York and District Mind

'I told my mum I thought I was really a girl. She told me, don't be silly, you'll grow out of it.'

'All my friends thought I was just one of the lads. I couldn't tell them how I was really feeling. The only way I could survive was to pretend. I was living a lie.'

'I couldn't pretend any longer. I was feeling so depressed and frustrated, so I decided to take a risk and tell my family I was a transsexual. At first they didn't believe me, they thought I was joking. Once they got over the initial shock, they have been understanding and supportive.'

Most people never question the gender they are assigned at birth. But for some people it is the most important question they can ask. Those who feel they have been born into the wrong gender are often aware there is 'something wrong' early in childhood. Because society places great emphasis on sexual and gender classification, and on gender-appropriate behaviour, a child who senses that there is something wrong often feels very different from their peers and uncertain about their identity. The medical term now often used to describe anxiety or confusion about gender identity is 'gender dysphoria'.

This feeling of being the wrong gender may come and go over the years, but it can pervade all aspects of life. Some people may only have a mild anxiety about their assigned gender, and perhaps cross-dress occasionally. For others, anxiety about being 'in the wrong body' can be the major driving force within their lives, leading them to seek gender reassignment - commonly known as sex-change. Still others question the rigidity of gender roles, and seek to establish a 'transgender' identity.

What is gender identity?

When a baby is born, the first question most people ask is: 'Is it a boy or a girl?' The appearance of the baby's genitals provides the answer to what sex it is. The term 'sex' refers to the biological distinction between male and female; the term 'gender' refers to the social attributes that distinguish males and females. The gender attributes are generally assumed to follow the sexual ones.

Gender assignment at birth will be the most important influence on which of two distinct developmental paths a child is expected to follow - to grow up to be a man, or to grow up to be a woman. Each of these paths has a distinct set of expectations and behaviours that are considered to be gender- appropriate. These expectations and behaviours can vary between different societies and cultures. In the western world it is accepted that there are only two genders; in some other cultures it is accepted that there is a third gender, which lies somewhere between male and female.

The term 'gender identity' refers to a person's ability to categorize themselves as male or female. A child develops their sense of gender identity at a very early age, usually around two years old. At this age, most children begin to make some sort of verbal distinction between words such as 'boy' and 'girl' or 'mummy' and 'daddy'. Hereafter a process known as 'gender-role learning' occurs, whereby a child's behaviour is continually matched according to sets of standards shared by parents, teachers and other children. Problems can arise if a child's perception of their own identity does not match those shared by parents, teachers and other children.

What is gender dysphoria?

Gender dysphoria, also known as 'gender identity disorder', is a medical term for anxiety, confusion or discomfort about birth gender. Milder forms of gender dysphoria can cause occasional feelings of belonging to the opposite sex. The most intense form, when the individual seeks to change their sex, is called transsexualism.

The Diagnostic and Statistical Manual - 4th Edition (DSM-lV) states that in order to make a diagnosis of gender identity disorder, there must be evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is, of the opposite sex. This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. There must also be evidence of persistent discomfort about one's assigned sex, or a sense of inappropriateness in the gender role of that sex. The diagnosis is not made if the individual has a concurrent physical 'intersex' condition, such as androgen insensitivity syndrome or congenital adrenal hyperplasia (rare conditions in which a person may possess some of the physical attributes of the opposite sex). To make the diagnosis of gender identity disorder there must be evidence of clinically significant distress or impairment in social, occupational or other important areas of functioning.

People who experience gender dysphoria are often afraid to express their feelings publicly, due to fears of rejection or feelings of guilt or shame. They can develop an anxiety which deepens over time. This can lead to chronic depression; some consider or attempt suicide.

Transsexualism

A transsexual is a person, male or female, who has a lifelong feeling of being trapped in the wrong body. The identification with the opposite sex is so strong and persistent that transsexual people feel that the only way to achieve peace of mind is to change the body to match the mind. Some go through the process of living in their chosen gender role with the help of hormones, eventually leading to gender reassignment surgery. Others seek help such as counselling or therapy to help them to cope with their confusion or discomfort.

This term is used to denote people who have passed puberty and feel a persistent or recurrent discomfort or sense of inappropriateness about their assigned gender identity. They cross-dress persistently, or imagine themselves doing this, but are not sexually excited by these actions or fantasies, nor are they preoccupied with changing any of their primary or secondary sexual characteristics.

How prevalent is gender dysphoria?

There are no recent epidemiological studies to provide data on the prevalence of gender dysphoria. Referrals to gender clinics suggest that approximately 1 in 30,000 adult males and 1 in 100,000 adult females seek gender reassignment surgery. Gender dysphoria is more common in genetic males than in females. In childhood, boys with gender dysphoria outnumber girls by approximately five to one. This disparity between the genders may partly reflect the greater stigma that cross-gender behaviour carries for boys than for girls. In adult life, men with gender dysphoria outnumber women by between two and three to one.

