Transsexualism

A trans woman with the letters "XY" written on her palm

Transsexualism is when an individual identifies with a gender that is different from their biological sex. 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,^[1] or if a person experiences impaired functioning or distress as a result of that gender identification.^[2] 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. It remains controversial, however. Discrimination and 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.^[3] France has been the only country in the world to remove transexualism from its list of mental illnesses.

Diagnosis

Transsexualism appears in the two major diagnostic manuals used by mental health professionals worldwide, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM, currently in its fourth edition) and the International Statistical Classification of Diseases and Related Health Problems (ICD, currently in its tenth edition). The ICD-10 incorporates transsexualism, dual role transvestism and gender identity disorder of childhood into its gender identity disorder category, and defines transsexualism as "[a] desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex."^[4] The DSM does not distinguish between gender identity disorder and transsexualism, and defines transvestic fetishism as a separate phenomenon which may co-occur with transsexualism. The DSM diagnosis requires four components:^[5]

• A desire or insistence that one is of the opposite biological sex (that is not due to a perceived advantage of being the other sex)
• Evidence of persistent discomfort with, and perceived inappropriateness of the individual's biological sex
• The individual is not intersex (although a diagnosis of GID Not Otherwise Specified is available, which enables intersex people who reject their sex-assignment to access transsexual treatments)
• Evidence of clinically significant distress or impairment in work or social life.

Process

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 known as transgenders rather than transsexuals 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. (Brown 105)

Some people who desire sex reassignment therapy do not have gender identity disorder, as it's usually understood, and desire to transition for other reasons. This can include homosexual people who are unable to accept their homosexuality (or who were, up until the 1970s, encouraged by caretakers to change their gender role, including SRS), cross-dressers who feel more comfortable dressed as members of the opposite gender and may become confused (although it may be important to realize that many transsexual women go through a period where they self-identify as cross-dressers), and people with certain psychiatric disorders, such as schizophrenia, borderline personality disorder, dissociative identity disorder, and Munchausen syndrome. (Brown 106–107) Most professionals believe that sex reassignment therapy is not appropriate for such individuals, (Brown 107) and SRS is expected to have a negative effect for them.^[6].

Some transsexual people may suffer from co-morbid psychiatric conditions unrelated to their gender dysphoria. The DSM-IV itself states that in rare instances, gender identity disorder may co-exist with schizophrenia, and that psychiatric disorders are generally not considered contraindications to sex reassignment therapy, that is unless they are the primary cause of the patient's gender dysphoria. (Brown 108) Despite this permissiveness, the process of psychological treatment is usually much more complicated for transsexual people with co-morbid psychiatric conditions.

Some transsexual people have pressured 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.^[7] Furthermore, many people think that some psychologists and psychiatrists in viewing transsexualism as "a disease" have sought to develop specific models of transsexualism, such as Ray Blanchard's model, which they feel exclude many transsexual people.

In Japan, the expression "gender identity disorder" is not only used as the diagnosis, but generally and legally as well: in Japan national　health insurance coverage is not provided for sex reassignment surgery. The government regards the body of a transsexual as "normal" with the gender identity being a disorder, disregarding the statement of "Standards of Care" that sex reassignment is not "experimental," "investigational," "elective," "cosmetic," or optional in any meaningful sense; rather an effective and appropriate treatment for transsexualism or profound GID.

Relation to gender roles

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/male-to-female hormone replacement therapy and/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.

Origins

Billy Tipton was born in 1914. He began living as a man full-time by 1940 at age 26, had a career as a jazz and swing pianist and entertainer, a common law marriage (unregistered but publicly accepted), and three sons by adoption. He was discovered to have been female-bodied after he died in 1989 due to a hemorrhaging ulcer (that he refused to have treated). Like many Female-to-Male transsexuals of this day he did not have genital surgery.

Gender was originally a linguistic term. In many languages, words can be considered masculine, feminine, or neutral, completely independently from the attributes of the things to which the word applies. Different languages manifest gender in various ways, recognizing two genders (female, male), three genders (female, male, neuter), or none at all. In some (e.g. the Romance languages), variation by gender is indicated by relatively simple changes in nouns and adjectives, while others require more complex grammatical changes. In English, a transsexual person's first step in transition often includes the request to be referred to using pronouns for their target gender (he rather than she, him rather than her, and his rather than hers, or vice versa). Some English speakers who feel that they are best described as something in between or other than masculine or feminine prefer to use “ze” and “hir” (examples of gender neutral pronouns in English), or other invented neutral pronouns.

