Re-published by The Looking Glass Society by permission of the
This booklet was written as an introduction to the subject of Transsexualism. It includes a summary of current medical and scientific opinion about the condition, as well as observations on how it feels to actually be a transsexual woman.
The booklet is based very strongly on the author's own personal experiences as a transsexual woman, and therefore some other transsexuals may well choose to disagree with some of my opinions and observations. Likewise, the medical part of the booklet represents my understanding of the 'best consensus' of current medical and scientific opinion. Research is ongoing into many aspects of human gender and sexuality, particularly regarding genetics and neurophysiology. Contrary opinions are held by some researchers, and new information is appearing all the time.
This booklet deals only with male-to-female transsexualism. This is in no way meant as a slight to the female-to-male community, but as I am a male-to-female transsexual, I do not feel qualified to write about female-to-male transsexualism, although it is of course a closely related phenomenon.
For more in-depth technical or medical information, please refer to the considerable existing literature around the subject. This booklet was written as a general introduction for those seeking to understand the condition and its social and personal consequences, and is not meant in any way to replace such specialist material.
I would like to dedicate this booklet to all the people, both friends
and professionals, who have helped me through my own gender change. And
to all those who seek to understand and to help those of us who are
transsexual, I offer my sincere thanks.
This booklet is subject to Copyright (1995/6). It may be copied unchanged in its entirety and distributed for any non-commercial purpose promoting the understanding and well-being of transsexual people. No part of the booklet may be copied for any other purpose without the author's permission.
Transsexualism is a complex and little-understood condition. Because it involves very fundamental aspects of human identity, it attracts considerable misunderstanding, fear and prejudice. Sensational and inaccurate stories about 'sex-changes' abound in the popular media, and contribute to the misunderstanding and apprehension that many people feel about the condition.
Put very simply, a transsexual is a person whose gender (psychological sex) is opposite to their physiological sex. Many transsexual women, prior to gender reassignment, do consider themselves to be 'women trapped in male bodies'; others consider this description trite or even inaccurate.
The first part of this booklet aims to explain what transsexualism really
is, as well as dispelling the common confusion between transsexualism,
transvestism and homosexuality (they are three totally different phenomena).
The second part summarises the current medical viewpoint on the
causation of the condition. The third part describes how transsexual
people deal with the condition, and briefly describes the process of
gender reassignment ('sex change'). Finally, the social and legal
implications of the condition are discussed.
2 What is Transsexualism?
2.1 Sex, Gender and Gender Dysphoria
Before embarking on a detailed discussion of transsexualism, it is important to define some terms; Sex and Gender are two important and different concepts that are frequently confused.
Sex refers to someone's anatomical sex --- in other words, which type of genitals they possess. Except in very rare cases of hermaphroditism, anatomical sex is well-defined and easy to interpret.
Gender is rather more subtle, and refers to the person's own self-identity as a male, female or something else. The overwhelming majority of the population have a gender that accords with their anatomical sex, which is why few people understand that the two are different. Gender is less clearly defined than anatomical sex, and does not necessarily represent a simple binary choice: some people have a gender identity that is neither clearly female nor clearly male.
Gender consists of two related aspects: Gender Identity , which is the person's internal perception and experience of their gender, and Gender Role , which is the way that the person lives in society and interacts with others, based on their gender identity.
is an umbrella term covering a feeling of
unhappiness and incongruity concerning one's physical sex and/or gender
role. This covers a range of feelings, from a general sense of
discontentment with the socially expected role, through certain forms of
gender-motivated transvestism (dressing as the 'opposite' sex to
alleviate this dysphoria), through to full-scale transsexualism (with
an overwhelming desire to change one's body and genitals, and to
actually become, as far as medically possible, the other sex).
