Transsexualism

Transsexualism is a condition in which a person identifies with a physical sex different from the one with which they were born. Transsexualism is stigmatized in many parts of the world and has become more widely known in Western cultures in the mid to late 20th century, concurrently with the Sexual revolution and the development of sexual reassignment surgeries. It remains controversial, however. Discrimination and negative attitudes towards transsexualism accompany certain religious beliefs or cultural values. There are other cultures, however, that have not only held a place for transsexuals but even culturally sanction them, such as the so-called two-spirit people in some native American tribes.

Harry Benjamin, an endocrinologist and one of the first physicians to assist transsexuals obtain sex reassignment, quotes from a letter he received from Dr. Christian Hamburger, the physician who treated Christine Jorgensen: These many personal letters from almost 500 deeply unhappy persons leave an overwhelming impression. One tragic existence is unfolded after another; they cry for help and understanding. It is depressing to realize how little can be done to come to their aid. One feels it a duty to appeal to the medical profession and to the responsible legislature: do your utmost to ease the existence of these people who are deprived of the possibilities of a harmonious and happy life—through no fault of their own.

Gender dysphoria
Many transsexual people agree with the idea that gender is hard-wired in the brain before birth. As such, many transsexual people believe that being transsexual is instead an intersex condition, a congenital birth issue unseen by others due to its location in the brain: a mis-match in the sex of a person between that of the brain and that of the body. The main symptom of this condition is a unique type of depression, anxiety or even psychological pain: Gender Dysphoria. Commonly, transsexual people assert that their brain-based inner perception of their sexual self, their identity, is who they really are, and so change their physical sex in an effort to be on the outside as they feel they are on the inside. If untreated, it can lead to mental and emotional problems, and sometimes suicide.

Most transsexual men and women desire to establish a permanent social role as a member of the gender with which they identify. Many transsexual people also desire various types of medical alterations to their bodies. These physical alterations are collectively referred to as sex reassignment therapy and often include hormone replacement therapy and surgery. 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.

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 (formerly and until 2006 the Harry Benjamin International Gender Dysphoria Association). These are guidelines as the medical community struggles in how to deal with the treatment, and the nature of the treatment population changes, and are not obligatory. Some doctors may waive the psychotherapy requirement as an unnecessary expense in an emotionally mature and stable individual, or require only a psychological evaluation. The intentions of the standard are to prevent people from transitioning when such a transition would be inappropriate (as a dramatic example, a person seeking to transition in order to veil their identity from police), or ill-advised (e.g., a strong crossdresser, who still identifies themselves as their assigned gender), and other cases where if a transition were undertaken, it would be expected to have strongly negative consequences for the patient.

These standards are open to the criticism of being ineffective, or being too strict, discouraging genuinely transsexual people from seeking treatment. It is claimed that Meta-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. 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. The 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.

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."

For both men and women, medical treatment typically begins with hormone replacement therapy. Transwomen 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), although this time may be longer if the psychotherapist has concerns about the transsexual person's readiness. Transmen must generally wait two to three years after beginning testosterone treatment in order to allow for sufficient clitoral growth. However, some transsexuals, especially among transmen, may not wish to have this surgery. Others can spend years or even decades saving up enough money to pay for it. Some transwomen may have only orchiectomy and forego vaginoplasty. There are many reasons why some transsexuals opt out of genital surgery. Among these are cost (female-to-male (FTM) surgery can cost up to $80,000), surgical risks, (including genital nerve damage), and acceptance of a certain amount of physical deformity.

For female-to-male (FTM) mastectomy and chest reconstruction, the requirement is only either 3 months of psychological therapy or the same amount of time of Real-Life-Test. The latter may be impossible for transmen with large breasts, and while binding smaller breasts is partially effective, this can cause many health issues if done over a long period of time. Many transsexuals find these requirements to be unjust as cisnatal men and women are not required to undergo any psychological evaluation or wait times to undergo chest reconstructive surgery. However, an 18 month requirement for transwomen to have breast augmentation is typically to allow enough time for breast development due to hormones. Breast augmentation before the breasts have finished developing can result in poor shape.