Little is known about the causes of gender dysphoria. One theory is that changes in the brain prior to birth cause parts of the brain to develop in a pattern opposite to that of the physical gender. It has been found, for example, that significant proportions of male transsexuals have abnormally low levels of HY antigen. (HY antigen mediates the masculinizing effect of the Y chromosome in men.)

Another theory is that life experiences, especially those in early childhood, may affect the outward expressions of gender behaviour. Gender-appropriate behaviour is learned early in life; society places a huge emphasis on it, and deviations may result in castigation or ostracism. The problems, therefore, arise from society's attitude towards people who do not conform to its stereotypes, rather than being inherent in the person. Psychiatry's labelling of people who find they cannot 'fit in' with sexual stereotypes as suffering from a 'disorder' is a case in point.

In boys, cross-gender identification is generally displayed by a marked interest in traditionally feminine activities. They may have a preference for dressing in girls' or women's clothes. A boy who wants to be a girl and who admits this to others is likely to be 'corrected', ridiculed or reprimanded in a severe manner. They are expected to grow out of it quickly. A girl who wants to be a boy and expresses this is less likely to receive retribution for it. Girls who display boyish behaviour are often labelled as 'tomboys' - but they too are expected to grow out of it.

In many cases children do grow out of gender dysphoria; only a small number of children will continue to have these feelings in later adolescence and adulthood. Families vary in the extent of their acceptance of their offspring. Some children, living openly in their chosen gender role, endure the taunts of their peer group as well as pressure from their parents. Others cope by hiding their feelings and learning to play the gender role assigned to them, meanwhile going deeper into a private world of cross-gender fantasy and desire.

At this stage in life coping with gender dysphoria becomes far more complex, and different pressures begin to apply to the different genders. With the onset of puberty hormones are produced which trigger the growth of secondary sexual characteristics. Boys must contend with higher levels of testosterone leading to a deepening of the voice, beard and bodily hair growth. Girls must contend with the growth of their breasts and menstruation. These physical effects can be very distressing and confusing to young people with gender dysphoria.

Boys often combine excessive masturbation with secret cross-dressing to relieve their anxieties. Boys can also often employ overtly stereotypical masculine behaviour in an attempt to hide their secret desires to be female. Girls may adopt loose or baggy gender-neutral clothing in an attempt to hide their female bodies.

Early adulthood

Most people who have grown up with gender dysphoria display less overt cross-gender behaviour with time, parental intervention, or peer pressure. It has been found that by early adulthood, about three quarters of boys who had a childhood history of gender dysphoria may identify as being homosexual or bisexual, but they no longer have feelings of belonging to the wrong gender.

However, many young adults continue to experience gender dysphoria; they may make various attempts to rid themselves of their ever-increasing gender anxiety. They may get married and have children - in the hope that this will help, or simply to hide their feelings from others. Some seek professional help, typically to request a gender reassignment operation.

Later adulthood can be a very difficult time for people with gender dysphoria. Years of trying to overcome a deep-rooted desire and coping with anxiety can lead to depression; for some the pressure is so great that they commit suicide. Many reassess their lifestyle when they come to later life; some will seek professional help, others may try to relieve their desires and anxieties by more frequent cross-dressing, usually in private.

Gender identity is quite separate from a person's sexuality; people with gender dysphoria can be homosexual, bisexual or heterosexual. A male to female transsexual, for example, attracted to women, may consider themselves to be a lesbian. Others may be attracted to heterosexual men and would not identify as being homosexual since their adopted gender identity is female. Some adults with gender dysphoria, like other people, may go through a period of transvestite or homosexual behaviour while they are exploring their true natures.

A transvestite, or transvestic fetishist, is a person, male or female, who cross-dresses as a member of the opposite sex. Transvestites often derive sexual excitement from the experience of cross-dressing. Transvestism is quite distinct from transsexualism or other forms of gender dysphoria. A transvestite has no feelings of belonging to the opposite gender, and doesn't experience alienation from their body/sexual organs.

Transsexuals have normal male (XY) or female (XX) chromosomes appropriate for their physical sex. There are no identifiable physical characteristics for gender dysphoria, and there is no 'test' for the condition. Hermaphrodites and others with ambiguous sexual characteristics at birth are not transsexuals, and do not necessarily experience gender dysphoria.

Gender reassignment is a lengthy process that involves long term hormone treatment and surgery to alter the physical appearance of a person's reproductive organs. A person's chromosomes and reproductive organs cannot be changed; hormone treatment and gender reassignment surgery aims to achieve the physical appearance and sexual functions of the opposite gender. Post-surgical transsexuals cannot bear or father children, as fertility is lost in the gender reassignment process.