2.2 What Transsexualism Is Not
There are several other possible human conditions that are commonly confused with transsexualism, but are quite distinct. These are described briefly here to eliminate them from this discussion:
Gender-Motivated transvestites are usually unremarkably masculine, heterosexual men, who construct a female alter ego to allow themselves to express the 'feminine' character attributes such as sensitivity and emotionality that they deny themselves in their male role. The female persona is kept totally separate, and the transvestite, when in his male mode, will often refer to his female persona as if she was a totally different person. Gender-Motivated transvestites may or may not be gender dysphoric: some cross-dress to escape from a feeling of unhappiness with the male social role, many simply because they enjoy playing at being (their idea of) female. The former type would probably be regarded as being mildly gender dysphoric, the latter would certainly not. Nevertheless, transvestites are emphatically different from transsexuals: the transvestite always has a core male identity, even if he occasionally likes to escape into a female alter ego , while the (male-to-female) transsexual always has a core female identity.
Fetishistic transvestites cross-dress to obtain some form of sexual pleasure or stimulation. They are almost universally heterosexual, and are not regarded as gender dysphoric.
Transvestites generally regard themselves as fundamentally male, and most would be appalled by the idea of actually changing their sex. However, it is not uncommon for transsexuals to go through a phase of seeing themselves as (or perhaps trying to convince themselves that they are) merely transvestites, before they come to fully accept their true condition. Conversely, a few transvestites carry their fantasy 'female self' too far and delude themselves into thinking that they are transsexual. Rigorous psychiatric screening is used before allowing 'sex-change' treatment to minimise the possibility of such people embarking on a course of action that they would come to regret.
Transvestites are relatively common: some estimates would have several
percent of the male population showing some degree of transvestite behaviour.
Homosexuality and bisexuality are very common; some statistics even
suggest that people exhibiting some degree of bisexual or gay attraction
could outnumber pure heterosexuals. At the minimum, homosexuals and bisexuals
represent a large minority.
Many milder intersex conditions exist, often resulting in varying degrees of malformation or dysfunction of the genitals. Such conditions do appear to be significantly more common among transsexuals than among the general population, though the majority of transsexuals are not obviously physically intersexed.
The incidence of true hermaphroditism is reportedly somewhere around the one-in-a-million mark, although milder physical intersex conditions are very much more common. As many as 1 in 200 live births exhibit some degree of physical ambiguity, and as many as 1 in 400 people have a chromosome configuration that does not match either the standard male (XY) or standard female (XX) karyotypes.
Transsexualism is the most pronounced form of Gender Dysphoria. A typical medical definition of transsexualism would be along these lines:
A transsexual is someone who experiences a deep and long-lasting discomfort with their anatomical (genital) sex, and wishes to change their physical characteristics, including genitals, to the opposite of those usually associated with their anatomical sex, and to live permanently in the gender role opposite to that normally associated with their anatomical sex.
The medical definition is usually hedged around to exclude conditions such as hermaphroditism and various forms of psychosis which may lead to patients thinking they are transsexual without really being so. Some transsexuals also exhibit a degree of physical androgyny (which supports the view that transsexualism stems from an endocrine disorder, like hermaphroditism) but this is not part of the required conditions for diagnosis.
Transsexualism is still thought by many people to be a psychiatric condition, even though most transsexuals are perfectly sane and rational and recent research has shown that the condition has a physical basis --- that the 'female brain in a male body' is a biological reality. Nevertheless, in most countries the person in overall charge of a gender reassignment ('sex-change') will be a consultant psychiatrist. The psychiatrist's role is to ensure that the patient is sane, really is transsexual, and is mentally stable enough to make the necessary adaptation to the new gender role.