Currently, the causes of transsexualism are unknown, and estimates of prevalence vary substantially. It is commonly believed that it is a multifactorial condition, having many and different causes, some of which may include a naturally occurring variation in fetal sex differentiation and development. Causes may include some medications or hormones given to pregnant mothers, such as diethylstilbestrol. According to a medical advisory bulletin from Gender.org (Sep. 2002), as many as 25% of the FTM population has polycystic ovarian syndrome, a condition known to cause hormonal fluctuations.

Defining transsexualism
Transsexualism (also known as transsexuality) is a complex condition that is defined differently by different people. Many terms have been proposed through the years to describe transsexual people and the processes they go through. As with any terms used by a group, or to refer to a particular group, some of these terms are controversial, or have become controversial, not only to society at large, but even among the transsexual community.

The definition of "transsexuality" is somewhat debated. One common definition is that a transsexual is a person who believes that his or her body does not reflect his or her true 'inner' identification of physical sex or gender. Another common definition is that a transsexual is a person who has had or plans to have medical or surgical treatments that alter his or her body to better reflect what the individual believes is his or her true gender. The first definition allows greater freedom for individuals to self-identify as a transsexual. The latter defines the term based on actual or planned operative status and makes it more an external label than a term of self-definition.

The two terms of sex and gender have become popularly used as one concept, which blurs distinction, but they have different meanings. Physical sex refers more to one's biology and anatomy (that is, male or female) where gender is a more socio-cultural term of how a person presents or is taken (that is more at man or woman, or "like" a male or female" (see Milton Diamond, Ph.D. 2001 or U.S.S.C. Justice Antonin Scalia saying "The word gender has acquired the new and useful connotation of cultural or attitudinal characteristics (as opposed to physical characteristics) distinctive to the sexes. That is to say, gender is to sex as feminine is to female and masculine is to male.")

When genital surgery is undertaken it is commonly referred to as sex reassignment surgery or genital reconstructive surgery or even gender reassignment surgery by some health care providers and community members. An older term, sex change surgery may be seen as disrespectful.

The Diagnostic and Statistical Manual of Mental Disorders accepts the expression of desire to be of the opposite sex, or assertion that one is of the sex opposite from the one with which they were assigned at birth, as sufficient for being transsexual. The ICD-10 states in a similar way that transsexualism is defined by, "the desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his, or her body as congruent as possible with the preferred sex through surgery and hormone treatment." In contrast, transgenderists do not identify as being of, or desiring to be the opposite sex, but as being of or wanting to be another gender.

Transsexualism has been variously described as a physical disability, a condition, trait, disease, behavior, desire, mental illness, perversion, paraphilia, political identity, and lifestyle. The term perversion is often used in a derogatory manner (especially by Western religions). People may consider the use of such labels offensive whether they are or are not transsexual, or involved with Western religions, themselves.

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. However, some transsexuals object to this inclusion. 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 (indeed, today many gender therapists actively encourage their clients to explore support within the broader 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. 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.

Regardless of definition, transsexualism should not be confused with cross dressing or with the behaviour of drag queens and drag kings, which can be described as transgender but not transsexual. Also, transvestic fetishism usually has little, if anything, to do with transsexualism. As a general rule, transsexual people tend to dress and behave in a manner consistent with the gender they identify with, crossdressers tend to dress (and sometimes behave) in a manner consistent with stereotypical ideals of the opposite gender as opposed to the real-life behavior of that gender, and "drag queens" or "drag kings" tend to dress and behave in a flamboyant manner which parodies rather than emulates the opposite gender.

Gender terminology for transsexual people
Transsexual itself is most respectfully used as an adjective. In other words, one who wishes to be respectful would refer, as this article does, to "transsexual people," "transsexual men," or "transsexual CEOs," but would not use phrases like, "Transsexuals prefer pistachio to rocky road." This more respectful usage appears to have resulted as a response to cumulative dehumanization. The idea appears to be that if used only as an adjective, transsexual will inevitably be paired with words such as "people," "women," and "men" in ways that help to reemphasize transsexual humanity and increase sympathy.

Transsexual people almost universally 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 transmen and transwomen 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.

