Transsexual men and women, referred to as a trans man or trans woman respectively, desire to establish a permanent gender role as a member of the gender with which they identify, often pursuing medical interventions as part of the process. These physical alterations are collectively referred to as sex reassignment therapy and may include female-to-male or male-to-female hormone replacement therapy, or various surgeries such as orchiectomy, facial feminization surgery, sex reassignment surgery, trachea shave and mastectomy. The entire process of switching from one physical sex and social gender presentation to the other is often referred to as transition, and usually takes several years. As well as conforming to the heterosexual lifestyles and gender roles, transsexuals are now conforming and identifying according to a lesbian or a homosexual identity. Gender identity still takes precedent over morphological sex.
Transsexualism is an individual’s identification with a gender inconsistent or not culturally associated with their assigned sex. Simply put, it defines a person whose assigned sex at birth conflicts with their psychological gender. A medical diagnosis can be made if a person experiences discomfort as a result of a desire to be a member of the opposite sex, or if a person experiences impaired functioning or distress as a result of that gender identification. Transsexualism is stigmatized in many parts of the world but has become more widely known in Western culture in the mid to late 20th century, concurrently with the sexual revolution and the development of sex reassignment surgery (SRS). Discrimination or negative attitudes towards transsexualism often accompany certain religious beliefs or cultural values. There are cultures that have no difficulty integrating people who change gender roles, often holding them with high regard, such as the traditional role for ‘two-spirit’ people found among certain native American tribes.
The current diagnosis for transsexual people who present themselves for psychological treatment is “gender identity disorder” (leaving out those who have sexual identity disorders without gender concerns). The DSM changed its terminology in 1994 away from the diagnosis of “transsexualism”. According to the Standards Of Care formulated by the World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association, this diagnostic label is often necessary to obtain sex reassignment therapy with health insurance coverage, and states that the designation of gender identity disorders as mental disorders is not a license for stigmatization, or for the deprivation of gender patients’ civil rights. 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 transsexual people. The diagnosis of “gender identity disorder” is seen as insulting and irrelevant to some transsexuals, and may be considered a causal factor in instances of harm occurring to, or death of, transsexual people as the result of prejudice and discrimination when deprived of their civil rights. Many transsexual people have asked 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.
Psychological and biological causes for transsexualism have been proposed, with evidence leaning toward prenatal and genetic causes. One such cause is related to the BNST (bed nucleus of a stria terminalis),a constituent of the basal ganglia of the brain, which is affected by prenatal androgens. Some people consider research into the “causes” of transsexualism to be based on the assumption that it is a pathology, an assumption that is rejected by many transsexuals. Others think of the condition as a form of intersexuality, and support research into possible causes, 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. Note stigma has a role to play in the development of and adherence to both viewpoints. See the transfeminism article’s section on GID for further discussion.
Harry Benjamin wrote, “Summarizing my impression, I would like to repeat here what I said in my first lecture on the subject more than 10 years ago: Our genetic and endocrine equipment constitutes either an unresponsive, sterile, or a more or less responsive, that is to say, fertile soil on which the wrong conditioning and a psychic trauma can grow and develop into such a basic conflict that subsequently a deviation like transsexualism can result.” A few studies based on small samples suggest that transsexualism might be associated with a difference in the human brain called the bed nucleus of the stria terminalis (BSTc). In one study, the BSTc of male-to-female transsexuals and cisgender women were similar. Those of heterosexual and homosexual men were similar to each other and different from those of women (cis- and transsexual). Another study suggests that transsexuality may have a genetic component.
Sex reassignment therapy (SRT) is an umbrella term for all medical procedures regarding sex reassignment of both transgender and intersexual people. Though SRT is sometimes called “gender reassignment”, those who use the word “sex” to describe an individual’s biology and “gender” to describe their personal identity and social role consider this usage to be misleading. The process of changing from one gender presentation to another is often called transition. Individuals make different choices regarding sex reassignment therapy, which can include hormone replacement therapy (HRT) to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, facial feminization surgery and permanent hair removal for trans women. Transsexual people who transition usually change their social gender roles, legal names and legal sex designation.
To obtain sex reassignment therapy, transsexual people are generally required to undergo a psychological evaluation and receive a diagnosis of gender identity disorder in accordance with the Standards of Care (SOC) as published by the World Professional Association for Transgender Health. This assessment is usually accompanied by counseling on issues of adjustment to the desired gender role, effects and risks of medical treatments, and sometimes also by psychological therapy. The SOC are intended as guidelines, not inflexible rules, and are intended to ensure that clients are properly informed and in sound psychological health, and to discourage people from transitioning based on unrealistic expectations. Psychological techniques that attempt to alter gender identity to one considered appropriate for the person’s assigned sex are typically ineffective. The widely-recognized Standards of Care note that sometimes the only reasonable and effective course of treatment for transsexual people is to go through 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. These problems may be alleviated by a change of gender role and/or physical characteristics. Many transgender and transsexual activists, and many caregivers, note that these problems are not usually related to the gender identity issues themselves, but the social and cultural responses to gender-variant individuals. Some transsexual people reject the counseling that is recommended by the Standards of Care because they don’t consider their gender identity to be a psychological problem. Brown and Rounsley noted that “some transsexual people acquiesce to legal and medical expectations in order to gain rights granted through the medical/psychological hierarchy.” Legal needs such as a change of sex on legal documents, and medical needs, such as sex reassignment surgery, are usually difficult to obtain without a doctor and/or therapist’s approval.