Most transsexuals dislike the typical medical description, as it still tends to suggest a psychiatric, rather than physical, origin for the condition, in spite of the criterion that one must be sane to be allowed gender reassignment. The present author would like to suggest an alternative, and personal, view of what it means to be transsexual:
I am a woman who, probably due to some endocrine malfunction before birth, was born with male genitals. Since our society assumes that gender and sex always correspond, I was wrongly assigned to the gender pigeon-hole called 'male' by a doctor who looked at my genitals instead of my mind. Throughout my childhood I knew perfectly well that I was really a girl (after all, it's my mind, not my genitals, that make me the person that I am), but because my body seemed to insist otherwise, I was forced to try to fit in to the gender role of a boy. This produced intense unhappiness and almost totally ruined my life until I accepted the reality of my situation and underwent gender reassignment as an adult. I now live in the gender role called 'female' that matches my gender identity; the medical profession labels me as a 'post-operative true primary male-to-female transsexual', but I regard myself as a perfectly normal, well-adjusted and happy woman.
Bearing in mind the definitions of 'sex' and 'gender', some transsexuals are uncomfortable with the accepted medical term 'gender reassignment' to cover what is popularly known as 'a sex change'. While many medics would adopt the reductionist viewpoint that sex is properly determined by chromosomes and not by genitals, and that there can therefore be no true change of sex, it is not really a change of gender either. It is a change of gender role , to bring it into conformity with the person's gender identity , with hormonal and surgical reconstruction, as far as possible, of the body's sexual characteristics.
Many specialists draw a distinction between primary and secondary transsexuals, although in reality there is probably a spectrum rather than a black-and-white division. Primary transsexuals exhibit cross-gender identity and severe gender dysphoria from an early age, and are unable ever to function satisfactorily in their natal sex role. Secondary transsexuals arrive at their cross-gender identification later in life, often after being fully functional in their natal sex role for some time, perhaps having even married and raised families. It seems likely that primary transsexuals are the true 'female brain in male body' case, with extensive feminisation of the brain, while secondary transsexuals represent a less severe version of the condition, with only partial feminisation of the brain. This view has been borne out by psychometric tests that aim to quantify 'masculine' and 'feminine' personality traits.
Transsexualism is a fairly rare condition. About one person per thousand is gender dysphoric to some extent, although true primary transsexuals are far fewer. Recent estimates would suggest that around one person per 25,000 is a true primary transsexual, with perhaps ten times that number of secondary transsexuals.
After reassignment most, but by no means all, transsexuals are heterosexual. Among the transsexual population, the usual spectrum of human sexuality can be found. Gender identity and sexual preference are not very strongly connected. Interestingly, it appears that primary transsexuals exhibit a similar incidence of sexual preferences to the natural-born female population, while secondary transsexuals demonstrate a much higher incidence of lesbianism or bisexuality.
There is also an increasing number of people who label themselves as
'transgenderists'. They typically wish to live as members of the
opposite sex, but without undergoing genital surgery. This could be
regarded as a kind of mid-point between the Gender-Motivated
transvestite and the transsexual. While this unquestionably another
manifestation of Gender Dysphoria, it is debatable whether such people
are transsexual in the true sense.
3 The Medical Viewpoint
3.1 What Causes Transsexualism?
Transsexualism has been recognised as a distinct condition for about forty years; before that, anyone who was convinced that their true sex lay opposite to that suggested by their genitals was simply considered psychotic. For many years, opinion was divided as to whether the origin of the condition is psychiatric or physiological, despite the fact that no amount of psychotherapy, psychoactive drugs, aversion therapy or any other psychiatric method has ever 'cured' a true transsexual. The only treatment that seemed to work was gender reassignment, the use of hormones and surgery to modify the person's body and bring it into line with their true gender, and to enable them to live in their proper gender role.
It is now accepted by all reputable professionals in the field that transsexualism stems from a physiological cause, and is in no way a mental illness, perversion or 'lifestyle choice'. The consensus of opinion is that gender identity is determined before birth and is unchangeable thereafter:
All human foetuses start off in a female configuration, and in the absence of biochemical instructions to the contrary, will develop into baby girls --- irrespective of their chromosomal sex . This 'female by default' development is overridden in normal male foetuses by a complex sequence of hormonal processes. It starts about six weeks after conception, when the SRY gene on the Y chromosome causes a weak male hormone precursor to be secreted. This causes the foetal gonads to differentiate into testes instead of ovaries. Some weeks later, the primitive testes start working, and secrete a large dose of testosterone (the principal male hormone), which causes the foetal brain to differentiate into the male pattern. It is at this point that the brain structure responsible for gender identity, as well as all the other well-known (and measurable) brain differences between men and women, is laid down.
