Transsexuality

I met "Josh" in a university women's study course. He was a good-looking and friendly guy, and my seatmate for most lectures. The name of the course was "Perspectives on Sex and Gender," and Josh had more firsthand knowledge of the topic than our instructors. Josh told me that he was a female-to-male transsexual (FTM), or trans man. Born female, Josh saw himself as male, and had undergone hormone therapy and surgery to obtain a body that matched his identity.

Transsexual individuals feel that they were born as the wrong sex, and want to live as a member of the opposite sex. Biological men who identify as women are called male-to-female transsexuals (MTF), or trans women. Transitioning is the process of changing one's physical sex and integrating into society as a member of the opposite sex, and generally takes several years to complete. Like Josh, most transsexual individuals are indistinguishable from biological men and women after their transitions are complete. Here's a look at the steps along this path of transformation.

Psychiatric Assessment and Standards of Care

The prevalence of transsexuality is a matter of debate. According to the DSM-IV, published in 1994, one in 30,000 biological males and one in 100,000 biological females sought sex reassignment surgery in the United States. However, a 2007 paper argued that the prevalence of transsexualism might be as high as one in 500.

In the DSM-IV, transsexuality is classified under gender identity disorder (GID). However, not all individuals with GID are transsexuals. The four diagnostic criteria for the condition are:

1) "A strong persistent cross-gender identification."

2) "Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex."

3) "The disturbance is not concurrent with physical intersex condition."

4) "The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning."

GID can occur in childhood, adolescence, or adulthood. Untreated, GID can contribute to depression, anxiety, addiction, and other mental health problems, and increase the risk of suicide. In the majority of cases, these problems disappear or decrease significantly after the individual receives sex reassignment therapy, and begins to live as a member of his or her target gender.

In the United States and Canada, transsexual individuals must be diagnosed with GID before they can qualify for hormone treatment or surgery. Some transsexual individuals object to this requirement, arguing that they should not have to conform to stereotypical gender traits or exhibit emotional distress in order to qualify for sex reassignment therapy. Critics of the GID diagnosis argue that barring other psychiatric problems, transsexuality should not be classified as a mental illness, and that extended psychological counseling is not necessary for healthy individuals.

Guidelines for the medical care of transsexual individuals are outlined in the Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders. (Note: The Harry Benjamin International Gender Dysphoria Association is now known as the World Professional Association for Transgender Health, but the document dates to 2001, before the name change). The document offers recommendations for psychotherapy, hormone treatment, and surgery, and that transsexuals undergo a real-life experience prior to hormone therapy and surgery. During this time, the person will openly live and work as a member of their target gender. The experience is designed to ensure that the transsexual person is committed to transitioning, can function in their target gender, and will have adequate emotional and social supports in place after their transition. Critics of the real-life experience point out that people who are discovered to be transsexual often face discrimination and violence, and that it is difficult to "pass" as a member of the opposite sex prior to hormone treatment and surgery.

Hormone Therapy

Taking sex hormones, which have powerful and wide-ranging effects on the body, are usually the first step in transformation. Once begun, hormone treatment continues for the rest of their life. The hormone regimen is tailored to the individual, and may need to be adjusted over time, or to accommodate changes such as the surgical removal of the patient's ovaries or testes. Hormone therapy can reduce or eliminate fertility, and future genital surgery may make it impossible for the individual to reproduce. Therefore, individuals who wish to become biological parents should consider sperm or egg banking prior to hormone treatment or genital surgery.

The standards of care document has three eligibility criteria for hormone therapy. First, the patient must be 18 years of age or older. Second, the patient needs to understand what hormones can and cannot do medically, and the social benefits and risks associated with hormone therapy. Third, the patient is required to complete a three-month "Real Life Experience" or obtain a letter of recommendation from their therapist.

Hormone Therapy: MTF

Estrogens are the primary hormones used to treat MTF individuals. In addition, anti-androgens may be used to counteract the effects of testosterone and dihydrotestosterone (DHT), and progestin may be used. The feminizing effects of estrogen include breast development and softer skin. A change in subcutaneous fat distribution will occur over one to two years, causing more fat to collect in the hips, thighs, and buttocks. In about three years, the muscle mass in the shoulders and upper back will diminish. Estrogen will cause a reduction in the amount of body hair, but facial hair must be removed by electrolysis or other means. Estrogens cause a significant decrease in the size of the testes, along with reduced testosterone and sperm production. The penis and prostate will also diminish in size. Sexual function will decrease, but the effects will vary depending on the individual. Prolonged estrogen treatment may cause infertility.

