for examples.
These cases are often cited as reasons for the lengthy triadic process outlined in the Standards of Care, which specifies a treatment process combining supportive 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 or behaviour of some caretakers. The article above states that in some of these cases, transitioning could have been prevented if some demands made by caretakers, or demands perceived as coming from the caretakers, 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 indeed seen as a necessary for the diagnosis of transsexualism, and therefore the prerequisite for any further treatment; consequently, further treatment has indeed 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 is much more difficult, and this will often lead to social problems, depression, anxiety, or similar problems, and, in some rare cases, to a retransitioning. While there is no scientific study on the question, many trans*-organisations and groups claim from experience that the less pressure is felt by the patient to conform to any particular stereotype, the more satisfactory the outcome of the transition will be. This of course does not preclude any screening for mental problems which might lead to pseudo-transsexuality, nor a supportive psychological therapy if necessary.
- List of transgender-related topics
- The International Journal of Transgenderism (http://www.symposion.com/ijt/index.htm) - The Official Journal of the Harry Benjamin International Gender Dysphoria Association (HBIGDA)
- Basic TG/TS/IS Information (http://ai.eecs.umich.edu/people/conway/TS/TS.html) - including Successful Transwomen and Successful Transmen
- How to Respect a Transsexual Person (http://www.kisa.ca/respect.html)
- What transsexuality Is (http://transsexual.org/What.html)
- Transgender Law Center (http://www.transgenderlawcenter.org) - California, USA, civil rights organization advocating for transgender communities through direct legal services, public policy advocacy, and educational opportunities
- Press for Change (http://www.pfc.org.uk) - UK information about the trans rights campaign, and details about the legal, medical, political and social issues surrounding the people it represents
- The Gender Trust (http://www.gendertrust.org.uk) - The UK Charity for the support of trans individuals, their friends & family, employers and professionals
- Definition and Synopsis of the Etiology of Adult Gender Identity Disorder and Transsexualism (http://www.gires.org.uk/Web_Page_Assets/Etiology_definition_signed.htm) - prepared by 24 internationally recognized experts
Specific to transwomen
- Mom, I Need to Be a Girl (http://ai.eecs.umich.edu/people/conway/TS/Evelyn/Evelyn.html) - a book by the mother of a transsexual child
- Transsexual Road Map (http://www.tsroadmap.com) - practical and medical information
- Annelawrence.com (http://www.annelawrence.com/twr/) Medical and Other Resources for Transsexual Women
Specific to transmen
- FTM International (http://www.ftmi.org) - Female To Male International: practical and medical information
- American Boyz (http://www.amboyz.org) - practical and medical information