As I mentioned in an earlier column concerning adolescent transsexuality, the term transsexual entered our vocabulary in the 1950s. Transsexualism became a diagnosis in the American manual of mental disorders (DSM), third-edition, in 1980, and this term was later changed in DSM-IV (1994) to gender identity disorder (GID). [1]

Although there are many types of individuals who cross-dress, what distinguishes the transsexual person is cross-gender identity [1] – that is, people who want to live their lives fully in the opposite gender. Some writers [1] have suggested that by viewing gender (i.e., a cultural or social construction of what is considered masculine or feminine) and biological sex (male or female) as only having two distinct categories, we haven’t provided room for those who experience qualities, traits, or sexual characteristics of both. Although some transsexual individuals may find ways to adapt by creating their own third category of gender (transgender), most transsexual people desire sex reassignment surgery. [1]

Although the actual percentages of how frequently transsexuals are found in the population remains largely unknown, cross-cultural research (U.S. and the Netherlands) suggests that the ratio of transsexual men to women remains at approximately 3:1. [1]

In considering whether there are different types of transsexual individuals, the most obvious demarcation is between those who are male-to-female (MtF) and those who are female-to-male (FtM). This difference is highly significant because of their varying trajectories. Besides this, however, other researchers have created other typologies. For example, transsexual individuals can be divided into the groups of primary and secondary. The primary groups are aware of their internal cross-gender identities from a young age and are not conflicted by their feelings, whereas the secondary groups felt much internal discomfort regarding their cross-gendered feelings and consequently failed to integrate these into their personalities. [1]

Another typology is based on whether the individual is attracted to members of their same biologic sex, to members of the opposite biologic sex, or both. More favourable psychological outcomes and social adjustment have been reported with transsexual individuals who are attracted to members of their same biologic sex, [1] meaning that they following sex reassignment so that they are viewed by others as "heterosexual." As it turns out, most FtMs are attracted to women, just as most MtFs are attracted to men. This should not be surprising given that most individuals in the world have a heterosexual orientation. An interesting finding is that sometimes the sexual orientation of MtFs with primary interest in women will change to having an interest in men. [1] The reasons for this shift are not clearly understood presently.

Once an individual has been assessed as being transsexual, various options are available. For some, learning to live in the world as a transgendered person is possible and preferable without pursuing physical changes. For others, medical interventions are indicated. The first step here is usually about evaluating whether the person is a candidate for cross-sex hormone therapy.

The administration of hormones has predictable effects on the body. For the MtF, estrogen and testosterone blockers soften the skin and create breast growth, loss of muscle, and redistribution of body fat. Although hair loss is stopped, lost head hair does not grow back. The voice does not rise, fertility and testicular size diminish, and erections become less frequent and less firm. The physical changes noted above occur gradually. The MtF notices changes in mood, sex drive, and attitude much sooner.

FtMs treated with testosterone experience a deepening of their voice, enlargement of the clitoris, increased facial and body hair growth, male pattern baldness, and limited breast reduction. These changes are permanent. Other changes are reversible, including increased muscularity, weight gain, decreased hip fat, and increased sex drive and arousability. [1, 2]

Cross-sex hormone therapy has varying medical risks for biologic males and females alike, and they are not prescribed to everyone who requests them for this reason. The effect of these hormones needs to be medically monitored.

Either before, during, or after hormone therapy, the transsexual individual may decide to live full-time in their cross-sex role, known by some as the real-life test. For those wanting to later pursue sex reassignment surgery, this is a requirement. Although the duration of this is generally about 12 months, in Alberta currently, the 12-month period officially begins once the person has been assessed by an authorized psychiatrist. Unfortunately, there is presently only one psychiatrist in Alberta (residing in Edmonton) who is authorized, resulting in a "bottleneck" of care for individuals waiting to be assessed.

By proceeding in the above manner, the cost of sex reassignment surgery (once approved by the authorized psychiatrist and a second psychiatrist) is covered by Alberta Health Care. Many studies have shown sex reassignment to be effective for all types of transsexuals, [1] so the wait is generally considered worth it. Furthermore, most transsexual individuals report good sexual functioning following sex reassignment surgery. [1, 2] Surgeries that are considered "cosmetic" are not covered by Alberta Health Care, however, so many transsexual individuals end up spending considerable amounts of their own money in order to "pass" better and/or to enhance their appearance.

Some post-operative MtFs decide not to tell their sexual partners that they are biologic males. Presumably these are individuals that pass very well as biologic females. Nevertheless, experts recommend disclosure to partners and to family members alike, [1] generally resulting in positive outcomes.

The transsexual journey does not follow an easy path, and the bumps along the way can be excruciatingly treacherous and painful. All of us, however, need to follow a path that helps us develop and embrace self-acceptance and integrity. No one can ignore their own reflection indefinitely.

References:

1) Harry Benjamin International Gender Dysphoria Association. (2001). Standards of care for gender identity disorders (6th ed.). Retrieved November 25, 2005 from http://www.hbigda.org/Documents2/sosv6.pdf

2) Docter, R. F., & Prince, V. (1997).Transvestism: A survey of 1032 cross-dressers. Archives of Sexual Behavior, 26(6), 589-605.

3) Denny, D. (2004).Changing models of transsexualism. Journal of Gay & Lesbian Psychotherapy, 8(1-2), 25-40.

4) Ibid.

5) Seil, D. (2004).The diagnosis and treatment of transgendered patients. Journal of Gay & Lesbian Psychotherapy, 8(1-2), 99-116.

6) Ibid.

7) Smith, Y. L. S., van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. T. (2005). Transsexual subtypes: Clinical and theoretical significance. Psychiatry Research, 137(3), 151-160.

8) Lawrence, A. A. (2005). Sexuality before and after male-to-female sex reassignment surgery. Archives of Sexual Behavior, 34(2), 147-166.

9) Seil (2004).

10) Harry Benjamin International Gender Dysphoria Association. (2001).

11) Denny (2004).

12) De Cuypere et al. (2005).

13) Lawrence (2005).

14) De Cuypere, G., T’Sjoen, G., Beerten, R., Selvaggi, G., De Sutter, P., Hoebeke, P., Monstrey, S., Vansteenwegen, A., & Rubens, R. (2005). Sexual and physical health after sex reassignment surgery. Archives of Sexual Behavior, 34(6), 679-690.

15) Zamboni, B. D. (2006). Therapeutic considerations in working with the family, friends, and partners of transgendered individuals. Family Journal: Counseling and Therapy for Couples and Families, 14(2), 174-179.