Hormone Therapy: FTM

For FTM individuals, testosterone therapy is used to create a more masculine appearance. Irreversible changes caused by testosterone include a deeper voice, along with increased facial and body hair. The clitoris will enlarge, and on average will grow to four to five centimeters (two inches) after one to three years. The reversible effects of testosterone include increased sex drive, increased muscle mass in the upper body, and a redistribution of fat to the stomach from the hips and thighs. Testosterone therapy can cause changes in the ovaries that lead to infertility.

Hormone Therapy: Teens

For transsexual teens, GnRH agonists can be used stop the production of most natural sex hormones, and thus delay the onset of puberty. GnRH therapy will also make future hormone therapy more successful, since there will be no need to "undo" the physical changes caused by puberty. There is considerable controversy over how old patients should be before they can qualify for GnRH agonists. In exceptional cases, children as young as 12 have been treated with GnRH agonists. There is also a lot of debate over how long it is medically, morally, and legally safe to maintain a patient on GnRH agonists. Finally, GnRH agonists are much more expensive than FTM or MTF hormone therapy, and four years of GnRH therapy would cost about US$14,000.

Sex Reassignment Surgery

Sex reassignment surgery refers to procedures used to change a person's physical appearance and functioning to resemble that of the other sex. According to the standards of care document, sex reassignment surgery is "medically indicated and medically necessary" for transsexual individuals. Transsexual individuals who have not had sex reassignment surgery are often referred to as pre-op, and those who have had it are referred to as post-op. The specific procedures a transsexual individual selects depends on many factors, including personal choice, health, finances, and the expected outcome of the surgery.

In North America, transsexual individuals must fulfill a number of criteria before qualifying for genital surgery, including 12 months of hormone therapy, 12 months of continuous real-life experience, and letters of recommendation from two mental health professionals. From the patient's perspective, realistic appearance, sexual sensation, and sexual function are important outcomes in genital surgery.

Sex Reassignment Surgery: MTF

Breast augmentation is a common surgery for trans women. Some trans women also choose surgery reduce the appearance of the Adam's apple, and liposuction of the waist to achieve a more feminine figure. A variety of facial feminization surgeries are available, including rhinoplasty, forehead recontouring, cheek implants, lip lift and filling, brow lift, chin recontouring, face-lift, hairline correction, and cosmetic surgery of the eyelids.

Vaginoplasty is the procedure used to create a vagina and external female genitalia. The most popular method is called penile inversion. During this procedure, the erectile tissue of the penis is removed, and the skin of the penis, along with the attached blood vessels and nerves, is inverted and used to construct a vagina. Tissue from the penis is also used to create the labia minora, and the glans of the penis is commonly used to create the clitoris. The urethra is shortened and moved to a location appropriate for female anatomy. A second vaginoplasty method is called colovaginoplasty, where a section of the sigmoid colon is used to create the vaginal lining. In some cases, patients also choose to have a labiaplasty to improve the appearance of the labia and create a clitoral hood. The surgical removal of the testes is also commonly performed on trans women. Since this removes the source of testosterone, the patient will be able to stop treatment with anti-androgens and lower their dose of estrogens.

Sex Reassignment Surgery: FTM

For trans men, a double mastectomy is one of the most important steps in achieving a male appearance. It is also the only surgical procedure many trans men undergo. In order to achieve a more masculine figure, some trans men also choose liposuction to reduce the amount of fat in their hips, thighs and buttocks.

Phalloplasty is the procedure used to construct a penis. Since current techniques usually require multiple surgeries and sometimes do not provide satisfactory results, many choose not to have the procedure. In metoidioplasty, a small penis is created by extending and repositioning the clitoris. In other forms of phalloplasty, a tissue graft is taken from the arm, abdomen, or the muscles of the upper back, and rolled up to form the new penis. The urethra may be formed from part of the tissue graft or the inner labia. The new penis is positioned so that the clitoris sits at its base, and often a nerve from the graft is connected to the nerves of the clitoris to provide additional sensation. An erectile prosthesis can be inserted into the penis to allow for erections and sexual penetration. The labia are used to create a scrotum, which can hold prosthetic testicles. Other FTM surgeries include the surgical removal of the ovaries, vagina, and uterus.

Continuing Care

Transsexual individuals can benefit from specialized health care throughout their lives. Mental health professionals may be needed to help transsexual individuals adjust to life in their new gender. Healthcare providers need to be alert to health risks created by lifelong hormone therapy, for example, testosterone treatment increases the risk of polycystic ovarian syndrome, and may increase the risk of ovarian and uterine cancer. Transsexual individuals and their healthcare provider may also encounter some unusual medical concerns. For instance, a trans woman may still require prostate exams, while a trans man may still require pap smears. Some trans men who have not undergone genital surgery have even become pregnant and given birth. In all cases, healthcare professionals need to be knowledgeable, accepting, and sensitive in order to provide quality care.

Visit the following websites for more information: • TransGenderCare (MTF) • Trans-Medicine (FTM)

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