Transsexual people are often considered as part of the LGBT community, and although many do identify with this community, others do not, or prefer not to use the terms at all. Transsexual people typically feel it important for people to understand that transsexualism neither depends upon, nor is related to, sexual orientation. Transsexual men and women exhibit a range of sexual orientations just as non-transsexual (some times referred to as Cisgender) people do, and they will almost always use terms for their sexual orientation that relate to the sex with which they identify. For example, someone assigned to the male sex but who identifies as a woman, and who is attracted solely to men, will identify as heterosexual, not gay. Likewise, someone who was assigned to the female sex, 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
The transsexual 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. Some may even use terms that have become controversial to some, such as tranny and/or trans, despite others considering these terms to be offensive. Those who do use these terms claim that they are diminishing the power of the term as an insult, just as some members of the gay and African-American communities have embraced slurs directed at them. Others feel that the terms are insulting or inaccurate regardless of the context. Some feel that such words are problematic because they do not differentiate between transsexual people, and people who are merely "playing" with gender.

Some individuals may prefer to spell transsexual with only one s, thus writing transexual. They will typically assert that they are attempting to divorce the word from the realm of psychiatry and medicine and place it in the realm of identity. This trend is most common in the United States, and is almost never used in the United Kingdom.

Some prefer the term transsexed over transsexual, as they believe the term sexual found in transsexual is misleading and implies that transsexualism is a sexual orientation. Another justification made for this preference is that they feel it more closely parallels with the term intersex, which is considered by them to be important as more transsexual groups are welcoming them because they feel both groups have much in common. It is, by some definitions, possible to be both intersex and transsexed. Other attempts to avoid the misleading -sexual have been the increasing acceptance of transgender or trans* and in some areas, transidentity.

Some transsexual people may also prefer transgender over transsexual, because this minority sees the issue to be about gender rather than sexuality. (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, whose issue is about being between (inter) the genders rather than "intersexual". It is often assumed, particularly by transsexual people, that transsexualism is a subset of intersex. "Intersex" previously referred only to those who are physiologically intersex, e.g., with genitals that do not look classically male or female. (Despite that human genitals show an extremely wide variation in general, intersex people typically have genitalia that frustrate attempts to assign them within a binary sex system.) However, since sex in humans is composed of many different attributes, such as genes, chromosomes, regulatory proteins, hormones, hormone receptors, body morphology, brain sex, and gender identity, any variation among any of those attributes could fall under the rubric of "intersex." 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 research of physiological causes of transsexualism).

Harry Benjamin agreed with German sexologist Magnus Hirschfeld that transsexuals were a form of neurological intersex. Hirschfeld coined the term "Transvestite" in his seminal work on the matter, Die Transvestitien. In this work, he describes what is now known as transvestic fetishism as well as transsexuals. 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. The neo-Latin term “psychopathia transexualis” and English “transexual” (sic) were introduced by D. O. Cauldwell in 1949, who subsequently also used the term “trans-sexual” in 1950. Cauldwell appears to be the first to use the term in direct reference to those who desired a change of physiological sex. (In 1969, Benjamin claimed to have been the first to use the term “transsexual” in a public lecture, which he gave in December 1953. ) This term continues to be used by the public and medical profession alike. 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 term "Gender Dysphoria" and "Gender Identity Disorder" were not used until the 1970s when Laub and Fisk published several works on transsexualism using these terms. "Transsexualism" was replaced in the DSM-IV by "Gender Identity Disorder in Adolescents and Adults".

Some people prefer that transsexualism be referred to as Harry Benjamin's Syndrome as it follows the naming conventions of intersex conditions. This term is named for Harry Benjamin, a pioneer in sex reassignment and research on transsexual people, whose work of the 1950s and 1960s, which culminated in The Transsexual Phenomenon in 1966. Many transsexual people who prefer this term assert that scientific research has strongly suggested that their condition is biological rather than psychological in nature. 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. A small number of people who are post operative and living in their chosen role prefer to call themselves either a neo-woman or neo-man, thus omitting references in the term 'transsexual' to sexuality or being in between (trans).

While the above gives a fairly comprehensive view of terminology, it is important to note that some people may feel that both 'trans' and 'sexual', are misleading, and others may take objections to terminology that are unique to their perspective. While a large variety of other terms exist from those presented here, they have not been excluded with bias, although almost all of them are somewhat controversial.