Transsexualism is caused by that second burst of hormones failing to happen, or only happening very weakly (many male-to-female transsexuals do exhibit some masculine mental tendencies, but retain the feminine gender identity, suggesting that the masculinisation of the brain went part of the way and then failed). In the case of the most extreme primary transsexuals, with no detectable brain masculinisation at all, the second hormone surge is probably entirely absent. There are a number of possible reasons for this failure; in some cases, the genitals do not develop normally, and therefore do not manage to secrete testosterone on schedule to alter the brain. This is likely to produce a certain degree of physical intersex in the infant as well as transsexualism. Most transsexuals, however, are not obviously intersexed, so subtler causes must be involved.
Overall, the condition seems to have three possible causes:
Some other causes have been suggested in the past, but have by and large been discredited. In particular, all variants of the 'nurture' explanation (which suggests that the infant was subject to a 'wrong-gender' upbringing --- perhaps the parents really wanted a girl, not a boy) can be discounted, now it is known that male-to-female transsexuals have physiologically female brains --- after all, neither upbringing nor cultural influences can change the pre-natal wiring of one's brain.
Once the relevant stage of pregnancy has passed, there is no way that
the foetus's brain-sex (and hence gender) can be altered: postnatally, hormones can
alter the body, but the brain remains forever as it was born. This is
why it is impossible to change a transsexual's gender to match their
natal sex. It may seem strange to change someone's body-sex to match
their gender, but it is the only treatment possible, as the
brain cannot be altered to match the natal physiological sex. So gender reassignment
('sex-change') is the only successful way of treating transsexuals.
4 Dealing with Being Transsexual
There are a number of ways in which transsexuals deal with their condition, and many transsexuals will pass through several of these as 'stages' on their journey to self-fulfilment.
This is not a way of dealing with being transsexual, but is something that all transsexuals probably go through in the early stages. Trying to convince themselves that they are not really transsexual, or will grow out of it, or 'ignoring it and seeing if it goes away', all characterise the denial phase. Denial does not usually work for long, and there is considerable evidence that transsexuals who fail to escape this stage frequently commit suicide. Figures suggest that as many as thirty percent of transsexuals are not diagnosed and treated soon enough to prevent them from taking their own lives.
A few transsexuals come to a realisation of what they are, but consciously choose to live with the discomfort of an inappropriate body and gender role, perhaps because of religious beliefs or perhaps for the sake of wife or children. In a few cases, transsexuals may live in a way more reminiscent of transvestites, only expressing their true gender on agreed occasions. This type of adaptation is nearly always found to be unsatisfactory for the true transsexual, and similar problems to those of the Denial phase then occur.
For many transsexuals, the most pressing need is the need to alter their gender role and to live in accordance with their gender identity. This means, for a male-to-female transsexual, living completely as a woman. This is usually, but not always, done as a step in a journey leading to hormonal and surgical gender reassignment, but some people choose to stop here (and usually label themselves as 'transgenderists'), or maybe even to live a 'mixed-gender' lifestyle --- a few people with Gender Dysphoria feel that they are neither truly male nor truly female.
For male-to-female transsexuals, permanent removal of facial hair by electrolysis is usually a necessary step, and is usually done before, or just after, social reassignment. It is time-consuming, expensive and painful: two years of treatment at two or three hours per week is often required, at a cost that can often exceed £25 per hour. Many people find the pain barely tolerable, even with a local anaesthetic. It is normally impossible to obtain electrolysis from the NHS, so the transsexual must pay for private treatment.
