The high degree of acceptance most people have of their gender is so central to their sense of self that is extremely difficult to understand how some people who have the physical characteristics of one gender can actually believe themselves to be members of the other. Individuals who feel this way are known as transsexuals. Frequently, an explanation of this phenomenon will begin, "imagine that you wake up one morning and find yourself in the body of the other gender." But as transsexual author Kim Elizabeth Stuart has written in, The Uninvited Dilemma, "You can't compare an experience with a non-experience." So while it is virtually impossible for a non-transsexual to understand what this condition feels like, it may be possible to understand how this condition arises and how it can best be dealt with.
Miscast In the Play of Life
Transsexuals often express their feelings as akin to being cast in a role they are not suited for, for example, trying to play the hero when they are better suited to portraying the heroine. Nevertheless, they have to fit in to survive. They learn their lines and act the part. Actions and words that are foreign to their true nature are forced upon them because of their physical appearance. Eventually, as any actor would when performing in any long-running play, they get the role down pat. They can recite the lines, follow all the stage directions, and be a very convincing man or woman without even thinking about it. The trouble is that when they leave the stage, when they're alone with themselves, they know that the part isn't right for them. They know who they really are. They want nothing more than to be themselves, but they can't just take off the costumes and lead normal lives because the costumes are actually their bodies.
A Theory on the Origin of Transsexualism
The physical gender of a fetus is established by the pairing of a single chromosome from both parents at the moment of conception—XX for females and XY for males. However, not until later do physical differences based on the fetus' chromosomal gender develop. These differences are triggered by an infusion of hormones. At the same time, the fetus' corresponding gender identity—the "gender of the brain"—begins its development. According to a widely held theory which attempts to explain the origin transsexualism, if the timing of this "hormone shower" is off, or if the mix of hormones is somewhat faulty, a mismatch of mental and physical gender may occur. This is why transsexualism is frequently described as being a birth defect.
Unfortunately, for the transsexual trying to gain acceptance for others, this birth defect has no visible effects. The transsexual appears to be a perfectly normal male or female with normal primary and secondary sexual characteristics. Unlike the distinctive facial characteristics of Down's syndrome, or the lack of muscle control caused by cerebral palsy, transsexualism cannot be detected visually or by any other means. Since other people can't see anything amiss, they conclude that transsexualism is not a physical defect, but more an emotional/psychological problem. It is a common but erroneous belief that with a little self-discipline, or with counseling, a transsexual person can act normally and accept their lot in life.
There Is No Cure, But There Is Treatment
After decades of trying, psychiatrists have had to admit defeat in conquering this dilemma. In all the years that psychiatry has tried to "cure" transsexualism, not one case has responded positively and permanently. It wasn't until the 1950's that pioneering psychiatrist and endocrinologist Dr. Harry Benjamin decided to apply both of his specialties to the treatment of the transsexual. If the mind could not be changed to correspond to the body, he reasoned, then the body should be changed to match the mind. For the first time, transsexuals were able to live contentedly in their own bodies. But gender reassignment is not a cure, it is merely a treatment that may prevent other, more serious problems such as suicide or substance abuse.
Transsexuals do undergo extensive psychological evaluation and counseling. This process is not to convince the subject to "give up" his/her transsexualism, but to determine the appropriateness of the drastic and irreversible gender reassignment process. For example, if the person is not truly a transsexual, but is instead suffering from ego-dystonic homosexuality, the results of the treatment could be devastating. A misguided transvestite, who is normally happy living in their physical gender role but who has a compulsion to function occasionally in the role of the other gender, could also be made very unhappy by permanent gender reassignment. Therefore, an avowed transsexual must be evaluated by an experienced psychological counselor to make sure transsexualism is the real issue.
Once a diagnosis of transsexualism is confirmed, the medical portion of the treatment begins. A person who enters this portion of the treatment is often called a preoperative transsexual. Hormone treatment gradually helps the transsexual out of his or her "costume" and into the body which will allow him/her to drop the "role" and fit into society in what he/she considers her/his rightful place. (The dual-gender identification used here is to recognize the existence of both male-to-female and female-to-male transsexuals, NOT to insinuate a dual gender identity on the part of the individuals.) After some time, lasting from several months to several years, the transsexual publicly assumes the new gender role. Psychological counseling continues during the entire period of hormone therapy to help the transsexual unlearn a the role he or she has played for many years. There is a lot of trauma involved. The transsexual needs help not only in learning the new role, but also in learning that it's now okay to play it.