Prevalence
There are no reliable statistics on the prevalence of transsexualism. The DSM-IV (1994) quotes 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 population based estimate of the incidence occurrence is from the Amsterdam Gender Dysphoria Clinic 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.

In September 2007, however, Olyslager and Conway presented a paper at the WPATH 20th International Symposium demonstrating that the data from this and similar studies actually implies much higher prevalence rates, with minimum lower bounds of 1:4,500 assigned males and 1:8,000 assigned females across a number of countries worldwide. They also present other evidence suggesting the actual prevalence might be as high as 1:500 births overall.

Other data presented in the paper implies 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 of course ignores all other U.S. SRS surgeons, the popularity among U.S. transsexuals of obtaining their surgery in other countries such as Thailand where the cost may be less prohibitive, and the high proportion of transsexuals who have not yet had reassignment surgery or have not yet even sought help for their condition, making that figure (1:10,000) clearly untenable.

Causes of transsexualism
Many psychological causes for transsexualism have been proposed, while research has been presented to suggest that the cause of transsexualism has its roots in biology. There remains no agreement, however, as to the cause of transsexualism.

Some transsexual people and professionals feel that research into causes of transsexualism assumes at face value the legitimacy of a normative gender identity, and/or that transsexualism is contrary to normal development, and could be considered a disease, or syndrome, which transsexual people may find stigmatizing. This subset usually considers such research to be unnecessary, and wonder if such studies might possibly be causing more harm than good for transsexual people.

Meanwhile, other transsexual individuals and professionals believe that transsexualism is, in fact, a syndrome with a physiological basis as a form of intersexuality. Those with this viewpoint generally support research as to the cause, 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 an insight to this.

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."

Studies indicate that transsexualism is connected with a difference in the human brain called the bed nucleus of the stria terminalis. In one study, male-to-female transsexuals and cisgendered women were shown to have brains that were similar to each other in the BSTc area of the brain. Both heterosexual and homosexual men showed male brain structuring in this area.

Psychological treatment
Psychological techniques that attempt to alter gender identity to one considered appropriate for the person's assigned sex have typically been shown to be ineffective. The internationally accepted and followed Standards of Care note that sometimes the only reasonable and effective course of treatment for transsexual people is to go through sex reassignment therapy.

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. Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role and/or physical characteristics.

Many transgender and transsexual activists, and many caregivers, point out that these problems usually are not related to the gender identity issues themselves, but to problems that arise from dealing with those issues and social problems related to them. Also, many feel that those problems are much more likely to be diagnosed in transsexual people than in the general population, because transsexual people are usually required to visit a mental health professional to obtain approval for hormones and sex reassignment surgery. This exposes the transsexual community to a higher level of evaluation for mental health issues than the general populace.

A growing number of transsexual people are resenting or even refusing psychological treatment which is mandated by the Harry Benjamin Standards of Care, because they believe that gender dysphoria itself is untreatable by psychological means, and that they have no other problems that need treatment. Unfortunately, this can often cause them significant problems when they attempt to obtain physical treatment as health professionals expect such therapy to be occurring concurrently with physical treatment.

Therapists' records reveal that many transsexual people do not believe they need psychological counseling, but rather they will acquiesce to legal and medical expectations in order to gain rights which are thusly granted through the medical/psychological hierarchy. (Brown 103) Legal needs such as a change of sex on legal documents, and medical needs, such as sex reassignment surgery, are usually impossible to obtain without a doctor and/or therapist's approval. Because of this, many transsexual people feel coerced into affirming pre-ordained symptoms of self-loathing, impotence, and sexual-preference, in order to overcome simple legal and medical hurdles. (Brown 107) Transsexual people who do not submit to this medical hierarchy typically face the option of remaining invisible, with no legal rights and possibly with identification documents incongruent with gender presentation.

Diagnosing transsexualism
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). As the DSM has changed its terminology, the diagnosis of "transsexualism" has become unused in recent years. This diagnostic label is often necessary to obtain sex reassignment therapy. However, some people diagnosed with gender identity disorder 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 them. (Brown 105) Again, see Transfeminism's section on GID.

Some people who desire sex reassignment therapy do not have gender identity disorder, as the term is usually defined, and desire to transition for other reasons. This can include homosexual people who are unable to accept their homosexuality (or which 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 do 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) If SRS is performed in such cases, the result is usually expected to be very negative for the individual, since it, unlike with patients with GID, typically does not alleviate issues for them, but rather leaves them with an intolerable body.