Most transsexuals undertake hormone treatment to bring their body shape and appearance into closer accord with their gender identity. Hormone treatment may start before or after social reassignment: a few transsexuals can 'pass' in their new social role without hormone treatment, many may require some months of treatment before undertaking social reassignment. In Britain, hormones can only be prescribed by a consultant psychiatrist as part of a gender reassignment programme.
The initial hormone treatment is largely reversible if stopped early, and this is often used as a safety check to prevent people who are not truly transsexual (such as confused transvestites who convince themselves that they are transsexual) from taking a disastrous course of action. Since transvestites have male brain structure and core identity, and their behaviour is mediated by male sex hormones, their cross-dressing behaviour stops when female hormones are administered. This effect is used to 'weed out' people who are not true transsexuals: a true transsexual will feel natural and happy under the effects of female hormones, anyone else will feel wrong and will stop their apparent cross-gender behaviour as male hormone function ceases.
Large doses of hormones are used to overcome the body's own sex hormones, which carry some risk of side effects. After genital surgery, the dosage is greatly reduced as the body no longer produces hormones in opposition to the prescribed ones, but a post-operative transsexual will need to take a maintenance dose of hormones for life.
Some transsexuals continue in a pre-operative state for long periods, taking hormones and living in their preferred gender role, but perhaps never having surgery. There is evidence that continuing the high hormone dosages required for pre-op transsexuals for long periods may be harmful.
Male-to-female hormone treatment causes development of breasts, usually rather small, as well as redistribution of body fat and a general feminisation of the figure, hair and skin. Body hair is often reduced but not removed, and hormones seldom have any large effect on facial hair. Hormones will not alter a male voice (nor will genital surgery), so male-to-female transsexuals must usually undertake some kind of speech training, learning to raise and soften the voice as well as using more feminine inflection and vocabulary.
This is seen by some as the entire purpose of the long process of gender reassignment, while others feel that it is more of a final step to achieve congruity of body and mind after the really hard work of establishing a life in the proper gender role has been done.
The process, for male-to-female transsexuals, involves removal of the male genitals and the construction of a set of female genitals (excluding uterus and ovaries, of course) using material from the male genitals. Present state-of-the-art surgical technique produces a very good approximation to natural female genitals (even gynaecologists have been known not to realise that a patient is a post-op transsexual), with fairly good nervous sensation, although of course it is dependent on the skill of the surgeon.
The operation is a major surgical procedure (requiring about ten days in hospital, and four hours or more under anaesthetic), is quite painful and invariably expensive. Many transsexuals in Britain opt for private treatment as it has become very difficult, and impossible in many areas, to obtain NHS treatment and the waiting lists are very long.
No reputable surgeon will perform surgical reassignment without
recommendations from two psychiatrists. It is normally impossible to
obtain permission for surgery without performing a 'Real Life Test' ---
living and working as a woman for at least one year.
5 Social, Economic and Legal Implications
Transsexuals in Britain face considerable social and legal obstacles to a successful gender role change. Widespread social prejudice means that transsexuals are often harassed, ostracised or even assaulted if their condition becomes known. Many transsexuals find themselves forced to abandon their previous life, job and social circle altogether and to start a new life 'from scratch' in a new area where their gender history is not known. Many transsexuals lose friends or family due to prejudice and lack of understanding. All this makes for considerable additional difficulty for the transsexual during what is inevitably a stressful and traumatic part of her life.
The economic situation also makes life difficult for the transsexual. Many transsexuals, prior to reassignment, are unable to function effectively as productive citizens because their Gender Dysphoria is so debilitating. After successful gender reassignment, the vast majority of transsexual people become fully functional members of society and contribute to the economy in full. The biggest difficulty arises at the 'in-between' stage: today it is almost impossible to obtain gender reassignment with NHS funding, leaving private treatment as the only available option for many people. But a person who is unable to function effectively in their natal sex role will probably find it extremely difficult to save enough money for treatment, and the problem is compounded by the requirement for the 'real-life test' --- it can be very difficult to hold down a job while 'in transition'; it is a difficult time for the transsexual herself, she may require considerable time off work for treatment, and if her transsexual status is discovered (and it can be very hard to conceal, especially prior to surgery) she is likely to lose her job. In the circumstances, it is not surprising that many transsexuals become suicidal when treatment is unobtainable, or that some resort to prostitution as the only way to pay for the treatment. Privately, gender reassignment costs a minimum of £10,000 for surgery, psychiatrists' fees and electrolysis; the cost can easily rise by thousands of pounds if the patient requires more than a minimal amount of electrolysis, or if she requires any cosmetic surgery in order to 'pass' as a woman.
