Sun
19
Apr
Transsexualism: mistaken sexual identity, and the sex change solution
by Daphne Howland
From the moment of a baby's birth, the whole world wants to know if it's a girl or a boy. Because a swaddled baby's gender is always ambiguous, parents often clarify things by using pink or blue. It's obvious that putting a baby in a blue blanket won't make her a boy. But for transgendered people (defined by Merriam Webster dictionary as "exhibiting the appearance and behavioral characteristics of the opposite sex") being born with a vagina or with a penis is no clear sign, either.
Science is woefully behind in understanding what gives us our "gender identity." But there is an increasing sense among scientists that gender is inborn and not necessarily dictated by genitals or even hormones. For transsexuals- those who feel a strong identity as the opposite sex - the beginning of their stories is almost always the same: "Growing up I was never comfortable as a boy" or "I never wanted to be a girl".
During childhood, sexual roles are not yet entrenched, and societal norms allow a bit of leniency to girls who behave like "tomboys" or boys who may gravitate to more feminine activities. But during adolescence and adulthood, most transgendered people struggle with the disconnection between their identity, their genitals and the world's perception of them. Depression, not surprisingly, is common. For many, relief comes only with hormone or surgical treatment (or both).
Transsexual surgery - an evolving practice
A generation ago, anyone seeking transsexual surgery had to travel long distances--to places like Denmark or Casablanca. Finding a surgeon was difficult and some people even died during the procedure. But thanks to an international association of health care professionals people with gender identity issues have more, safer, and better organized options.
In the 1990s, transsexual surgery appears to be out of the closet. Although formal statistics are not publicized, one rough estimate is that 1000 to 1500 transsexual surgeries are performed annually in the United States alone. While advances in technology and changes in societal mores have not eliminated all of the difficult issues that must be faced before and after surgery, at least it's now possible to find health care professionals who are knowledgeable and competent in this field.
One organization -- Harry Benjamin International Gender Dysphoria Association (HBIGDA) -- has developed and published medical and ethical guidelines for the growing numbers of health professionals--including surgeons--who treat transsexuals.
Named for Harry Benjamin, the physician who popularized the word "transsexual," this 300-member international organization has published detailed standards of care that help practitioners to provide the mental health and medical care services that a transsexual should receive before making the decision to undergo surgery.
"There wasn't a lot of information in the past," says Anne Lawrence, MD. "Finding a surgeon was difficult; it was all very furtive. There were people who were mutilated and even died." Lawrence, an anesthesiologist who also also happens to be a male to female (MTF) transsexual, is an advisor to the board of HBIGDA.
The Harry Benjamin Guidelines
When transsexuals like Christine Jorgensen and Renee Richards sought treatment in the 1950s and 1960s, the process was far different than it is today. Psychologists were held responsible for "curing" a person of gender dysphoria (the technical term for people whose native gender causes them distress), rather than assessing their need for surgery. Surgeons-- who usually had no expertise in psychology or in assessing gender dysphoria--had the final say over whether surgery was necessary. Jorgensen was able to get surgery in Denmark only after a lengthy evaluation and petitioning the Danish ministry of Justice. And it took years and years before Richards found a willing surgeon in the United States.
Since then, health care practitioners with expertise in gender dysphoria, gender-bending endocrinology, and gender-reassignment surgery have joined together to form HBIGDA. The medical and ethical standards set forth by HBIGDA are extensive and detailed. While some are for the patient, most are for practitioners. The basics are:
Anyone seeking gender-transforming medical treatments must live in the sought-after gender role for at least three months before starting hormones and for at least one year before surgery. Living in this role should be complete. The candidate should be "out" at work or school, should legally change his or her name to reflect the gender change (if needed) and should be able to provide documentation that people besides his or her therapist know of the acquired gender. A mental health professional with expertise in gender dysphoria should determine whether a person is eligible and ready for gender reassignment treatments. An endocrinologist should obtain at least one letter from a mental health professional before prescribing hormones. A surgeon should get at least two recommendations--one of which is from the patient's mental health practitioner--before performing transsexual surgery.
The guidelines are designed in part to prevent the administration of too many hormones or performing a surgical procedure on anyone who might later regret it. But they were written with the assumption that hormones and surgery are the normal and recommended treatments for many--if not most--gender identity disorders.
"Gender identity disorder varies from person to person, in terms of its intensity, its fluidity, and its stability," says Lin Fraser, Ed.D, a psychologist who sees many "pre-op" transsexuals. "Some people have a cross-gender identity that has been very stable since childhood. Others have developed their identities over time. It can wax and wane. If you're doing something irreversible like transsexual surgery, you want a stable gender identity. The best way to observe that is over time."