Magnus Hirschfeld coined the term "Transvestite". He described what is now called transvestic fetishism as well as transsexualism.^[8] In 1930, he supervised the first genital reassignment surgery to be reported in detail in a peer-reviewed journal on Lili Elbe of Denmark. The German term “Transsexualismus” was introduced by Hirschfeld in 1923.^[9] The neo-Latin term “psychopathia transexualis” and English “transexual” (sic) were introduced by D. O. Cauldwell in 1949,^[10] who subsequently also used the term “trans-sexual” in 1950.^[11] Cauldwell appears to be the first to use the term in direct reference to those who desired a change of physiological sex.^[12] (In 1969, Benjamin claimed to have been the first to use the term “transsexual” in a public lecture, which he gave in December 1953.^[13]) This term continues to be used by the public and medical profession alike.^[8] It was included for the first time in the DSM-III in 1980 and again in the DSM-III-R in 1987, where it was located under Disorders Usually First Evident in Infancy, Childhood or Adolescence.

The word transsexual was used by Harry Benjamin in his seminal 1966 book The Transsexual Phenomenon to describe transsexuals on a scale (later called the "Benjamin scale") that recognizes three levels of intensity of transsexualism: "Transsexual (nonsurgical)", "Transsexual (moderate intensity)", and "Transsexual (high intensity)".^[14] Some transsexuals [6] believe that to be considered a "true" transsexual one needs to have a desire for surgery, and while some researchers disagree,^[15][16] in The Transsexual Phenomenon, Benjamin described "true" transsexualism in this way: "True transsexuals feel that they belong to the other sex, they want to be and function as members of the opposite sex, not only to appear as such. For them, their sex organs, the primary (testes) as well as the secondary (penis and others) are disgusting deformities that must be changed by the surgeon's knife."^[17] Benjamin suggested that moderate intensity male to female transsexuals may benefit from estrogen medication as a "substitute for or preliminary to operation."^[14] Some people have had SRS but do not meet the common definition of a transsexual (e.g., Gregory Hemingway).^[18][19]. While other people do not desire SRS, they do not meet Dr. Benjamin's definition of a "true transsexual".^[20] Beyond Benjamin's work, which focused on male-to-female transsexuals, there is the case of the female to male transsexual for whom genital surgery may not be practical.

Relation to transgenderism

Transsexualism is often included within the broader term transgender, which is generally considered an umbrella term for people who do not conform to typical accepted gender roles, for example cross-dressers, drag queens, and people who identify as genderqueer. Some transsexuals object to this inclusion.

Anthropologist David Valentine contextualizes the objection to including transsexuals in his book "Transgender, an Ethnography of a Category." ^[21] He writes that transgender is a term coined and used by activists to include many people who do not necessarily identify with the term. He observes that many current health clinics and services set up to serve gender variant communities employ the term, but that most of the service-seekers do not identify with the term. The rejection of this political category, first coined by self-identified activist Leslie Feinberg, illustrates the difference between a self-identifier and categories imposed by observers to understand other people.^[22]

Historically the reason that transsexuals rejected associations with the transgender or broader LGBT community is largely that the medical community in the 1950s through the late 1980s encouraged (and in many ways required) this rejection of such a grouping in order to be a 'good transsexual' who would thus be allowed to access medical and surgical care. The animosity that is present today is no longer fed by this same kind of pressure from the medical community.