However, 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. Furthermore, many people express that some psychologists and psychiatrists in viewing transsexualism as "a disease" have sought to develop specific models of transsexualism, which they feel exclude many transsexual people, such as Ray Blanchard's model.

Andrea James in an article rejecting terminology and disease-models of transsexuality, has proposed the terms "interest in feminization" and "interest in masculinization" to refer to a desire for sex reassignment therapy, regardless of whether the person with the desire is transsexual. Although she herself admitted that there are numerous difficulties and issues with this terminology that she herself could easily list, she hasn't advanced this terminology as a finalized terminology, but rather a start towards finding terminology that avoids the traditional issues surrounding transsexuality which describe it as a "disease" or a "deviant" condition. Critics of her terminology would point out that she has swung the pendulum too far in the other direction, now equating transsexuality to a "life-style choice", which often offends those transsexuals who feel that their condition has a biological origin. Andrea herself agreed with this position that transsexuality is not a choice, but she was rather strong in rejecting any assertion that it should be classified as a disease rather than a part of typical human variance. This strident desire to divorce transsexual people from medical diagnoses or use such diagnoses to deflect fault from the transsexual person for various undesired side effects of coming out or transitioning as a transsexual person is best explained through sympathetic reasoning, such as in the article on transfeminism.

Other people, under the position that transsexualism is a physical condition and not a psychological issue, assert that sex reassignment therapy should be given if requested, and may even align with those who feel that all body modification should be offered on demand. (Brown 103)

Sex reassignment therapy
Sex reassignment therapy (SRT) is an umbrella term for all medical procedures regarding sex reassignment of both transgender and intersexual people. Sometimes SRT is also called gender reassignment, even though many people consider this term inaccurate as SRT alters physical sexual characteristics to more accurately reflect the individual's psychological/social gender identity, rather than vice versa as is implied by the term "gender reassignment."

Sex reassignment therapy can consist of hormone replacement therapy (HRT) to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, and permanent hair removal for transwomen.

In addition to undergoing medical procedures, transsexual people who go through sex reassignment therapy usually change their social gender roles, legal names and legal sex designation. The entire process of change from one gender presentation to another is known as transition.

Legal and social aspects
Many Western societies have procedures whereby an individual can change their name, and sometimes, their legal gender, to reflect their gender identity (see Legal aspects of transsexualism). Laws regarding changes to the legal status of transsexuals are different from country to country. Within the US, some state jurisdictions do allow amendments or complete replacement of the original birth certificates. Some jurisdictions may even seal earlier records against all but court orders in order to protect the transsexual's privacy.

In many other countries, it is still not possible to change birth records or other legal documents relating to ones gender status. Since many governments are revising the legal status of post-operative transsexuals, there are many individuals pioneering changes to these laws, such as Estelle Asmodelle whose book documents her struggle to change the Australian birth certificate and passport laws, although there are other individuals who are were instrumental in changing laws and thus attaining more acceptance for transsexual people in general.

Medical treatment for transsexual and transgender people is also 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. In the United States, November 20 has been set aside as the "Day of Remembrance" for all murdered transgender people.

Some people who have switched their gender role enter into traditional social institutions such as marriage and the role of parenting. They sometimes adopt or provide foster care for children, as complete sex reassignment therapy inevitably results in infertility. Sometimes, they adopt children who are also transsexual or transgender and help them live according to their gender identity. 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. A recent study shows that this does not harm the development of these children in any way.

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.

Employment issues
Transsexual people have historically had difficulty maintaining employment. Most transsexual people find it necessary to remain employed during transition in order to cover the costs of living and transition. However, employment discrimination against trans people is rampant and many of them are fired when they come out or are involuntarily outed at work. Transsexual people must decide whether to transition on-the-job, or to find a new job when they make their social transition. The transsexual community usually regards this as a personal decision, though those who are fired during transition will have to find new jobs. Finding employment is often a challenge, especially for those in mid-transition.