The Harry Benjamin standards of care are controversial among some transsexuals, especially in the female-to-male (FTM) community. There's some resentment about the time (and cost) requirement and the living-in-role time. Most transsexuals believe that they are ready for treatment long before these requirements are met.
"There are many problems with the guidelines, although they were established for very well-intentioned reasons. The first problem is that therapists and other health care providers are in control of our decisions about our health care needs," says Jed Bell, editor of the FTM International newsletter. "Second, they were set up for MTFs and tend to be inappropriate for FTMs."
A common problem for FTM's, for example, is the stipulation that hormones be prescribed before surgery can be performed. A large-breasted woman who is required to take hormones before undergoing surgery will eventually acquire a low voice and a beard, which Fraser terms as "inhumane."
Michael Brownstein, MD, one of the leading FTM-mastectomy surgeons in the country, agrees with Fraser. He would definitely perform surgery before hormone therapy was initiated as long as the candidate were recommended by a therapist. And according to Sheila Kirk, M.D.-- the world's only known transsexual gender-reassignment surgeon and a member of the board of HBIGDA-- the standards leave plenty of room for that kind of flexibility.
"The guidelines are really just that -- not rigid rules. Not every foot fits the very same shoe," Kirk told HealthGate. "The professional has room to make judgments."
FTM vs. MTF
There are many differences between the male-to-female and female-to-male communities, most of which are too numerous and complex to mention here. But some are the product of the history of transsexualism, state-of-the-art of surgery, and the anatomical differences between men and women.
Some speculate that the strong feminist bent of many women who transition to men makes them less patient with the prominent role of psychologists and other professionals in the health care decision-making process. Others say that it's more difficult for a woman to live in the role for the first three months without the help of hormones. For example, women's smaller stature and their breasts make it impossible for many of them to enter a men's restroom during that first three month period.
The male-to-female transsexuality has a longer known history than that of female- to-males, going back to at least the 1930s. Perhaps for that reason, there is more expertise in the MTF medical world. Although surgeries have come a long way, mastectomy and phalloplasty (building a penis)--at least in this country--lag behind the advances of vaginal construction.
New techniques appear to provide transsexual women with a higher rate of orgasm than has previously been achieved. "There's more attention to creating a functional clitoris because consumers want that," says Dr. Lawrence. "Consumer awareness is starting to drive this market. Having a penectomy, undergoing castration, and constructing a vagina is no longer enough. Transsexual women want genitals that allow them as much sexual function as possible, and I think we're seeing that."
There isn't that level of satisfaction or expectation in the FTM community. "Scarring isn't as inherent to these procedures as we've been led to believe. And the reason why many people choose not to have phalloplasty is that nobody has seen a good one," says Bell. "These surgeries should be better and cheaper by now in the United States. Popular surgeons should have improved their methods over the past eight or 10 years."
Bell believes that neither surgery nor hormones is necessary for someone to live as a complete transsexual. But he believes that the surgery for FTMs in the United States is unnecessarily sub-par. He says that physicians in Belgium, for example, routinely give FTMs reconstructed chests that have little scarring and ample nipple sensation. Phalloplasty in Belgium and in other areas of Europe is also more advanced. "The state of the art exists," Bell says. "There's no excuse for U.S. surgeons."
Beyond hormones and surgery
There are other issues faced by transsexuals during the process of transforming their bodies to the opposite gender. While it's easier to remove a phallus than to create one, secondary male sex characteristics are much more difficult to excise. Voice surgery is risky and unreliable, but reduction of the Adam's apple is quite straightforward and has a low complication rate. Greg Postma, MD, a surgeon at the Wake Forest University Center for Voice Disorders won't even perform such surgery. "In general, it doesn't work," Postma said. "So we don't do primary surgery for voice modulation--we just fix others' screwups.
FTMs may be luckier in this regard because hormones alone often have profound effects. "Most FTMs are very happy with the transformation they're able to effect with hormones," says Bell. (Practitioners who support the Benjamin guidelines also point out that these male effects are almost always irreversible.)
More important, though, is the adjustment to life after transition. "There's so much more to the female in terms of her nature, her spirit," says Dr. Kirk. "The goal is the surgery often times, and it's a terrible surprise for some."
Adds Dr. Lawrence: "Surgery simply doesn't correct the myriad problems one has to face as a human being, trying to sort out the meaning of life. But what changes is that you approach these problems from a place that seems more congruent with who you are inside."
Bell has great confidence in the average FTM transsexual's ability to make these adjustments and tackle life's big questions. "Men with experience living as females are great men," he says.
From the moment of a baby's birth, the whole world wants to know if it's a girl or a boy. Because a swaddled baby's gender is always ambiguous, parents often clarify things by using pink or blue. It's obvious that putting a baby in a blue blanket won't make her a boy. But for transgendered people (defined by Merriam Webster dictionary as "exhibiting the appearance and behavioral characteristics of the opposite sex") being born with a vagina or with a penis is no clear sign, either.
Science is woefully behind in understanding what gives us our "gender identity." But there is an increasing sense among scientists that gender is inborn and not necessarily dictated by genitals or even hormones. For transsexuals- those who feel a strong identity as the opposite sex - the beginning of their stories is almost always the same: "Growing up I was never comfortable as a boy" or "I never wanted to be a girl".
During childhood, sexual roles are not yet entrenched, and societal norms allow a bit of leniency to girls who behave like "tomboys" or boys who may gravitate to more feminine activities. But during adolescence and adulthood, most transgendered people struggle with the disconnection between their identity, their genitals and the world's perception of them. Depression, not surprisingly, is common. For many, relief comes only with hormone or surgical treatment (or both).
Transsexual surgery - an evolving practice
A generation ago, anyone seeking transsexual surgery had to travel long distances--to places like Denmark or Casablanca. Finding a surgeon was difficult and some people even died during the procedure. But thanks to an international association of health care professionals people with gender identity issues have more, safer, and better organized options.
In the 1990s, transsexual surgery appears to be out of the closet. Although formal statistics are not publicized, one rough estimate is that 1000 to 1500 transsexual surgeries are performed annually in the United States alone. While advances in technology and changes in societal mores have not eliminated all of the difficult issues that must be faced before and after surgery, at least it's now possible to find health care professionals who are knowledgeable and competent in this field.
One organization -- Harry Benjamin International Gender Dysphoria Association (HBIGDA) -- has developed and published medical and ethical guidelines for the growing numbers of health professionals--including surgeons--who treat transsexuals.
Named for Harry Benjamin, the physician who popularized the word "transsexual," this 300-member international organization has published detailed standards of care that help practitioners to provide the mental health and medical care services that a transsexual should receive before making the decision to undergo surgery.
"There wasn't a lot of information in the past," says Anne Lawrence, MD. "Finding a surgeon was difficult; it was all very furtive. There were people who were mutilated and even died." Lawrence, an anesthesiologist who also also happens to be a male to female (MTF) transsexual, is an advisor to the board of HBIGDA.
The Harry Benjamin Guidelines
When transsexuals like Christine Jorgensen and Renee Richards sought treatment in the 1950s and 1960s, the process was far different than it is today. Psychologists were held responsible for "curing" a person of gender dysphoria (the technical term for people whose native gender causes them distress), rather than assessing their need for surgery. Surgeons-- who usually had no expertise in psychology or in assessing gender dysphoria--had the final say over whether surgery was necessary. Jorgensen was able to get surgery in Denmark only after a lengthy evaluation and petitioning the Danish ministry of Justice. And it took years and years before Richards found a willing surgeon in the United States.
Since then, health care practitioners with expertise in gender dysphoria, gender-bending endocrinology, and gender-reassignment surgery have joined together to form HBIGDA. The medical and ethical standards set forth by HBIGDA are extensive and detailed. While some are for the patient, most are for practitioners. The basics are:
Anyone seeking gender-transforming medical treatments must live in the sought-after gender role for at least three months before starting hormones and for at least one year before surgery. Living in this role should be complete. The candidate should be "out" at work or school, should legally change his or her name to reflect the gender change (if needed) and should be able to provide documentation that people besides his or her therapist know of the acquired gender. A mental health professional with expertise in gender dysphoria should determine whether a person is eligible and ready for gender reassignment treatments. An endocrinologist should obtain at least one letter from a mental health professional before prescribing hormones. A surgeon should get at least two recommendations--one of which is from the patient's mental health practitioner--before performing transsexual surgery.
The guidelines are designed in part to prevent the administration of too many hormones or performing a surgical procedure on anyone who might later regret it. But they were written with the assumption that hormones and surgery are the normal and recommended treatments for many--if not most--gender identity disorders.
"Gender identity disorder varies from person to person, in terms of its intensity, its fluidity, and its stability," says Lin Fraser, Ed.D, a psychologist who sees many "pre-op" transsexuals. "Some people have a cross-gender identity that has been very stable since childhood. Others have developed their identities over time. It can wax and wane. If you're doing something irreversible like transsexual surgery, you want a stable gender identity. The best way to observe that is over time."