However, where some of the beliefs of modern day transsexual people that they are not transgender, is reflective of this historical division (Denny 176), other transsexual people state that someone choosing to retain their former physical sex (no SRS) is very different from someone who needs to be of "the other sex", that the groups have different issues and concerns and are not doing the same things.^[16] The latter view is rather contested, with opponents pointing out that merely having or not having some medical procedures hardly can have such far-reaching consequences as to put those who have them and those who have not into such distinctive categories. Notably Harry Benjamin's original definition of transsexualism does not require that they need to have had SRS.^[14]

Terminology

The word "transsexual" is most often used as an adjective rather than a noun – a "transexual person" rather than simply "a transexual". Transsexual people prefer to be referred to by the gender pronouns and terms associated with their target gender. For example, a transsexual man is a person who was assigned the female sex at birth on the basis of his genitals, but despite that assignment identifies as a man and is transitioning or has transitioned to a male gender role and has or will have a masculine body. Transsexual people are sometimes referred to with "assigned-to-target" sex terms such as "female-to-male" for a transsexual man or "male-to-female" for a transsexual woman. These terms may be abbreviated as "M2F", "F2M", "MTF", "F to M", etc. These terms are particularly helpful in preventing confusion, because to some people the term "transsexual woman" is a female transitioning to become a male, and to others a male transitioning to become a female. When the terms trans man and trans woman are used though, it is typical for them to be used to refer to the gender that the person identifies with, regardless of their appearance or state of transition.

Although some do identify as part of the LGBT community, others do not. Transsexual people often feel that gender identity and sexual orientation are not the same thing. Transsexual men and women are of various sexual orientations just as non-transsexual (some times referred to as cisgender) people are, and they will almost always use terms for their sexual orientation that relate to the sex with which they identify. For example, someone born biologically male who identifies as a woman, and who is attracted solely to men, will commonly identify as heterosexual. Likewise, someone who was born biologically female, identifies as a man, and prefers male partners, will identify as gay, not heterosexual. Transsexual people, like other people, can also be bisexual or asexual as well.

Older medical texts often referred to transsexual people as members of their original sex by referring to a male-to-female transsexual as a "male transsexual". They also described sexual orientation in relation to the person's assigned sex, not their gender of identity; in other words, referring to a male-to-female transsexual who is attracted to men as a "homosexual male transsexual." This usage is considered by many to be scientifically inaccurate and clinically insensitive today. As such someone who would have been referred to as a "homosexual male transsexual" would now be called and most likely identify herself as a heterosexual transsexual woman. Although the original usage is dwindling, some medical textbooks still refer to transsexual people as members of their assigned sex, but now many use "assigned-to-target" terms.

Alternative terminology

Because these terms describe identities, their definitions are contested and usage varies. Some people use terms not discussed here.

The transgender community typically use the short form "trans", or simply "T" as a substitution for the full word "transsexual", e.g. TS, trans guy, trans dyke, T-folk, trans folk. Terms like as tranny, or trans are considered by some to be derogatory, but others use them, arguing that they are diminishing the power of the term as an insult (in the same way that gay and African-American communities have embraced terms or phrases that were originally derogatorives. Others feel that the terms are problematic because they do not differentiate between transsexual people, and other people categorised as transgender.

Some transsexual people may prefer transgender over transsexual, because this minority sees the issue to be about gender rather than sex, and to those unfamiliar with transsexuality, the term transsexual may connote sexual undertones, while transgender does not. . (Note that this distinction, violating norms of gender vs. violating norms of sex, is precisely why crossdressers, as one of many examples, are classified as transgender rather than transsexual.) This subset of transsexual people make a parallel with intergender, who think of themselves as between the genders rather than between sexes. Some transsexual people think of transsexualism as a subset of intersex. "Intersex" usually refers to people whose genitals are not typically male nor female. Transsexualism, in this view, simply becomes a form of being neurologically intersex that was mistakenly categorized outside of the rubric of intersex because of the historical lack of proof for a specific etiology. (See below for hypotheses on the possible causes of transsexualism.)

The term "gender dysphoria" and "gender identity disorder" were not used until the 1970s^[8] when Laub and Fisk published several works on transsexualism using these terms.^[23][24] "Transsexualism" was replaced in the DSM-IV by "gender identity disorder in adolescents and adults".

Harry Benjamin Syndrome [7] is proposed terminology that some people would prefer be used to refer to what Harry Benjamin referred to as true transsexualism, utilizing the medical practice of naming some medical syndromes after their first 'describer'. Those suggesting this term consider it a medical syndrome as originally suggested by Harry Benjamin. They believe this is confirmed by scientific research that has strongly suggested that their condition is biological rather than psychological in nature.^{[25][26][27][28]} They also feel that 'trans' is misleading, as they believe that their gender was fixed in their brains, and has never changed. Thus that nothing about their steps in correcting themselves is actually "trans" at all, but rather they are simply taking steps to assert what they feel that they are already.