Because of this, some transsexual people feel coerced into affirming outdated concepts of gender to overcome simple legal and medical hurdles. After an initial psychological evaluation, men and women may begin medical treatment starting with hormone replacement therapy or hormone blockers. People who change sex are usually required to live as members of their target sex for at least one year prior to genital surgery, so-called Real-Life Experience (RLE) or Real-Life Test (RLT). Transsexual individuals may undergo some, all, or none of the medical procedures available, depending on personal feelings, health, income, and other considerations. Some people posit that transsexualism is a physical condition, not a psychological issue, and assert that sex reassignment therapy should be given on request. People who undergo sex reassignment surgery can develop regret for the procedure later in life, largely due to lack of support from family or peers, with data from the 1990s suggesting a rate of 3.8%.
A review of Medline literature suggests the total rate of patients expressing feelings of doubt or regret is estimated to be as high as 8%. 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. Laws regarding changes to the legal status of transsexuals are different from country to country. Some jurisdictions allow an individual to change their name, and sometimes, their legal gender, to reflect their gender identity. Within the US, some states allow amendments or complete replacement of the original birth certificates. Some states seal earlier records against all but court orders in order to protect the transsexual’s privacy. In many places, it is not possible to change birth records or other legal designations of sex, although changes are occurring. Estelle Asmodelle’s book documented her struggle to change the Australian birth certificate and passport laws, although there are other individuals who have been instrumental in changing laws and thus attaining more acceptance for transsexual people in general.
Medical treatment for transsexual and transgender people is 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 parenting. They sometimes adopt or provide foster care for children, as complete sex reassignment therapy inevitably results in infertility. 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, with no harm to 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. Deliberate mis-gendering is perceived to be a form of transphobia. Transsexuals can have difficulty maintaining employment. Most 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. Other stresses that transsexuals face in the workplace are being fearful of coworkers negatively responding to their transition, and losing job experience under a previous name–even deciding which rest room to use can prove challenging. Finding employment can be especially challenging for those in mid-transition. Laws regarding name and gender changes in many countries make it difficult for transsexual people to conceal their trans status from their employers. Some transsexual men and women choose to live completely as members of their target gender without being public about their past. This approach is sometimes called stealth. Some people feel that they have an obligation to be open about their past in order to further the cause of civil rights for LGBT people. There are examples of people having 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 endocarditis. 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 having one’s trans status discovered. Tyra Hunter died after being denied care by paramedics and emergency room physicians after she was injured in an automobile accident.
Transsexualism was discussed in the mass media as long ago as the 1930s. The American magazine Time in 1936 devoted an article to what it called “hermaphrodites”, treating the subject with sensitivity and not sensationalism. It described the call by Avery Brundage, who led the American team to the 1936 Summer Olympics in Berlin, that a system be established to examine female athletes for “sex ambiguities”; two athletes changed sex after the Games. Before transsexual people were depicted in popular movies and television shows, Aleshia Brevard — an actual transsexual whose surgery took place in 1962 — was actively working as an actress and model in Hollywood and New York throughout the 1960s and ’70s. Aleshia never portrayed a transsexual or transgender person, though she appeared in eight Hollywood produced films, on most of the popular variety shows of the day including The Dean Martin Show, and was a regular on The Red Skelton Show and One Life to Live before returning to University to teach Drama and Acting.
Thomas Harris’s Silence of the Lambs included a serial killer who considered himself a transsexual. 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. In the novel, it is noted that the character is not actually a transsexual; this distinction is made only briefly in the film. Films depicting transgender issues include: Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, The World According to Garp, The Adventures of Priscilla, Queen of the Desert, 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. The film Wild Zero features Kwancharu Shitichai, a transsexual Thai actor. When the main character is conflicted about falling in love with a “woman who is also a man”, Guitar Wolf tells him “Love knows no race, nationality or gender!” 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).
Calpernia Addams has appeared in numerous movies and television shows, including the 2005 movie Transamerica, in which Felicity Huffman portrays a 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 trans women and two trans men, 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. Also in 2006, Lifetime aired a movie biography on the murder of “Eddie”/”Gwen” Araujo called A Girl Like Me: The Gwen Araujo Story. The film earned extremely well acclaim by the critics and audiences alike. Transsexual people have also been depicted in popular television shows. In part of the first season of the 1970s t.v. comedy series, Soap, Billy Crystal plays Jodie Dallas, a gay man who is about to undergo a sex change in order to legally marry his male lover, who breaks off the relationship just before the surgery. 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 an episode of Becker Dr. Becker gets an out-of-town visit from an old friend who turns out to have undergone SRS, it plays out very similar to the situations in Just Shoot Me!.
This same thing happens in an episode of Two and a Half Men. In a 1980s episode of The Love Boat, McKenzie Phillips portrays a trans woman who is eventually accepted as a friend by her old high school classmate, series regular Fred Grandy. In the 1970s on The Jeffersons, George’s Navy buddy Eddie shows up as Edie and is eventually accepted by George. In Ugly Betty, the character Alexis Meade (Rebecca Romijn), formerly Alex Meade, is a post-op transsexual who, before transitioning, faked her own death so she could start her life over as a woman. When Alexis realizes that she can get back at her father (who said he would rather see her dead than as a woman) she comes out of stealth and takes over their business. Dramas including Law & Order and Nip/Tuck have had episodes featuring transsexual characters and actresses. While in Nip/Tuck the role was played by a non-transsexual woman, in Law & Order some were played by professional cross-dressers. Without a Trace and CSI: Crime Scene Investigation have had episodes dealing with violece against transsexual characters. Many transsexual actresses and extras appeared on the CSI episode, “Ch-Ch-Changes,” including Marci Bowers and Calpernia Addams. The trans woman victim, Wendy, was played by Sarah Buxton, a cisgender woman. Candis Cayne, a transsexual actress, appeared in CSI: NY as a transsexual character. From 2007–2008, she also portrayed a transsexual character in the ABC series Dirty Sexy Money.