The Harry Benjamin standards of care are controversial among some transsexuals, especially in the female-to-male (FTM) community. There's some resentment about the time (and cost) requirement and the living-in-role time. Most transsexuals believe that they are ready for treatment long before these requirements are met.
"There are many problems with the guidelines, although they were established for very well-intentioned reasons. The first problem is that therapists and other health care providers are in control of our decisions about our health care needs," says Jed Bell, editor of the FTM International newsletter. "Second, they were set up for MTFs and tend to be inappropriate for FTMs."
A common problem for FTM's, for example, is the stipulation that hormones be prescribed before surgery can be performed. A large-breasted woman who is required to take hormones before undergoing surgery will eventually acquire a low voice and a beard, which Fraser terms as "inhumane."
Michael Brownstein, MD, one of the leading FTM-mastectomy surgeons in the country, agrees with Fraser. He would definitely perform surgery before hormone therapy was initiated as long as the candidate were recommended by a therapist. And according to Sheila Kirk, M.D.-- the world's only known transsexual gender-reassignment surgeon and a member of the board of HBIGDA-- the standards leave plenty of room for that kind of flexibility.
"The guidelines are really just that -- not rigid rules. Not every foot fits the very same shoe," Kirk told HealthGate. "The professional has room to make judgments."
FTM vs. MTF
There are many differences between the male-to-female and female-to-male communities, most of which are too numerous and complex to mention here. But some are the product of the history of transsexualism, state-of-the-art of surgery, and the anatomical differences between men and women.
Some speculate that the strong feminist bent of many women who transition to men makes them less patient with the prominent role of psychologists and other professionals in the health care decision-making process. Others say that it's more difficult for a woman to live in the role for the first three months without the help of hormones. For example, women's smaller stature and their breasts make it impossible for many of them to enter a men's restroom during that first three month period.
The male-to-female transsexuality has a longer known history than that of female- to-males, going back to at least the 1930s. Perhaps for that reason, there is more expertise in the MTF medical world. Although surgeries have come a long way, mastectomy and phalloplasty (building a penis)--at least in this country--lag behind the advances of vaginal construction.
New techniques appear to provide transsexual women with a higher rate of orgasm than has previously been achieved. "There's more attention to creating a functional clitoris because consumers want that," says Dr. Lawrence. "Consumer awareness is starting to drive this market. Having a penectomy, undergoing castration, and constructing a vagina is no longer enough. Transsexual women want genitals that allow them as much sexual function as possible, and I think we're seeing that."
There isn't that level of satisfaction or expectation in the FTM community. "Scarring isn't as inherent to these procedures as we've been led to believe. And the reason why many people choose not to have phalloplasty is that nobody has seen a good one," says Bell. "These surgeries should be better and cheaper by now in the United States. Popular surgeons should have improved their methods over the past eight or 10 years."
Bell believes that neither surgery nor hormones is necessary for someone to live as a complete transsexual. But he believes that the surgery for FTMs in the United States is unnecessarily sub-par. He says that physicians in Belgium, for example, routinely give FTMs reconstructed chests that have little scarring and ample nipple sensation. Phalloplasty in Belgium and in other areas of Europe is also more advanced. "The state of the art exists," Bell says. "There's no excuse for U.S. surgeons."
Beyond hormones and surgery
There are other issues faced by transsexuals during the process of transforming their bodies to the opposite gender. While it's easier to remove a phallus than to create one, secondary male sex characteristics are much more difficult to excise. Voice surgery is risky and unreliable, but reduction of the Adam's apple is quite straightforward and has a low complication rate. Greg Postma, MD, a surgeon at the Wake Forest University Center for Voice Disorders won't even perform such surgery. "In general, it doesn't work," Postma said. "So we don't do primary surgery for voice modulation--we just fix others' screwups.
FTMs may be luckier in this regard because hormones alone often have profound effects. "Most FTMs are very happy with the transformation they're able to effect with hormones," says Bell. (Practitioners who support the Benjamin guidelines also point out that these male effects are almost always irreversible.)
More important, though, is the adjustment to life after transition. "There's so much more to the female in terms of her nature, her spirit," says Dr. Kirk. "The goal is the surgery often times, and it's a terrible surprise for some."
Adds Dr. Lawrence: "Surgery simply doesn't correct the myriad problems one has to face as a human being, trying to sort out the meaning of life. But what changes is that you approach these problems from a place that seems more congruent with who you are inside."
Bell has great confidence in the average FTM transsexual's ability to make these adjustments and tackle life's big questions. "Men with experience living as females are great men," he says.