Andrea James proposed the descriptions "interest in feminization" and "interest in masculinization" to refer to a desire for sex reassignment therapy, regardless of whether the person self-identifies as transsexual or not.^[29] Others point out that this incorrectly represents transsexuality as a "life-style choice", since many transsexual people feel that their condition has a biological origin. While many feel that transsexuality is not a choice, they think of it as part of normal human variation, rather than as a pathology.^[29]

Other languages and cultures

Pattaya: Kathoeys on the stage of a cabaret show.

Gender-variant people experience different degrees of acceptance in different cultures. Terms and concepts concerning gender identity and sexuality vary significantly among different language or cultural groups. Thus, in some cultures, whether or not a person is considered homosexual depends on what role they take in a sexual interaction, not simply on the sex of their partner. Also, it is difficult to extend western concepts of gender identity and sexuality to a society where being a male homosexual is unacceptable and is penalized, but being a male-to-female transsexual is allowed.

For example, before the Islamic Revolution in 1979, the issue of transsexualism in Iran had never been officially addressed by the government. Beginning in the mid-1980s, however, transsexual individuals have been officially recognized by the government and allowed to undergo sex reassignment surgery (see Transsexuality in Iran), while male same-sex relations are still forbidden.

In Thailand, kathoey (who are often, but not always, transsexual) are accepted to a greater extent than in most countries, but are not completely free of societal stigma. Feminine transsexual kathoey are much more accepted than gay male kathoey; this may be seen as an example of heteronormativity. Due to the relative prevalence and acceptance of transsexualism in Thailand, there are many accomplished Thai surgeons who specialize in male-to-female sex reassignment surgery. Thai surgeons are a popular option for Western transpeople seeking surgery because of the lower costs.

Transsexual- (and tg-) related issues remain largely taboo in much of Africa.^[30]

Prevalence

There are no reliable statistics on the prevalence of transsexualism. The DSM-IV (1994) quotes a prevalence of roughly 1 in 30,000 assigned males and 1 in 100,000 assigned females seek sex reassignment surgery in the USA. The most reliable estimate of prevalance is from the Amsterdam Gender Dysphoria Clinic^[31] The data, spanning more than four decades in which the clinic has treated roughly 95% of Dutch transsexuals, gives figures of 1:10,000 assigned males and 1:30,000 assigned females.

Olyslager and Conway presented a paper^[32] at the WPATH 20th International Symposium (2007) arguing that the data from their own and other studies actually imply much higher prevalence, with minimum lower bounds of 1:4,500 male-to-female transsexuals and 1:8,000 female-to-male transsexuals for a number of countries worldwide. They suggest the prevalence might be as high as 1:500 births overall.

Olyslager and Conway also argued that the U.S. population of assigned males having already undergone reassignment surgery by the top three U.S. SRS surgeons alone is enough to account for the entire transsexual population implied by the 1:10,000 prevalence number. This excludes all other U.S. SRS surgeons, surgeons in countries such as Thailand, Canada, and others, and the high proportion of transsexuals who have not yet sought treatment, suggesting that a prevalance of 1:10,000 is too low.

A presentation at the LGBT Health Summit in Bristol, UK,^[33] based upon figures from a number of reputable European and UK sources, shows that this population is increasing rapidly (14% per year) and that the mean age of transition is actually rising.

Causes

There's not a solid consensus on the cause of transsexuality, nor for any other sexual or gender identity. Psychological and biological causes for transsexualism have been proposed.^{[25][26][27][28]} 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 some 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 [or] fertile soil on which the wrong conditional and a psychic trauma can grow and develop into such a basic conflict that subsequently a deviation like transsexualism can result."^[34]

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 cisgendered women were similar. Those of heterosexual and homosexual men were similar to each other and different from those of women (cis- and transgendered).^[35] Another study suggests that transsexuality may have a genetic component.^[36]

Sex reassignment therapy

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, 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 usually required to receive psychological therapy and a diagnosis of gender identity disorder in accordance with the Standards of Care (SOC) as issued by the World Professional Association for Transgender Health (until 2006 called the Harry Benjamin International Gender Dysphoria Association).^[37] The SOC are intended as guidelines, not inflexible rules, meant to discourage people from transitioning based on unrealistic expectations.