Most reassignment protocols require living and working in the new role for a minimum of 12 to 18 months before gender reassignment surgery is authorized. This phase is called the Real Life Test or "RLT." Both the patient and the psychological counselor must be fully convinced that the surgery will be helpful, not harmful. Then, the primary therapist refers the patient to a second doctor, usually a psychiatrist, for another evaluation to confirm that surgery is appropriate. Only then will a reputable surgeon accept the patient.
Surgical gender reassignment is an irreversible process. It must be undertaken with extreme caution. The American medical profession has adopted a conservative view toward treating transsexualism with hormone therapy and gender reassignment surgery. Without a competent, experienced psychological/psychiatric evaluation, no competent, ethical physician or psychiatrist will prescribe hormone therapy. Without two such evaluations, no reputable surgeon will perform gender reassignment surgery. These rigorous requirements are intended to insure that individuals who change their gender do so not because of mental instability, but because that person has totally proven his or her mental stability in the desired gender role.
Notes on Personal Relationships
Because of their extensive experience in acting "normally," i.e. in the manner determined by their physical gender, many people find it difficult to believe that the person they long have know as a member of one gender is actually a member of the other. In almost every case, the discovery of the condition and physical changes that accompany treatment come as a surprise to everyone. The common reaction among family and friends is one of disbelief, feelings of having been deceived, and revulsion. One could ask, then, why would a person enter into relationships under "false colors," knowing that they will quite probably inflict a high level of suffering on others?
While many transsexuals know they are different at a very early age, they also feel an intense pressure to conform to the role society says is appropriate for men or for women. As a result, the transsexual sometimes denies that he or she is really different. This process of conforming and denying often involves forming friendships, and closer types of personal relationships. A transsexual's eventual acknowledgment of their true gender identity and their commencement of treatment exacts a severe toll on these relationships. At first, family members, friends or spouses try to have the transsexual "cured" through analysis or therapy because they are unwilling to accept the inevitable result. But as they come to realize that the cure they hoped for is not possible, the relationship is put under intense pressure. When the relationship is based on personal characteristics other than gender, the relationship can continue but with obvious changes. For example, a loving son can be just as loving as a daughter; a male co-worker can be just as competent and as congenial as a female colleague. It is a sad fact that many of these relationships dissolve, some amicably-albeit sadly, while others are torn apart with recriminations. But what of those relationships that are based on gender; marriages for example? Many surgeons require that married transsexuals be divorced before they can have surgery. In a very few instances, partners who are friends as well as lovers may remain together in a Platonic relationship. In several recent cases, courts have awarded custody or visitation rights to transsexual parents.
What about forming relationships after gender reassignment? Most postoperative transsexuals do not find it necessary to inform new friends or lovers that they used to be a member of the other gender. This is especially true if the transsexual has made a complete break with his or her past. But after surgery, some transsexuals pick up their lives where they had left them when they began the change. They retain their same last name; they work in the same business; they even keep the same friends. Sexual relationships may be problematical for even the most open and candid transsexual. For example, the knowledge that a woman used to be a man may jeopardize heterosexual relationships. But not all transsexuals desire a heterosexual relationship after surgery. It is not uncommon for a post-operative male-to-female transsexual to declare herself a lesbian, or a female-to-male transsexual to proclaim himself to be gay. These types of relationships can also difficult for transsexuals because some lesbians and gay men harbor deep prejudices against transsexuals just as many heterosexuals do. Finally, many transsexuals are not sexually active at all. This range of sexual orientation is possible because sexual orientation and libido are distinct from gender identity. While an individual's sexuality is often expressed through their gender, their sexuality is not determined by it.
Transsexuals sometimes express their feelings of being different in terms of "living a lie." If there is any fraud involved in being a transsexual, it is the fraud perpetrated by the transsexual before treatment. The person who completes treatment is now the genuine article. He or she has left behind a life of deception and unhappiness. In spite of great odds, he or she has emerged as the person he or she has always been. When you meet a transsexual, you are meeting a person who knows how to love, knows how to appreciate him or herself and, as a result, knows how to love and appreciate others. How many "normal" people can claim that distinction?