Individuals requesting gender reassignment are generally referred to a recognized gender identity clinic by a psychiatrist, GP or social worker. A detailed history of gender development from childhood through puberty and thereafter is central to the evaluation. Medical and personal history is considered along with current life circumstances and general stability. Additional psychological assessments may be arranged to clarify unanswered questions.

Gender reassignment is not the solution for everyone, it needs very careful consideration. If any alternatives to gender reassignment are considered possible, the clinic will actively pursue these options. A number of people who initially attend clinics requesting gender reassignment are encouraged to pursue less drastic possibilities, for example, to pursue their chosen lifestyle without surgical intervention, or to access other forms of support such as counselling or self-help groups.

Recognized gender identity clinics generally follow the guidelines and standards set out by the Harry Benjamin International Gender Dysphoria Association. For a male wishing to become a female, treatment with female hormones is required for at least one year before any irreversible surgical steps are taken. This produces changes in the secondary sexual characteristics, such as body hair reduction, breast development, and a general feminization of body shape and skin texture.

Patients are required to be living full-time as a woman for a minimum of one year before any surgery can be authorized. During this period some transsexuals may choose to have facial hair removed by electrolysis, some others may choose to undergo cosmetic surgery to help feminize facial features, while others learn to raise the pitch of their voice to a more 'feminine' level. When a patient feels ready, they may apply for medical approval of reassignment surgery. The clinical team will review the patient's progress and adaptation to their new role. Surgery may then be approved based on this evaluation.

Gender reassignment is a major surgical procedure. Under general anaesthetic, the testes and erectile tissue of the penis are removed. An artificial vagina is then created and lined with the skin of the penis, the nerves and blood vessels of which remain largely intact. Scrotal tissue is then used to create the labia, and the urethra is shortened and positioned in the female location.

For a female wishing to become a male, treatment with testosterone, the male hormone, produces largely irreversible effects of beard growth and masculine muscle development. A mastectomy may be authorized as early as six months into the hormone programme, as it is of significant benefit in helping the person to appear male in public. After at least a year of hormone treatment the ovaries and uterus are removed. For many female to male transsexuals this is as far as they will go with surgery, as additional procedures are more complex, costly and difficult to obtain. For those who do continue, phalloplasty (penis construction) and artificial testes implants are available, as are procedures to create a male urethra and relocation of the clitoris to the head of the penis.

In the U.K. it is possible legally to change one's name, and to have this name inserted on official documentation such as passport and driving licence. It is not, however, legally possible to change the gender on one's birth certificate. Under British law a transsexual officially remains the gender which they were assigned at birth. Under current laws this means, for example, that a male to female transsexual cannot legally marry a man. The British passport agency has recently stated that on receipt of reasonable proof that a person's change of gender is thought to be permanent, they will issue a full ten-year passport in the new gender, even if the person is of a pre-operative status.

There is no doubt that transsexuals and others with gender dysphoria face discrimination from society in general. However, in 1997 British transsexuals won the right to sue employers for harassment and discrimination experienced because of having undergone gender reassignment. The Employment Appeal Tribunal said that such bias violates the Sex Discrimination Act. 'This bold and far-reaching decision finally recognizes that transsexuals need legal protection against the considerable discrimination they face,' said Kamlesh BahI, chair of Britain's Equal Opportunities Commission.

The response transsexuals receive from family friends and colleagues varies hugely. Some transsexuals face a great deal of hostility and rejection, while many have found acceptance and support, even to the point of retaining the same job throughout their transformation. Fortunately, for most, the reactions are generally more positive than they may have feared. How one presents the news to others may have a great deal of bearing on how it is received, and counselling on this and other issues should be considered as part of the professional treatment provided.

The Gender Trust
B.M. GenTrust, London WC1 N 3XX

The Beaumont Society
27 Old Gloucester Street, London WC1N 3XX

Gendys
B.M. Gendys, London WC1N 3XX

Seahorse Society
B.M. Seahorse, London WC1 N 3XX

Northern Concord
P.O. Box 258, Manchester M60 1 LN

Press For Change
B.M. Network, London WC1N 3XX, tel. 0171 372 5917

Trans Essex
P.O. Box 3, Basildon, Essex SS14 1PT, tel. 01268 583761

Belfast Butterfly
Club RO. Box 210, Belfast BT1 1BG, tel. 01585430408

FTM Network
B.M. Network, London WC1 N 3XX

Gender Identity Consultancy Services  
tel.0181 5168784

Transvestite / Transsexual Support Group UK  
tel. 0161 2743705

TransWales
tel. 01639896626

Scotland Crosslynx  
tel.0141 3323333


For friends and relatives
Women of the Beaumont Society
27 Old Gloucester Street, London WC1N 3XX, tel. 01223441 246