It is claimed that reviews of post-operative transsexuals prior to 1991 reveal a rate of serious regrets of less than 1% for transsexual men and less than 2% for transsexual women, while studies published after 1991 have reported a decrease in the rates for both, likely due to improved psychological and surgical treatments and increasing acceptance from society.^[38] While such studies lend support for existing protocols concerning care of transsexuals, post-operative follow-up research is considered to be lacking. However a note on a report in the UK Guardian Newspaper states:

There is no conclusive evidence that sex change operations improve the lives of transsexuals, with many people remaining severely distressed and even suicidal after the operation, according to a medical review conducted exclusively for Guardian Weekend tomorrow.
A review of more than 100 international medical studies of post-operative transsexuals by the University of Birmingham's aggressive research intelligence facility (Arif) found no robust scientific evidence that gender reassignment surgery is clinically effective. ^[39]

Against the statistic above indicating that 1% to 2% of post-operative persons have serious regrets, the Report itself states:

Paradoxically, a growing number of post-operative transsexuals are scathing about their medical care. International research suggests that 3–18% of them come to regret switching gender.^[40]

Psychological treatment

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^[41] note that sometimes the only reasonable and effective course of treatment for transsexual people is to go through sex reassignment therapy.^[42][43]

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.^[44] These problems may be alleviated by a change of gender role and/or physical characteristics.^[45]

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 counselling that is recommended by the Standards of Care^[41] because they don’t consider their gender identity to be a psychological problem.

Brown and Rounsley^[46] noted that "[s]ome 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 (Brown 107).

Medical aspects

After initial psychological counseling, men and women may begin medical treatment starting with hormone replacement therapy^[47][48] 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 Test or Real-Life Experience).^[47] 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. (Brown 103)

Legal and social aspects

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^[49]. 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.^[50] In the United States, November 20 has been set aside as the "Day of Remembrance" for all murdered transgender people.^[51]

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.^[52]

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.

Neither "transsexualism" nor "gender identity disorders not resulting from physical impairments" are specifically covered under the Americans with Disabilities Act Section 12211 ^[53]

Coming out

Employment issues

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 transpeople is rampant and many of them are fired when they come out or are involuntarily outed at work.^[54] Transsexual people must decide whether to transition on-the-job^[55], 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 negativity responding to their transition, losing job experience under a previous name, and even deciding which bathroom is proper to use creates a challenging situation.^[56] 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.^[57] Because the Harry Benjamin Standards of Care require a one year RLT prior to SRS, some feel this creates a Catch 22 situation which makes it difficult for transpeople to remain employed or obtain SRS.

In many countries, laws provide protection from workplace discrimination based on gender identity or gender expression, including masculine women and feminine men, whether gay or straight. An increasing number of companies are including "gender identity and expression" in their non-discrimination policies.^[49][58] Often these laws and policies do not cover all situations and are not strictly enforced. California's anti-discrimination laws protect transsexual persons in the workplace and specifically prohibit employers from terminating or refusing to hire a person based on their transsexuality. The European Union provides employment protection as part of gender discrimination protections following the European Court of Justice decisions in P v S and Cornwall County Council.^[59]

Stealth

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.^[60] For example, Leslie Feinberg was once turned away from a hospital emergency room where he had sought treatment for endocarditis.^[61] 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 actually being discovered. Tyra Hunter died after being denied care by paramedics and emergency room physicians after she was injured in an automobile accident.^[60]

Critics of "coming out" (whereby a transsexual person who has hidden their true gender identity reveals their true self) cite prejudice, sensationalism, and the triggering of unconscious personal feelings and emotions as motivation to choose the "stealth" approach.

Regrets and detransitions

After transitioning, transsexual people sometimes regret their transition, or even choose to detransition to their original sex. However, every recent study done on the number of detransitions states that their number is well below 1%, and that the reasons for detransitioning are very diverse.^[38] 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.^[62]

These cases are often cited as reasons for the lengthy triadic process outlined in the standards of care for gender identity disorders, which specifies a treatment process combining psychological, hormonal, and surgical care. While many have criticized this process as being too slow for some, it is argued that without the safeguards within the Standards of Care, the incidence of unsuccessful surgical transitions would be much higher. This is also questioned by many critics, especially with regard to particular demands of some caregivers. The article above states that in some of these cases, transitioning could have been prevented if some demands made by caregivers, or demands perceived as coming from the caregivers, had been less rigid; particularly, if the patients had not felt that talking about any problems or doubts would jeopardize their further treatment. An unwavering demand for medical treatment and the absolute conviction of "doing the right thing" is often seen as a necessity for the diagnosis of transsexualism, and therefore the prerequisite for any further treatment; consequently, further treatment has been denied to people who uttered any doubts or even questions.

Critics claim that when patients cannot talk about problems or doubts, but have to present themselves as having neither, the patients, anxious to get treatment they perceive at this point to be absolutely necessary, will face these problems or doubts after transitioning, when dealing with them may be much more difficult, and this will often lead to social problems, depression, anxiety, or other problems. They believe that, in some cases, this may lead to a retransitioning. While there is no scientific study on the question, many trans*-organizations and groups claim that patients who feel less pressure to conform to any particular stereotype will have more satisfactory outcomes after transition. This does not preclude any screening for mental problems which might lead to pseudo-transsexualism, nor supportive psychological therapy, if necessary.

In the media

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 ^[63]. 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.

Transsexual women are found in all walks of life and professions, but are highly visible in pornographic works. Transsexual pornographic actresses, commonly referred to as "shemales", often do not seek SRS, valuing their male genitalia for either personal or economic reasons. Regardless of whether or not they've undergone SRS, the majority of transsexual women consider the word "shemale" to be offensive, and being referred to as a "shemale" to be highly insulting.

Films depicting transgender issues include: Crocodile Dundee, Transamerica, 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.

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).

Transsexual people have also been depicted in some popular television shows. 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 80's. on "The Jeffersons" one of George's navy buddies 'Eddie' shows up as a woman 'Edie' and is eventually accepted by George.

In part of the first season of the 1970s t.v. comedy series, "Soap", Billy Crystal plays a gay man that is about to undergo a sex change in order to legally marry his male lover, who dumps him for someone else just before the surgery.

In the television show, "Ugly Betty", the character Alexis Meade (Portrayed by 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 after she tips the authorities off that her father killed Fey Sommers, a character whose death immediately preceded the start of the first series. A serious car accident later leaves Alexis with amnesia, and she forgets the entire previous two years – including her transition from male to female.

The series Law & Order and Nip/Tuck have had transsexual characters, but they were played by non-transsexual women or professional cross-dressers. The series Without a Trace featured an episode in which a transsexual woman went missing and is almost killed by her ex-wife's husband after visiting her family, which she abandoned before transitioning. CSI: Crime Scene Investigation had an episode dealing with a transsexual victim, Ch-Ch-Changes.^[64] Many transsexual actresses and extras appeared on the episode, including Marci Bowers and Calpernia Addams.^[65] The trans woman victim, Wendy, was played by Sarah Buxton, a cisgender woman. Addams has appeared in numerous movies and television shows, including the 2005 movie Transamerica, in which Felicity Huffman portrays a pre-op transsexual woman.^[66]

Candis Cayne, a transsexual actress, appeared in CSI: NY as a transsexual character. From 2007–2008 she also portrayed a transsexual character (this time recurring) in the ABC series, Dirty Sexy Money.

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.^[67] 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.^[68]

Thomas Harris' 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 a transsexual; this distinction is made only briefly in the film.^[69]

Pageantry

Since 2004, with the goal of crowning the top transsexual of the world, a beauty pageant by the name of The World's Most Beautiful Transsexual Contest has been held in Las Vegas. The pageant accepts pre-operation and post-operation transwomen, but providing proof of their original gender is required. The winner of the 2004 pageant was a woman by the name of Mimi Marks.

See also

• List of transgender-related topics
• List of transgender-rights organizations
• List of LGBT-related organizations
• List of transgendered people

References

Bibliography

• Pepper, Shanti M.; Peggy Lorah (2008). Career Issues and Workplace Considerations for the Transsexual Community: Bridging a Gap of Knowledge for Career Counselors and Mental Heath Care Providers. The Career Development Quarterly, 56(4), 330–343. http://proquest.umi.com/pqdweb?did=1502846951&sid=1&Fmt=3&clientId=19912&RQT=309&VName=PQD. 

External links

• Asociación Española de Transexuales. AET Transexualia
• Basic TG/TS/IS Information – including Successful Transwomen and Successful Transmen
• FTM International – Female To Male International: practical and medical information
• FTM Australia – Comprehensive information for all men identified female at birth in Australia.
• Hudson's FTM Resource Guide – Comprehensive information for female to male trans men and allies – USA-based
• Gender.org – The home of Gender Education & Advocacy, a nonprofit corporation using the web to provide education and advocacy for transsexual and transgender issues.
• Definition and Synopsis of the Etiology of Adult Gender Identity Disorder and Transsexualism – prepared by 24 internationally recognized experts, published by the Gender Identity Research and Education Society (GIRES)(See: http://www.gires.org.uk)
• How to Respect a Transsexual Person
• The International Journal of Transgenderism – The Official Journal of the World Professional Association for Transgender Health (formerly HBIGDA)
• TransParentcy – supports transgender parents and their advocates (lawyers, mental health professionals, friends, family) by providing information and resources.
• Transsexual Road Map – practical and medical information concerning male-to-female transition.
• Lynn Conway's transsexual resources pages
• The Gender Identity Research and Education Society

Lesbian, gay, bisexual, and transgender (LGBT) topics   Academic fields · Discourse Gender studies · Lavender linguistics · Lesbian feminism · LGBT literature · LGBT/Queer studies · Queer theory · Transfeminism   Community · Culture Coming out · Drag king · Drag queen · Gay bar · Gay village · Gay icon · Lesbian utopia · LGBT-affirming religious groups (LGBT-affirming churches) · Pride · Pride parade · Gay rodeo · Literature  · List of LGBT-related organizations · Periodicals · Same-sex relationship · Slang · Slogans · Symbols · Tourism · Category:LGBT culture   Gender identities · Sexual identities Sexual identity Bisexual · Gay · Lesbian Gender identity Transgender · Transsexual Other Intersex · Queer · Third sex / third gender · Two-Spirit · Non-heterosexual   History LGBT history History of lesbianism · LGBT History Timeline · Social movements · History of Christianity and homosexuality · History of same-sex unions · Pederasty · Category:LGBT history Pre-modern era Adelphopoiesis · Homosexuality in ancient Greece · Homosexuality in ancient Rome · Homosexuality in ancient Egypt · Homosexuality in ancient Peru 16th to 19th century Mollies · Urnings 20th century Gay Liberation · Homosexuals in Nazi Germany and the Holocaust · Inversion · Sea queens · Stonewall riots · Festival of Light action · White Night riots 21st century   Rights · Legal issues LGBT rights by country or territory Africa  · Americas  · Asia  · Europe  · Oceania  · List of LGBT rights articles by region LGBT rights topics Adoption · Civil unions and partnerships · Hate crime laws · Legal aspects of transsexualism · Military service · Parenting · Same-sex marriage (Status · Timeline) · Socialism · Sodomy laws LGBT rights movements Gay Liberation · LGBT rights groups · LGBT rights activists   Sexual orientation Sexual orientations Homosexuality · Bisexuality Medicine, science and sexology Biology and sexual orientation · Demographics · Environment and sexual orientation · Homosexuality and psychology · Neuroscience and sexual orientation · Timeline of sexual orientation and medicine · Heterosexual-homosexual continuum · Kinsey scale · Klein Grid   Social attitudes · Prejudice · Violence Social attitudes Heteronormativity · LGBT rights opposition · LGBT stereotypes · Religion and homosexuality · Transgenderism and religion Prejudice · Violence Corrective rape · Biphobia · Gay bashing · Heterosexism · Homophobia · Lesbophobia · Transphobia · Racism in the LGBT community · List of unlawfully killed transgender people · Violence against LGBT people Category:LGBT · LGBT portal