Legal policies regarding name and gender changes in many countries make it difficult for pre-op transsexual people to conceal their trans status from their employers. 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 are providing increasing protection from workplace discrimination to transpeople, and an increasing number of companies are including "gender identity" in their non-discrimination policies. However, these laws and policies often have gaps, and they are not always fully implemented and enforced. California has strigent anti-discrimination laws to protect transsexual persons in the workplace and specifically prohibits employers from terminating or refusing to hire persons who are discovered to be transsexual. Member states of the European Union provide employment protection as part of gender discrimination protections following the European Court of Justice decisions in P v S and Cornwall County Council

Stealth
After transsexual men and women are living full-time as members of their target gender, they may wish to blend in with other members of their new sex, and will avoid revealing their past. They do this believing that it will provide greater peace and security on the other side of a stressful and potentially dangerous transition, and/or because they wish to be seen only as members of their target sex, not as transsexuals.

This behaviour, known as stealth, is recognized by most people in the transsexual community as an individual decision that one must make. Some, however, within and outside the transsexual community, feel that one should be upfront about his or her past, and that stealth living would be dishonest. Some draw a parallel with a perceived need for lesbian and gay people to "come out", and may perceive a failure to do so as betrayal of a greater community, seeing hope for advancement of civil rights and public image in the visibility of greater numbers. However, most people within the community understand that revealing one's transsexual history is a deeply personal choice. Moreover, this is part of an individual's medical history, and as such should be his or hers alone to disclose.

Several examples also exist of people who have been denied medical treatment upon discovery of their trans status, whether it was revealed by the patient or inadvertently discovered by the doctors. For example, Leslie Feinberg was once turned away from a hospital emergency room where he had sought treatment for encephalitis. (Feinberg 2) Like Tipton, 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. Additionally, Tyra Hunter died after being denied care by paramedics and emergency room physicians after she was injured in an automobile accident.

The equating of "coming out" (whereby a transsexual person who has hidden their true gender identity while maintaining their originally assigned gender role, reveals their true self) with honesty or social activism has been countered by the explanation that, because of prejudice, sensationalism, and the triggering of unconscious personal feelings and emotions, knowledge of someone's transsexual past can prevent the average person from being able to see the transitioned person's true self.

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.

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. Minister and former transgender Jerry Leach, in association with Exodus International, includes stories from regretful trans patients as part of his "sexual addiction" ministry website.

These cases are often cited as reasons for the lengthy triadic process outlined in the Standards of Care, 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.

Additionally, some people detransition after SRS because their desire was to undergo SRS and continue living in the gender role assigned to them at birth. However, they transition temporarily in order to satisfy the requirement of a real-life test.

Depictions of transsexualism in the media
Although many transsexual people are modest about their bodies, and are found in all walks of life and professions, transsexual women are commonly featured in pornographic works. When depicted without having undergone vaginoplasty, they are usually referred to as "shemales". While some pre-operative transwomen call themselves and others like them "shemales," the term is regarded as offensive by many transsexual people.

Films depicting transgender issues include The World According to Garp 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!. In a 1980s episode of The Love Boat, McKenzie Phillips portrays a transwoman who is eventually accepted as a friend by her old high school classmate, series regular Fred Grandy. In the 80's. on "The Jefferson" one of George's navy buddies 'Eddie' shows up as a woman 'Edie' and is eventually accepted by George.

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. Many transsexual actresses and extras appeared on the episode, including Marci Bowers and Calpernia Addams. The transwoman 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.

Recently, Candis Cayne, a transsexual performer, appeared in CSI: NY as a transsexual character. Beginning in the fall 2007 TV season, Candis will also play a transsexual character (this time reoccurring) in the new 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 transwomen and two transmen, in various stages of transition. 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.

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. While the movie and novel initially sparked more intolerance toward transsexuals, it has since diminished from public criticism of transsexuality.

Transsexualism in non-Western cultures
Transsexual people experience varying degrees of acceptance in non-Western societies.

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).



This stance is also seen in countries such as Brazil and Thailand. Thailand is thought to have the highest prevalence of transsexualism in the world. 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 sex reassignment surgery. Thai surgeons are a popular option for Western transpeople seeking surgery, largely due to the lower cost of surgery in Thailand.

Transsexual- (and tg-) related issues remain largely taboo in much of Africa and in developing countries around the world.