An untreated transsexual may well be a burden on the state if she cannot keep a job, she may have persistent psychological problems such as depression, and she may well eventually commit suicide, costing the state a great deal to 'clear up'. After successful treatment, she would most likely be a fully productive member of society, and would repay in taxation many times the cost to the NHS of providing the reassignment; recent figures show a 97 % long-term success rate. Denial of NHS treatment to transsexual people is not only a false economy for the state, it is an iniquitous denial of basic rights to a group of citizens with a genuine and debilitating medical condition.
If the social and economic difficulties are bad, the legal situation is in many ways worse, and acts to compound the other difficulties. Under present UK law, a post-treatment transsexual exists in a kind of legal 'limbo': It is not difficult to obtain a legal change of name, and after gender reassignment it is possible to have much civil documentation re-issued in the new name and gender --- for example, passport, driving licence and medical records. The single biggest problem, however, is that owing to a 25-year-old court ruling based on reasoning that is now known to be invalid in the light of new medical knowledge, transsexuals are not allowed to change their Birth Certificates , even after surgery. As a consequence, for many legal purposes the original natal sex is considered still to apply. This means, for example, that a transsexual woman may not marry a man, and if convicted of a criminal offence may be sent to a male prison, with dreadful consequences.
Prior to that Court ruling, transsexuals in Britain were allowed to change the gender recorded on their Birth Certificates after surgery. Today, the UK and Eire are the only countries in the EU that deny this fundamental right to their transsexual citizens, with far-reaching consequences for those citizens.
Since the Birth Certificate is the primary form of identification document in Britain, a post-treatment transsexual may have to reveal her history to a prospective employer, which may well lead to discrimination. Furthermore, the DSS and Inland Revenue will not recognise the new gender, so a transsexual woman will not receive her pension until 65 rather than 60 and will be treated as male for taxation purposes. This, and similar anomalies, can all too easily lead to the person's history being revealed.
(Some people object to the idea of changing the Birth Certificate, on the grounds that it 'should' record the genital sex into which the person was born --- the problem arises because the Birth Certificate is used as an identification document rather than merely as a historical record. This objection can be addressed by the method adopted by some states in the USA: a new certificate, with the new name and gender, is issued, but the original certificate is sealed and kept on file, where it can be accessed only on the order of a Court.)
Furthermore, existing case law in Britain holds that the Sex Discrimination Act does not apply to transsexuals, and that an employer may fire an employee at will merely for being transsexual. In April 1996, the European Court of Human Rights ruled, in a test case, that this was unlawful and thus that the coverage of the Act should be extended to include transsexuals; however the present UK government is still resisting this ruling and the relevant statute law has not yet been formally amended.
All of this leads to a significant denial, to the transsexual, of basic rights and civil liberties that all other citizens take for granted. Britain lags significantly behind most other developed countries in this respect, and change is long overdue.
Modernising the law to allow post-treatment transsexuals the same rights
and responsibilities as other members of their gender would not only
offer a significant direct improvement in quality of life for
transsexuals, but would also send a clear signal to society at large
that transsexual people are to be treated the same as anybody else. Over
a few years, this could significantly ease the problems of social
discrimination --- at the moment, the fact that transsexuals are
marginalised and oppressed by the law signals to the public that it is
acceptable to mistreat and discriminate against transsexuals.
The key points discussed in this booklet have been as follows: