Transsexual

Transsexualism
Classification and external resources
Specialty	psychiatry
ICD-10	F64.0
MedlinePlus	001527
MeSH	D014189

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

Transsexual people experience a gender identity that is inconsistent with, or not culturally associated with, their assigned sex, and desire to permanently transition to the gender with which they identify, usually seeking medical assistance (including hormone replacement therapy and other sex reassignment therapies) to help them align their body with their identified sex or gender. Transsexual is generally considered a subset of transgender,^[1][2][3] but some transsexual people reject the label of transgender.^[4][5][6][7] A medical diagnosis of gender dysphoria can be made if a person expresses a desire to live and be accepted as a member of their identified sex,^[8] or if a person experiences impaired functioning or distress as a result of their gender identity.^[9]

Terminology

Origin and use of transsexual

Norman Haire reported that in 1921,^[10] Dora R of Germany began a surgical transition, under the care of Magnus Hirschfeld, which ended in 1930 with a successful genital reassignment surgery. In 1930, Hirschfeld supervised the second genital reassignment surgery to be reported in detail in a peer-reviewed journal, that of Lili Elbe of Denmark. In 1923, Hirschfeld introduced the (German) term "Transsexualismus",^[11] after which David Oliver Cauldwell introduced "transsexualism" and "transsexual" to English in 1949 and 1950.^[12][13]

Cauldwell appears to be the first to use the term to refer to those who desired a change of physiological sex.^[14] In 1969, Benjamin claimed to have been the first to use the term "transsexual" in a public lecture, which he gave in December 1953.^[15] Benjamin went on to popularize the term in his 1966 book, The Transsexual Phenomenon, in which he described transsexual people on a scale (later called the "Benjamin scale") of three levels of intensity: "Transsexual (nonsurgical)", "Transsexual (moderate intensity)", and "Transsexual (high intensity)".^[16][17][18] In his book, Benjamin described "true" transsexualism as the following:

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.^[19]

Benjamin suggested that moderate intensity male to female transsexual people may benefit from estrogen medication as a "substitute for or preliminary to operation."^[16] Some people have had SRS but do not meet the above definition of transsexual (e.g. Gregory Hemingway).^[20][21] Other people do not desire SRS although they meet the other element's of Benjamin's definition of a "true transsexual".^[22] Transexuality 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.

Beyond Benjamin's work, which focused on male-to-female transsexual people, there are cases of the female to male transsexual, for whom genital surgery may not be practical. Benjamin gave certifying letters to his MTF transsexual patients that stated "Their anatomical sex, that is to say, the body, is male. Their psychological sex, that is to say, the mind, is female." After 1967 Benjamin abandoned his early terminology and adopted that of "gender identity."^[23]

Relationship of transsexual to transgender

Around the same time as Benjamin's book, in 1965, the term transgender was coined by John Oliven.^[2] By the 1990s, transsexual had come to be considered a subset of the umbrella term transgender.^[1][2][3] The term transgender is now more common, and many transgender people prefer the designation transgender and reject transsexual.^[24][25][26] The term transsexual, however, continues to be used,^[27] and some people who pursue medical assistance (for example, sex reassignment surgery) to change their sexual characteristics to match their gender identity prefer the designation transsexual and reject transgender.^[24][25][26] One perspective offered by transsexual people who reject a transgender label for that of transsexed is that, for people who have gone through sexual reassignment surgery, their anatomical sex has been altered, whilst their gender remains constant.^[28][29][30]

Historically, one reason some people preferred transsexual to transgender is that the medical community in the 1950s through the 1980s encouraged a distinction between the terms that would only allow the former access to medical treatment.^[31] Other self-identified transsexual people state that those who do not seek sex reassignment surgery (SRS) are fundamentally different from those who do, and that the two have different concerns,^[18] but this view is controversial, and others argue that merely having some medical procedures does not have such far-reaching consequences as to put those who have them and those who have not (e.g. because they cannot afford them) into such distinctive categories. Another reason for objecting to the term transsexual is the concern that it implies something to do with sexuality, when it is actually about gender identity.^[32] For example, Christine Jorgensen, the first widely known person to have sex reassignment surgery (in this case, male to female), rejected transsexual and instead identified herself in newsprint as trans-gender, on this basis.^[33][34]

Terminological variance

The word transsexual is most often used as an adjective rather than a noun – a "transsexual person" rather than simply "a transsexual". Like other trans people, transsexual people prefer to be referred to by the gender pronouns and terms associated with their gender identity. For example, a trans 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; in the case of a transsexual man, he furthermore has or will have a masculine body. Transsexual people are sometimes referred to with directional terms, such as "female-to-male" for a transsexual man, abbreviated to "F2M", "FTM", and "F to M", or "male-to-female" for a transsexual woman, abbreviated "M2F", "MTF" and "M to F".

Individuals who have undergone and completed sex reassignment surgery are sometimes referred to as transsexed individuals;^[35] however, the term transsexed is not to be confused with the term transexual, which can also refer to individuals who have not yet undergone SRS, and whose anatomical sex (still) does not match their psychological sense of personal gender identity.

The terms gender dysphoria and gender identity disorder were not used until the 1970s,^[27] when Laub and Fisk published several works on transsexualism using these terms.^[36][37] "Transsexualism" was replaced in the DSM-IV by "gender identity disorder in adolescents and adults".

Male-to-female transsexualism has sometimes been called "Harry Benjamin's syndrome" after the endocrinologist who pioneered the study of dysphoria.^[38] As the present-day medical study of gender variance is much broader than Benjamin's early description, there is greater understanding of its aspects,^[23] and use of the term Harry Benjamin's syndrome has been criticized for delegitimizing gender-variant people with different experiences.^[39][40]

Androphilia and gynephilia

The use of homosexual transsexual and related terms have been applied to transgender people since the middle of the 20th century, though concerns about the terms have been voiced since then. Harry Benjamin said in 1966:

...it seems evident that the question "Is the transsexual homosexual?" must be answered "yes" and " no." "Yes," if his anatomy is considered; "no" if his psyche is given preference.

What would be the situation after corrective surgery has been performed and the sex anatomy now resembles that of a woman? Is the "new woman" still a homosexual man? "Yes," if pedantry and technicalities prevail. "No" if reason and common sense are applied and if the respective patient is treated as an individual and not as a rubber stamp.^[41]

Many sources, including some supporters of the typology, criticize this choice of wording as confusing and degrading. Biologist Bruce Bagemihl writes "..the point of reference for "heterosexual" or "homosexual" orientation in this nomenclature is solely the individual's genetic sex prior to reassignment (see for example, Blanchard et al. 1987[24], Coleman and Bockting, 1988[25], Blanchard, 1989[26]). These labels thereby ignore the individual’s personal sense of gender identity taking precedence over biological sex, rather than the other way around."^[42] Bagemihl goes on to take issue with the way this terminology makes it easy to claim transsexuals are really homosexual males seeking to escape from stigma.^[42] Leavitt and Berger stated in 1990 that "The homosexual transsexual label is both confusing and controversial among males seeking sex reassignment.^[43][44] Critics argue that the term "homosexual transsexual" is "heterosexist",^[42] "archaic",^[45] and demeaning because it labels people by sex assigned at birth instead of their gender identity.^[46] Benjamin, Leavitt, and Berger have all used the term in their own work.^[41][43] Sexologist John Bancroft also recently expressed regret for having used this terminology, which was standard when he used it, to refer to transsexual women.^[47] He says that he now tries to choose his words more sensitively.^[47][47] Sexologist Charles Allen Moser is likewise critical of the terminology.^[48]

Use of androphilia and gynephilia was proposed and popularized by psychologist Ron Langevin in the 1980s.^[49] Psychologist Stephen T. Wegener writes, "Langevin makes several concrete suggestions regarding the language used to describe sexual anomalies. For example, he proposes the terms gynephilic and androphilic to indicate the type of partner preferred regardless of an individual's gender identity or dress. Those who are writing and researching in this area would do well to adopt his clear and concise vocabulary."^[50]

Psychiatrist Anil Aggrawal explains why the terms are useful in a glossary:

Androphilia – The romantic and/or sexual attraction to adult males. The term, along with gynephilia, is needed to overcome immense difficulties in characterizing the sexual orientation of transmen and transwomen. For instance, it is difficult to decide whether a transman erotically attracted to males is a heterosexual female or a homosexual male; or a transwoman erotically attracted to females is a heterosexual male or a lesbian female. Any attempt to classify them may not only cause confusion but arouse offense among the affected subjects. In such cases, while defining sexual attraction, it is best to focus on the object of their attraction rather than on the sex or gender of the subject.^[51]

Psychologist Rachel Ann Heath writes, "The terms homosexual and heterosexual are awkward, especially when the former is used with, or instead of, gay and lesbian. Alternatively, I use gynephilic and androphilic to refer to sexual preference for women and men, respectively. Gynephilic and androphilic derive from the Greek meaning love of a woman and love of a man respectively. So a gynephilic man is a man who likes women, that is, a heterosexual man, whereas an androphilic man is a man who likes men, that is, a gay man. For completeness, a lesbian is a gynephilic woman, a woman who likes other women. Gynephilic transsexed woman refers to a woman of transsexual background whose sexual preference is for women. Unless homosexual and heterosexual are more readily understood terms in a given context, this more precise terminology will be used throughout the book. Since homosexual, gay, and lesbian are often associated with bigotry and exclusion in many societies, the emphasis on sexual affiliation is both appropriate and socially just."^[52] Author Helen Boyd agrees, writing, "It would be much more accurate to define sexual orientation as either "androphilic" (loving men) and "gynephilic" (loving women) instead."^[53] Sociomedical scientist Rebecca Jordan-Young challenges researchers like Simon LeVay, J. Michael Bailey, and Martin Lalumiere, who she says "have completely failed to appreciate the implications of alternative ways of framing sexual orientation."^[54]

Medical diagnosis

Transsexualism appears in 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. It 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."

Historically, transsexualism has also been included in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). With the DSM-5, transsexualism was removed as a diagnosis, and a diagnosis of gender dysphoria was created in its place.^[55] This change was made to reflect the consensus view by members of the APA that transsexuality is not in and of itself a disorder and that transsexual people should not be stigmatized unnecessarily.^[56] By including a diagnosis for gender dysphoria, transsexual people are still able to access medical care through the process of transition.

Similarly, the World Professional Association for Transgender Health (WPATH), and many transsexual people, have recommended the removal of transsexualism from the mental health chapter of the upcoming ICD, ICD-11 (due to be released in 2017).^[57] They argue that at least some mental health professionals are being insensitive by labelling transsexualism as "a disease", rather than the inborn trait which those who have it believe it to be.^[58] Principle 18 of The Yogyakarta Principles, a document of international human rights law,^[59] opposes such diagnosis as mental illness as medical abuse.

The current diagnosis for transsexual people who present themselves for medical treatment is gender dysphoria (leaving out those who have sexual identity disorders without gender concerns).^[55] According to the Standards of care formulated by the World Professional Association for Transgender Health (WPATH),^[60][61] formerly the Harry Benjamin International Gender Dysphoria Association, this diagnostic label is often necessary to obtain sex reassignment therapy with health insurance coverage, and the designation of gender identity disorders as mental disorders is not a license for stigmatization or for the deprivation of gender patients' civil rights.

Causes, studies and theories

Psychological and biological causes for transsexualism have been proposed by various researchers including Dick Swaab, and there is evidence of prenatal and genetic causes.^[62][63][64] In particular, several studies have shown that sexually dimorphic brain structures in transsexuals are shifted away from what is associated with their birth sex and towards what is associated with their preferred sex. (Researchers caution that there are known brain differences between homosexual and heterosexual people and that the brain changes in response to hormone-treatment, which many transsexuals use; studies which have distinguished andro- from gynephilic transsexuals have yielded clearer results than studies which have not.) For example, there is also considerable evidence that prenatal exposure to endocrine-disrupting anti-miscarriage drugs such as diethylstilbestrol (DES) may also be positively associated with transsexualism, though research in this area has yet to establish a firm causal link.^{[65][66][67][68]} Another study suggests that transsexuality may have a genetic component.^[69]

Brain-based studies

One proposed cause of transsexuality is related to the bed nucleus of a stria terminalis, or BSTc, a constituent of the basal ganglia of the brain which is affected by prenatal androgens.^[70] In one study, the BSTc of male-to-female transsexual women was similar to those of cisgender women whose psychological gender identity and assigned sex are the same. However, those of both heterosexual and homosexual men were similar to each other but different from those of women (both cis- and transsexual).^[63]

Androphilic male-to-female transsexuals

Studies have shown that androphilic male-to-female transsexuals (sometimes called homosexual MtF transsexuals) show a shift towards the female direction in brain anatomy. In 2009, the German team of radiologists led by Gizewski compared 12 androphilic transsexuals with 12 cisgender males and 12 cisgender females. Using functional magnetic resonance imaging (fMRI), they found that when shown erotica, the cisgender men responded in several brain regions that the cisgender women did not, and that the sample of androphilic transsexuals was shifted towards the female direction in brain responses.^[71]

Rametti and colleagues used diffusion tensor imaging (DTI) to compare 18 androphilic male-to-female transsexuals with 19 gynephilic males and 19 androphilic cisgender females. The androphilic transsexuals differed from both control groups in multiple brain areas, including the superior longitudinal fasciculus, the right anterior cingulum, the right forceps minor, and the right corticospinal tract. The study authors concluded that androphilic transsexuals were halfway between the patterns exhibited by male and female controls.^[72]

Gynephilic male-to-female transsexuals

Likewise, gynephilic male-to-female transsexuals also show differences in the brain from non-transsexuals, in a pattern intermediate between male or female, or more female than male. Researchers of the Karolinska Institute of Stockholm used MRI to compare 24 gynephilic male-to-female transsexuals with 24 cisgender male and 24 cisgender female controls. None of the study participants were on hormone treatment. The researchers found sex-typical differentiation between the MtF transsexuals and cisgender males, and the cisgender females; but the gynephilic transsexuals "displayed also singular features and differed from both control groups by having reduced thalamus and putamen volumes and elevated GM volumes in the right insular and inferior frontal cortex and an area covering the right angular gyrus."

These researchers concluded that:

Contrary to the primary hypothesis, no sex-atypical features with signs of 'feminization' were detected in the transsexual group....The present study does not support the dogma that [male-to-female transsexuals] have atypical sex dimorphism in the brain but confirms the previously reported sex differences. The observed differences between MtF-TR and controls raise the question as to whether gender dysphoria may be associated with changes in multiple structures and involve a network (rather than a single nodal area).^[73]

In Sweden, non-androphilic transsexual women were tested when they were smelling odorous steroids. The results showed that the transsexual women demonstrated "a pattern of activation away from the biological sex, occupying an intermediate position with predominantly female-like features."^[74]

Anne Lawrence, a sexologist, physician, and self-identified autogynephilic transsexual, has hypothesized that the desire by persons with autogynephilia, including some cross dressers and some transsexuals, to alter their body can be compared with apotemnophilia (alternately body integrity identity disorder if framed as an identity issue rather than a fetish).^[75] Some transsexuals argue that explanations that base on libido the desire to transition are unscientific^[76] and/or transphobic.^[77]

Mixed samples of male-to-female transsexuals

Several teams of researchers have examined the brains of MtF transsexuals without separating the samples into androphilic (or homosexual) and gynephilic (or heterosexual) types. These studies have yielded contradictory results: some reported differences between the (mixed groups of) MtF transsexuals and the non-transsexual controls, but other studies found no differences.

The corpus callosum was studied in MtF transsexuals because it is larger and differently shaped in men than in women. In 1991, a University of Texas team reported comparing the corpora callosa of 10 MtF transsexuals, 10 FtM transsexuals, 20 control males, and 20 control females. No significant differences were found.^[78]

In a pair of reports, the Dutch team that Dick Swaab led examined the volume^[79] and neuron count^[80] in the bed nucleus of the stria terminalis in six estrogen-treated transsexuals and one pre-treatment transsexual. They found the BSTc to be female-shifted (smaller) among the transsexuals than among the male control subjects. A subsequent study by Swaab found that the BSTc becomes sexually dimorphic only in adulthood, suggesting that differentiation of the BSTc does not cause transsexualism.^[81] Rather, the difference in the BSTc might instead be the result of a "failure to develop a male-like gender identity" (p. 1032). The BSTc has also been reported to be smaller in other sexually atypical populations unrelated to transsexualism.^[82]

Another team of Dutch researchers examined the effects of cross-gender hormone treatment on the brain in 8 male-to-female transsexuals and in 6 female-to-male transsexuals, finding that the hormones changed the sizes of the hypothalamus in a gender consistent manner. Treatment with male hormones shifted the hypothalamus towards the male direction in the same way as in male controls, and treatment with female hormones shifted the hypothalamus towards the female direction in the same way as female controls.^[83]

A 2003 study by Haraldsen and colleagues compared the performance of 52 persons with Gender Identity Disorder (33 from Norway and 19 from the U.S.) with that of 29 control subjects on a series of tests that tap into the functioning of different parts of the brain and on which men and women perform differently. The people in the GID sample "were either homosexually attracted by males or females (n=38), by both (n=3) or by neither (n=9)." No effects of transsexual status were detected.^[84]

Johns Hopkins researchers in 2005 reported on another test of brain functioning using test performance. The study subjects included 27 MtF transsexuals and 16 control men, and the authors reported that no female-typical patterns in cerebral lateralization or cognitive performance were found within the transsexual sample.^[85]

In 2009, UCLA researchers used MRIs to examine a mixed sample of 24 non-hormone-treated male-to-female transsexuals (6 were androphilic, and 18 were gynephilic), comparing them with 30 non-transsexual males and 30 non-transsexual females. The results "revealed that regional gray matter variation in MTF transsexuals is more similar to the pattern found in men than in women," except for the "right putamen.". They concluded that "These findings provide new evidence that transsexualism is associated with distinct cerebral pattern, which supports the assumption that brain anatomy plays a role in gender identity."^[86]

Gynephilic female-to-male transsexuals

Brain-based research has repeatedly shown that female-to-male transsexuals have several male-like characteristics in neuroanatomy. In 2010, a team of neuroscientists compared 18 female-to-male transsexuals with 24 male and 19 female gynephilic controls, using an MRI technique called diffusion tensor imaging or DTI.^[87] DTI is a specialized technique for visualizing white matter of the brain, and white matter structure is one of the differences in neuroanatomy between men and women. The study found that the white matter pattern in female-to-male transsexuals was shifted in the direction of biological males, even before the female-to-male transsexuals started taking male hormones (which can also modify brain structure).

Another team of neuroscientists, led by Nawata in Japan, used a technique called single-photon emission computed tomography (SPECT) compare the regional cerebral blood flow (rCBF) of 11 female-to-male transsexuals (attracted to women) with that of 9 biological females (attracted to men). Although the study did not include a sample of biological males so that a conclusion of "male shift" could be made, the study did reveal that the female-to-male transsexuals showed significant decrease in blood flow in the left anterior cingulate cortex and a significant increase in the right insula, two brain regions known to respond during sexual arousal.^[88]

Related developments in other fields

Brain structure differences associated with transsexualism do not exist in isolation. Similar brain structure differences have been noted between gay and heterosexual men, and between lesbian and heterosexual women.^[89][90]

More recent studies have found that circumstance, such as parenting, and repeated activities such as meditation modify brain structures in a process called brain plasticity or neuroplasticity. In May 2014, the Proceedings of the National Academy of Sciences reported that for fathers parenting "rewires the male brain".^[91]

Gene-related studies

In 2008, a study was performed to attempt to find a link between genes and transsexuality. The researchers compared 112 male-to-female transsexuals (both androphilic and gynephilic), mostly already undergoing hormone treatment, with 258 cisgender male controls. The male-to-female transsexuals were more likely than non-transsexual males to have a longer version of a receptor gene for the sex hormone androgen or testosterone. The research suggests reduced androgen and androgen signaling contributes to the female gender identity of male to female transsexuals. The authors say that a decrease in testosterone levels in the brain during development might prevent complete masculinization of the brain in male to female transsexuals and thereby cause a more feminized brain and a female gender identity.^[92][93]

A twin study was subsequently published which examined pairs of twins where either one or both of the twins had undergone, or had plans and had received medical approval to undergo, gender transition (both types of people were classified as trans in the study). The study combined a survey of such twins, with a literature review of published reports mentioning transgender twins. The study found that one third of identical twin pairs in the sample were both transgender, whereas among the non-identical twin pairs, there were almost no pairs where both were transgender.^[94]

Blanchard's typology

Blanchard's transsexualism typology characterizes trans women as having one of two motivations for transition.^[95][96][97] Whereas previous descriptions of transgender people included very many combinations of sexual orientation, gender identity, and the desire to cross-dress, Blanchard interprets his evidence as suggesting that there were only two basic phenomena. One phenomenon was androphilia (male homosexuality), which ranged from typical gay men to, when extreme, androphilic or homosexual transsexualism. The other phenomenon was autogynephilia, which ranged from typical cross-dressers to, when extreme, autogynephilic transsexualism (or non-homosexual transsexualism). Androphilic male-to-female transsexuals are characterized by sexual attraction to males and by overt and obvious femininity since childhood, whereas autogynephilic transsexuals are characterized by sexual attraction to females (or sometimes to females and males, or by asexuality) and whose presentations are internal and typically unremarkable until they choose to disclose them, typically later in life. There are community activists who dislike the theory.^[98]

Scientific criticism of the theory includes papers from Veale, Nuttbrock, Moser, and others who argue that the theory is poorly representative of MTF transsexuals, non-instructive, the experiments poorly controlled, or contradicted by other data.^{[99][100][101][102]} Many sources, including some supporters of the theory, criticize Blanchard's choice of wording as confusing or degrading.

Also the DSM V workgroup has been quoted as saying:

In contemporary clinical practice, sexual orientation per se plays only a minor role in treatment protocols or decisions. Also, changes as to the preferred gender of sex partner occur during or after treatment (DeCuypere, Janes, & Rubens, 2005; Lawrence, 2005; Schroder & Carroll, 1999). It can be difficult to assess sexual orientation in individuals with a GI diagnosis, as they preoperatively might give incorrect information in order to be approved for hormonal and surgical treatment (Lawrence, 1999). Because sexual orientation subtyping is of interest to researchers in the field, it is recommended that reference to it be addressed in the text, but not as a specifier. It should also be assessed as a dimensional construct.^[103]

Blanchard is a member of the DSM V Sexual and Gender Identity Disorders Work Group chaired by Kenneth J. Zucker. Though it has supporters, the transsexual community has for the most part vehemently rejected Blanchard's typology theory.

Medical assistance

Sex reassignment therapy

Sex reassignment therapy (SRT) is an umbrella term for all medical treatments related to sex reassignment of both transgender and intersex 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.

Individuals make different choices regarding sex reassignment therapy, which may include female-to-male or male-to-female hormone replacement therapy (HRT) to modify secondary sex characteristics, sex reassignment surgery (such as orchiectomy) to alter primary sex characteristics, chest surgery such as top surgery or breast augmentation, or, in the case of trans women, a trachea shave, facial feminization surgery or permanent hair removal.

To obtain sex reassignment therapy, transsexual people are generally required to undergo a psychological evaluation and receive a diagnosis of gender identity disorder in accordance with the Standards of Care (SOC) as published by the World Professional Association for Transgender Health.^[60] This assessment is usually accompanied by counseling on issues of adjustment to the desired gender role, effects and risks of medical treatments, and sometimes also by psychological therapy. The SOC are intended as guidelines, not inflexible rules, and are intended to ensure that clients are properly informed and in sound psychological health, and to discourage people from transitioning based on unrealistic expectations.

Gender roles and transitioning

After an initial psychological evaluation, trans men and trans women may begin medical treatment, starting with hormone replacement therapy^[61][104] or hormone blockers. In these cases, people who change their gender are usually required to live as members of their target gender for at least one year prior to genital surgery, gaining real-life experience, which is sometimes called the "real-life test" (RLT).^[61] 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)

Like other trans people, transsexual people may refer to themselves as trans men or trans women. Transsexual people desire to establish a permanent gender role as a member of the gender with which they identify, and many transsexual people pursue medical interventions as part of the process of expressing their gender. The entire process of switching from one physical sex and social gender presentation to another is often referred to as transitioning, and usually takes several years. Transsexual people who transition usually change their social gender roles, legal names and legal sex designation.

Not all transsexual people undergo a physical transition. Some find reasons not to; for example, the expense of surgery, the risk of medical complications, or medical conditions which make the use of hormones or surgery dangerous. Some may not identify strongly with another binary gender role. Others may find balance at a mid-point during the process, regardless of whether or not they are binary-identified. Many transsexual people, including binary-identified transsexual people, do not undergo genital surgery, because they are comfortable with their own genitals, or because they are concerned about nerve damage and the potential loss of sexual pleasure, including orgasm. This is especially so in the case of trans men, many of whom are dissatisfied with the current state of phalloplasty, which is typically very expensive, not covered by health insurance, and commonly does not achieve desired results. For example, not only does phalloplasty not result in a completely natural erection, it may not allow for an erection at all, and its results commonly lack penile sexual sensitivity; in other cases, however, phalloplasty results are satisfying for trans men. By contrast, metoidioplasty, which is more popular, is significantly less expensive and has far better sexual results.^{[105][106][107]}

Some transsexual people live heterosexual lifestyles (see heteronormative), while some identify as gay, lesbian,^[23] or bisexual. Many transsexual people choose the language of how they refer to their sexual orientation based on their gender identity, not their birth assigned sex,^[23] though some transsexual people still find identification with a physical-sex-based community: many trans men, for instance, are involved with lesbian communities.

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^[61] note that sometimes the only reasonable and effective course of treatment for transsexual people is to go through sex reassignment therapy.^[61][108]

The need for treatment of transsexual people 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.^[109] These problems are alleviated by a change of gender role and/or physical characteristics.^[110]

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 counseling that is recommended by the Standards of Care^[61] because they do not consider their gender identity to be a cause of psychological problems.

Brown and Rounsley^[111] 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 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).

Regrets and detransitions

People who undergo sex reassignment surgery can develop regret for the procedure later in life, largely due to lack of support from family or peers, with data from the 1990s suggesting a rate of 3.8%.^[112][113] 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.^[114] A 2009 review of Medline literature suggests the total rate of patients expressing feelings of doubt or regret is estimated to be as high as 8%.^[115] An issue reported by some is the inability to find sexual partners.

A 2010 meta-study, based on 28 previous long-term studies of transsexual men and women, found that the overall psychological functioning of transsexual people after transition was similar to that of the general population and significantly better than that of untreated transsexual people.^[116]

Prevalence

Estimates of the prevalence of transgender are highly dependent on the specific case definitions used in the studies, with prevalence rates varying by orders of magnitude.^[117] The most frequently quoted estimate of prevalence is from the Amsterdam Gender Dysphoria Clinic;^[118] over four decades the clinic has treated roughly 95% of Dutch transsexual clients, and it suggests a prevalence of 1:10,000 among assigned males and 1:30,000 among assigned females. In the US, the DSM-IV (1994) says that roughly 1 in 30,000 assigned males and 1 in 100,000 assigned females seek sex reassignment surgery. Though no direct studies on the prevalence of GID have been done, a variety of clinical papers published in the past 20 years provide estimates ranging from 1:7,400 to 1:42,000 in assigned males and 1:30,040 to 1:104,000 in assigned females.^[119] A 2008 study of the number of New Zealand passport holders who changed the sex on their passport estimated that 1:3,639 birth-assigned males and 1:22,714 birth-assigned females were transsexual.^[120]

The most recent (2016) systematic review of prevalence, leading to a meta-analysis of 27 studies, found estimates per 100,000 population of 9.2 (95% CI = 4.9–13.6) for surgical or hormonal gender affirmation therapy and 6.8 (95% CI = 4.6–9.1) for transgender-related diagnoses. Of studies assessing self-reported transgender identity, prevalence was 871 (95% CI = 519–1,224); however, this result was influenced by a single outlier study. After removal of that study, the figure dropped to 355 (95% CI = 144–566). Significant heterogeneity was observed in most analyses.^[117]

Olyslager and Conway presented a paper^[121] 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 transsexual people and 1:8,000 female-to-male transsexual people for a number of countries worldwide. They estimate the number of post-op women in the US to be 32,000 and obtain a figure of 1:2500 male-to-female transsexual people. They further compare the annual incidences of SRS and male birth in the U.S. to obtain a figure of 1:1000 MTF transsexual people and suggest a prevalence of 1:500 extrapolated from the rising rates of SRS in the US and a "common sense" estimate of the number of undiagnosed transsexual people. Olyslager and Conway also argue that the US population of assigned males having already undergone reassignment surgery by the top three US SRS surgeons alone is enough to account for the entire transsexual population implied by the 1:10,000 prevalence number, yet this excludes all other US SRS surgeons, surgeons in countries such as Thailand, Canada, and others, and the high proportion of transsexual people who have not yet sought treatment, suggesting that a prevalance of 1:10,000 is too low.

These studies have suggested that trans women are noticeably more common than trans men, but a study of Swedes estimated a ratio of 1.4:1 trans women to trans men for those requesting sex reassignment surgery and a ratio of 1:1 for those who proceeded.^[122]

A presentation at the LGBT Health Summit in Bristol, UK,^[123] 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.

Society and culture

An apparent transsexual named Elagabalus was the Roman Emperor from 218 to 222.^[124][125]

A number of Native American and First Nations cultures have traditional social and ceremonial roles for individuals who do not fit into the usual roles for males and females in that culture. These roles can vary widely between tribes, because gender roles, when they exist at all, also vary considerably among different Native cultures. However, a modern, pan-Indian status known as Two-Spirit has emerged among LGBT Natives in recent years.^[126]

Legal and social aspects

Poland's Anna Grodzka^[127] is the first transsexual MP in the history of Europe to have had sex reassignment surgery.^[128]

Laws regarding changes to the legal status of transsexual people 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.^[129] Some states seal earlier records against all but court orders in order to protect the transsexual person'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.^[130] In the United States, November 20 has been set aside as the "Day of Remembrance" for all murdered transgender people.^[131]

Jurisdictions allowing changes to birth records generally allow trans people to marry members of the opposite sex to their gender identity and to adopt children. Jurisdictions which prohibit same sex marriage often require pre-transition marriages to be ended before they will issue an amended birth certificate.^[132]

Health-practitioner manuals, professional journalistic style guides, and LGBT advocacy groups advise the adoption by others of the name and pronouns identified by the person in question, including present references to the transgender or transsexual person's past.^{[133][134][135]} Family members and friends who may be confused about pronoun usage or the definitions of sex are commonly 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 transsexual person's desired pronouns consistently. According to Julia Serano, deliberate mis-gendering of transsexual people is "an arrogant attempt to belittle and humiliate trans people"^[136]

Both "transsexualism" and "gender identity disorders not resulting from physical impairments" are specifically excluded from coverage under the Americans with Disabilities Act Section 12211.^[137] Gender dysphoria is not excluded.^[138]

Employment issues

Openly transsexual people 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 trans people is rampant and many of them are fired when they come out or are involuntarily outed at work.^[139] Transsexual people must decide whether to transition on-the-job,^[140] or to find a new job when they make their social transition. Other stresses that transsexual people face in the workplace are being fearful of coworkers negatively responding to their transition, and losing job experience under a previous name—even deciding which rest room to use can prove challenging.^[141] 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.^[142] Because the Harry Benjamin Standards of Care requires one-year of real life experience prior to SRS, some feel this creates a Catch 22 situation which makes it difficult for trans people 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. An increasing number of companies are including "gender identity and expression" in their non-discrimination policies.^[129][143] 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.^[144]

In the United States National Transgender Discrimination Survey, 44% of respondents reported not getting a job they applied for because of being transgender.^[145] 36% of trans women reported losing a job due to discrimination compared to 19% of trans men.^[145] 54% of trans women and 50% of trans men report having been harassed in the workplace.^[145] Transgender people who have been fired due to bias are more than 34 times likely than members of the general population to attempt suicide.^[145]

Stealth

Many transsexual men and women choose to live completely as members of their gender without disclosing details of their birth-assigned sex. This approach is sometimes called stealth. Stealthy transsexual people choose not to disclose their past for numerous reasons, including fear of discrimination and fear of physical violence.^[146] 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.^[147]

In the media

Nina Poon, a transsexual model who has appeared in Kenneth Cole ads, at the 2010 Tribeca Film Festival.

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.^[148] 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.

Christine Jorgensen was a transgendered woman who received considerable attention in American mass media in the 1950s. Jorgensen was a former G.I. that went to Denmark to receive sex reassignment surgery. Her story appeared in publications including Time and Newsweek. Other representations of transgendered women appeared in mainstream media in the 1950s and 1960s, such as Delisa Newton, Charlotte McLeod, Tamara Rees, and Marta Olmos Ramiro, but Jorgensen received the most attention. Her story was sensationalized, but received positively. In comparison, news articles about Newton, McLeod, Rees, and Ramiro had negative implications. ^[149]

Before transsexual people were depicted in popular movies and television shows, Aleshia Brevard — an actual transsexual whose surgery took place in 1962 — was actively working as an actress and model in Hollywood and New York throughout the 1960s and '70s. Aleshia never portrayed a transsexual person, though she appeared in eight Hollywood produced films, on most of the popular variety shows of the day including The Dean Martin Show, and was a regular on The Red Skelton Show and One Life to Live before returning to University to teach Drama and Acting.^[150][151]

Thomas Harris's 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 actually a transsexual; this distinction is made only briefly in the film.^[152]

Films depicting transgender issues include: Come Back to the Five and Dime, Jimmy Dean, Jimmy Dean, The World According to Garp, The Adventures of Priscilla, Queen of the Desert, All About My Mother 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. The film Wild Zero features Kwancharu Shitichai, a transsexual Thai actor. When the main character is conflicted about falling in love with a "woman who is also a man", Guitar Wolf tells him "Love knows no race, nationality or gender!"

Although Better Than Chocolate is primarily about the romance of two lesbians, a subplot in the 1999 Canadian film has Judy (Peter Outerbridge), a trans woman with a crush on Frances (Ann-Marie MacDonald), the owner of a lesbian bookstore. Within the film has a few scenes showing how Judy loses her parents who are unable to accept her, and buy her off with a bye forever present in purchasing a home for her.

Southern Comfort is a 2001 documentary by filmmaker Katie Davis, which follows the final months of the life of Robert Eads, a female-to-male transsexual living in Georgia. Eads was diagnosed with ovarian cancer and rejected for treatment by over two dozen doctors due to his transsexuality. The documentary follows Eads and several of his closest friends, a support group of transsexual southerners known as "Southern Comfort". The documentary won several awards, including the Grand Jury Prize at the Sundance Film Festival, First Prize at the Seattle International Film Festival, and the Special Audience Award at the Berlin International Film Festival.^[153]

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). Calpernia Addams has appeared in numerous movies and television shows, including the 2005 movie Transamerica, in which Felicity Huffman portrays a transsexual woman.^[154]

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.^[155] 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.^[156] Also in 2006, Lifetime aired a movie biography on the murder of "Eddie"/"Gwen" Araujo called A Girl Like Me: The Gwen Araujo Story.

Transsexual people have also been depicted in popular television shows. In part of the first season of the 1970s t.v. comedy series, Soap, Billy Crystal plays Jodie Dallas, a gay man who is about to undergo a sex change in order to legally marry his male lover, who breaks off the relationship just before the surgery. 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 trans woman who is eventually accepted as a friend by her old high school classmate, series regular Fred Grandy. In the 1970s on The Jeffersons, George's Navy buddy Eddie shows up as Edie and is eventually accepted by George.

Dramas including Law & Order and Nip/Tuck have had episodes featuring transsexual characters and actresses. While in Nip/Tuck the role was played by a non-transsexual woman, in Law & Order some were played by professional cross-dressers. Without a Trace and CSI: Crime Scene Investigation have had episodes dealing with violence against transsexual characters. Many transsexual actresses and extras appeared on the CSI episode, "Ch-Ch-Changes," including Marci Bowers and Calpernia Addams.^[157] The trans woman victim, Wendy, was played by Sarah Buxton, a cisgender woman. Candis Cayne, a transsexual actress, appeared in CSI: NY as a transsexual character. From 2007 to 2008, she also portrayed a transsexual character (this time recurring) in the ABC series Dirty Sexy Money.

Hit & Miss is a drama about Mia, played by Chloë Sevigny, a preop transsexual woman who works as a contract killer and discovers she fathered a son.

There's Something About Miriam was a 2003 reality television show. It featured six men wooing 21-year-old Mexican model Miriam without revealing that she was a pre-operative trans woman until the final episode.

"Coronation Street" once had a transsexual woman named Hayley, who was Harold in her childhood. She died on 20 January 2014.

In 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 was held in Las Vegas, Nevada. The pageant accepted pre-operation and post-operation trans women, but required proof of their gender at birth. The winner of the 2004 pageant was a woman named Mimi Marks.

Jenna Talackova, the 23-year-old woman who forced Donald Trump and his Miss Universe Canada pageant to end its ban on transgender contestants, competed in the pageant on May 19, 2012 in Toronto.^[158]

On Saturday, January 12, 2013, Kylan Arianna Wenzel was the first transgender woman allowed to compete in a Miss Universe Organization pageant since Donald Trump changed the rules to allow women like Wenzel to enter officially. Miss Wenzel was the first transgender woman to compete in a Miss Universe Organization pageant since officials disqualified 23-year-old Miss Canada Jenna Talackova the previous year after learning she was transgender.^[159][160]

Events and organizations

Trans communities in various countries hold several events annually; in the United States, the most prominent are the Transgender Day of Remembrance held every year on November 20, and the Trans March, one of three protests held in San Francisco, California during "Pride Weekend", the last weekend of June.

All About Trans is an organization in the UK whose goal is to influence and improve media professionals' understanding and portrayal of transsexual people. They do this by connecting media outlets with members of the transsexual community throughout the UK in order to foster a greater sensitivity toward this group of people.^[161] Paris Lees works as a facilitator with this organization and was recognized on The Independent on Sunday's Pink List in 2013 for being the most influential figure in the LGBT community in the UK.^[162]

Transgender At Work (TAW) is an organization with a focus on addressing issues in the workplace for transsexual individuals. Its goal is to allow transsexual employees to work productively without feeling as if they must hide an essential part of themselves. This includes addressing such issues as transsexual individuals being excluded from employer health care on the basis of their transsexuality.^[163]

The National Transgender Advocacy Coalition is a lobbying organization in the United States dedicated to preserving the civil rights of transsexual individuals. It began in Virginia in 1999 and held its first lobbying event in 2001. It has no paid employees, but consists of a board of experienced lobbyists and activists.^[164]

The Renaissance Education Association is a non-profit organization founded in Pennsylvania that is dedicated to providing education and social support regarding transgender issues. This includes providing educational programs, support groups, and resources to community care providers. It also strives to provide personal and educational resources for individuals struggling with issues related to transsexuality and those close to them.^[165]

Survivor Project is a non-profit organization founded in 1997 that is devoted to assisting intersex and transsexual survivors of domestic and sexual violence. This is done through caring action and education. The Project provides presentations, workshops, and consultation materials to many communities and universities across the United States. It also works to find information regarding the specific issues faced by intersex and transsexual individuals who are victimized. Empowering survivors and allowing them to participate in anti-violence activism is one major philosophy of the organization.^[166]

The Transgender Law and Policy Institute (TLPI) was founded by Paisley Currah, Associate Professor of Political Science at Brooklyn College. It is dedicated to engaging in effective advocacy for transgender people in our society. The TLPI brings experts together to work on law and policy initiatives designed to advance transgender equality. Their website provides information and resources on legislation, case law, employer and college policies and other resources.They also work with the Gay & Lesbian Advocates & Defenders (GLAD) in New England.^[167]

Trans*topia is section of Youth Resource (a project of Advocates for Youth, a nonprofit organization located in Washington D.C.) designed for the needs of transsexual youth. Their website includes articles about being young and transgender, both personal accounts and scientific articles that are intended to help transgender youth become more informed and comfortable with their sexuality and gender.^[168]

See also

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

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69. Male transsexual gene link found BBC News 26 October 2008 (accessed 26 October 2008)
70. Psychology The Science Of Behaviour, pg 418, Pearson Education, Neil R.Carlson
71. Gizewski, E. R.; Krause, E.; Schlamann, M.; Happich, F.; Ladd, M. E.; Forsting, M.; Senf, W. (2009). "Specific cerebral activation due to visual erotic stimuli in male-to-female transsexuals compared with male and female controls: An fMRI study". Journal of Sexual Medicine 6: 440–448. doi:10.1111/j.1743-6109.2008.00981.x.
72. Rametti, G.; Carrillo, B.; Gómez-Gil, E.; Junque, C.; Zubiarre-Elorza, L.; Segovia, S.; Gomez, Á.; Guillamon, A. (2010). "The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment: A DTI study". Journal of Psychiatric Research 45: 949–954. doi:10.1016/j.jpsychires.2010.11.007.
73. Savic, I.; Arver, S. (2011). "Sex dimorphism of the brain in male-to-female transsexuals". Cerebral Cortex 21: 2525–2533. doi:10.1093/cercor/bhr032.
74. Berglund, H.; Lindström, P.; Dhejne-Helmy, C.; Savic, I. (2008). "Male-to-Female Transsexuals Show Sex-Atypical Hypothalamus Activation When Smelling Odorous Steroids". Cerebral Cortex 18: 1900–8. doi:10.1093/cercor/bhm216. PMID 18056697.
75. Lawrence, A. A. (2006). "Clinical and theoretical parallels between desire for limb amputation and gender identity disorder". Archives of Sexual Behavior 25: 263–278. doi:10.1007/s10508-006-9026-6. PMID 16799838.
76. McCloskey, D. (2003) "...The academics don't like Bailey's use of the mantle of Science to push a conservative, unscientific agenda worthy of National Review, or of The National Enquirer..." in Queer Science: A data-bending psychologist confirms what he already knew about gays and transsexuals from Reason, a libertarian magazine covering politics, culture, and ideas. Retrieved on 2007-09-22.
77. Marks, J. (2004). "...The specific issue was whether the book (The Man Who Would Be Queen) was transphobic...The judges looked at the book more closely and decided it was..." quoted by Letellier, P (2004) in Group rescinds honor for disputed book from Advocate Online News on Gay.com, retrieved on 2007-09-11.
78. Emory, L. E.; Williams, D. H.; Cole, C. M.; Amparo, E. G.; Meyer, W. J. (1991). "Anatomic variation of the corpus callosum in persons with gender dysphoria". Archives of Sexual Behavior 20: 409–417. doi:10.1007/bf01542620.
79. Zhou, J. N.; Hofman, M. A.; Gooren, L. J. G.; Swaab, D. F. (1995). "A sex difference in the human brain and its relation to transsexuality" (PDF). Nature 378 (6552): 68–70. doi:10.1038/378068a0. PMID 7477289.
80. Kruijver, F.P., Zhou, J. N., Pool, C. W., Hofman, M. A., Gooren, L. J., & Swaab, D. F. (2000). Male-to-female transsexuals have female neuron numbers in a limbic nucleus. Journal of Clinical Endocrinology Metabolism, 85, 2034–2041. Archived March 23, 2012, at the Wayback Machine.
81. Chung, W.; De Vries, G.; Swaab, D. (2002). "Sexual differentiation of the bed nucleus of the stria terminalis in humans may extend into adulthood". Journal of Neuroscience 22: 1027–1033.
82. Schiltz, K.; Witzel, J.; Northoff, G.; Zierhut, K.; Gubka, U.; Fellman, H.; Kaufmann, J.; Tempelmann, C.; Wiebking, C.; Bogerts, B. (2007). "Brain pathology in pedophilic offenders: Evidence of volume reduction in the right amygdala and related diencephalic structures". Archives of General Psychiatry 64: 737–746. doi:10.1001/archpsyc.64.6.737. PMID 17548755.
83. Hulshoff Pol, H. E.; Cohen-Kettenis, P. T.; Van Haren, N. E.; Peper, J. S.; Brans, R. G.; Cahn, W.; et al. (2006). "Changing your sex changes your brain: Influences of testosterone and estrogen on adult human brain structure". European Journal of Endocrinology 155 (Suppl. 1): S107–S114. doi:10.1530/eje.1.02248.
84. Haraldsen, I. R.; Opjordsmoen, S.; Egeland, T.; Finset, A. (2003). "Sex-sensitive performance in untreated patients with early onset gender identity disorder". Psychoneuroendocrinology 28: 906–915. doi:10.1016/s0306-4530(02)00107-5.
85. Wisniewski, A. B.; Prendeville, M. T.; Dobs, A. S. (2005). "Handedness, functional cerebral hemispheric lateralization, and cognition in male-to-female transsexuals receiving cross-sex hormone treatment". Archives of Sexual Behavior 34: 167–172. doi:10.1007/s10508-005-1794-x.
86. Luders, E.; Sanchez, F. J.; Toga, A. W.; Narr, K. L.; Hamilton, L. S.; Vilain, E. (2009). "Regional gray matter variation in male-to-female transsexualism". NeuroImage 46: 904–907. doi:10.1016/j.neuroimage.2009.03.048. PMC 2754583. PMID 19341803.
87. Rametti, G.; Carrillo, B.; Gómez-Gil, E.; Junque, C.; Zubiarre-Elorza, L.; Segovia, S.; Gomez, Á; Guillamon, A. (2011). "White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study". Journal of Psychiatric Research 45: 199–204. doi:10.1016/j.jpsychires.2010.05.006. PMID 20562024.
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91. Eyal Abraham, Talma Hendler, Irit Shapira-Lichter, Yaniv Kanat-Maymon, Orna Zagoory-Sharon, and Ruth Feldman (May 2014). "Father's brain is sensitive to childcare experiences". Proceedings of the National Academy of Sciences 111 (27): 9792–9797. doi:10.1073/pnas.1402569111.
92. "Transsexual study reveals genetic link". abc.net.au.
93. Hare L, Bernard P, Sánchez FJ, Baird PN, Vilain E, Kennedy T, Harley VR (2009) Androgen receptor repeat length polymorphism associated with male-to-female transsexualism. Biol Psychiatry. 65(1):93-96
94. Diamond, Milton (May 2013). "Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation". International Journal of Transgenderism. Retrieved 14 June 2015.
95. Bailey, J. M. (2003). The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. Joseph Henry Press, ISBN 0-309-08418-0, ISBN 978-0-309-08418-5
96. Blanchard, R. (2005) "...Since the beginning of the last century, clinical observers have described the propensity of certain males to be erotically aroused by the thought or image of themselves as women..." in Early History of the Concept of Autogynephilia from the Archives of Sexual Behavior, Volume 34, Number 4, pages 439-446. Retrieved on 2007-09-22.
97. Smith, Y.L.S., van Goozen, S.H.M., Kuiper, A.J., Cohen-Kettenis, P.T.. (2005) "...The present study was designed to investigate whether transsexuals can be validly subdivided into subtypes on the basis of sexual orientation..." in Transsexual subtypes: Clinical and theoretical significance from Psychiatry Research, Volume 137, Issue 3, pages 151-160. Retrieved on 2007-09-22.
98. Serano, Julia (2007). Whipping girl: a transsexual woman on sexism and the scapegoating of femininity. Seal Press. p. 178. ISBN 978-1-58005-154-5. While Blanchard's controversial theory is built upon a number of incorrect and unfounded assumptions, and there are many methodological flaws in the data he offers to support it, it has garnered some acceptance in the psychiatric literature...
99. Moser, Charles (2010). "Blanchard's Autogynephilia Theory: A Critique". Journal of Homosexuality 57 (6): 790–809. doi:10.1080/00918369.2010.486241. PMID 20582803.
100. Veale, Jaimie F.; Clarke, Dave E.; Lomax, Terri C. (2008). "Sexuality of Male-to-Female Transsexuals". Archives of Sexual Behavior 37 (4): 586–597. doi:10.1007/s10508-007-9306-9. PMID 18299976.
101. Moser, Charles (2009). "Autogynephilia in Women". Journal of Homosexuality 56 (5): 539–547. doi:10.1080/00918360903005212. PMID 19591032.
102. Nuttbrock, L; Bockting, W; Mason, M; Hwahng, S; Rosenblum, A; Macri, M; Becker, J (2010). "A Further Assessment of Blanchard's Typology of Homosexual Versus Non-Homosexual or Autogynephilic Gender Dysphoria". Archives of Sexual Behavior 40 (2): 247–257. doi:10.1007/s10508-009-9579-2. PMC 2894986. PMID 20039113.
103. from DSM5.org rationale bullet 18. bullet 18 under rationale
104. Gooren, LJ; Giltay, EJ; Bunck, MC (2008). "Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience". J Clin Endocrinol Metab 93 (1): 19–25. doi:10.1210/jc.2007-1809. PMID 17986639.
105. Teich, Nicholas (2012). Transgender 101: A Simple Guide to a Complex Issue. Columbia University Press. p. 55. ISBN 0231504276. Retrieved August 20, 2015. Historically, many transmen who have had phalloplasty have not been satisfied with the results. Doctors continue to make improvements to this surgery, but many surgeons in the United States choose not to perform it because of the high risk of complications (severe scarring or fistulas for example), the significant risk of never regaining sensation in the penis or donor sites, and the chance that the result will not be aesthetically pleasing. However, some transmen are satisfied with their results and would choose to do it again if given the choice.
106. Susan Stryker, Stephen Whittle (2013). The Transgender Studies Reader. Routledge. p. 353. ISBN 1135398844. Retrieved August 20, 2015. In addition, phalloplasty 'cannot produce an organ rich in the sexual feeling of the natural one.'
107. Carroll, Janell (2015). Sexuality Now: Embracing Diversity. Routledge. p. 132. ISBN 1305446038. Retrieved August 20, 2015. Penises made from phalloplasty cannot achieve a natural erection, so penile implants of some kind are usually used (we will discuss these implants in more detail in Chapter 14). Overall, metoidioplasty is a simpler procedure than phalloplasty, which explains its popularity. It also has fewer complications, takes less time, and is less expensive (e.g., a metoidioplasty takes about 1 to 2 hours and can cost around $15,000 to 20,000, whereas, a phalloplasty can take about 8 hours can cost more than $65,000).
108. Endocrine Treatment of Transsexual People: A Review of Treatment Regimens, Outcomes, and Adverse Effects, Eva Moore, Amy Wisniewski and Adrian Dobs
109. Seattle and King County Health – Transgender Health
110. De Cuypere, Greta (2006). "Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery". Sexologies 15 (2): 126–133. doi:10.1016/j.sexol.2006.04.002. ...the suicide attempt rate dropped significantly from 29.3% to 5.1%
111. Brown, Mildred L.; Chloe Ann Rounsley (1996). True Selves: Understanding Transsexualism – For Families, Friends, Co-workers, and Helping Professionals. Jossey-Bass. ISBN 978-0-7879-6702-4.
112. Landén, M; Wålinder, J, Hambert, G, Lundström, B. (April 1998). "Factors predictive of regret in sex reassignment". Acta Psychiatr Scand. 97 (4): 284–9. doi:10.1111/j.1600-0447.1998.tb10001.x. PMID 9570489.
113. For examples see Jill Stark, 'I will never be able to have sex again. Ever', The Age, May 31, 2009.
114. Lawrence MD, A. A. (Aug 2003). "Factors associated with satisfaction or regret following male-to-female sex reassignment surgery". Archives of Sexual Behavior 32 (4): 299–315. doi:10.1023/A:1024086814364. PMID 12856892.
115. Baranyi, A; Piber, D, Rothenhäusler, HB. (2009). "Male-to-female transsexualism. Sex reassignment surgery from a biopsychosocial perspective". Wien Med Wochenschr. 159 (21–22): 548–57. doi:10.1007/s10354-009-0693-5. PMID 19997841.
116. Murad, Mohammad; Elamin, Mohomed; Garcia, Magaly; Mullan, Rebecca; Murad, Ayman; Erwin, Patricia; Montori, Victor (2010). "Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes". Clinical Endocrinology 72 (2): 214–231. doi:10.1111/j.1365-2265.2009.03625.x. PMID 19473181.
117. Collin, Lindsay, et al. "Prevalence of Transgender Depends on the “Case” Definition: A Systematic Review." The Journal of Sexual Medicine 13.4 (2016): 613-626
118. van Kesteren, Paul J. M; Henk Asscheman, Jos A. J Megens, Louis J. G Gooren (1997). "Mortality and morbidity in transsexual subjects treated with cross-sex hormones". J. Clin. Endocrinol. (Blackwell, Oxford, UK) 47 (3): 337–343. doi:10.1046/j.1365-2265.1997.2601068.x. PMID 9373456.
119. Transgender Mental Health, "The Prevalence of Transgenderism" http://tgmentalhealth.com/2010/03/31/the-prevalence-of-transgenderism/
120. Veale, Jaimie F. (October 2008). "Prevalence of transsexualism among New Zealand passport holders" (PDF). Australian and New Zealand Journal of Psychiatry 42 (10): 887–889. doi:10.1080/00048670802345490. PMID 18777233.
121. Olyslager, Femke; Lynn Conway (2007). "On the Calculation of the Prevalence of Transsexualism" (PDF).
122. Landén, M., Wålinder, J., Lundstrom, B. (1996) "...Results: During the 20-year period of the study, 233 requests for sex reassignment were processed, and the incidence data were calculated on the basis of this group. This means that the average annual frequency was 11.6 cases. The number of inhabitants in Sweden over 15 years of age increased during the study period from 6.5 million to 7.1 million, i.e. there was a mean population of 6.8 million (12), which gives an annual incidence of request for sex reassignment of 0.17 per 100,000 inhabitants. The sex ratio (male:female) is 1.4 :1. To resolve the question of whether transsexualism increases or decreases, we divided the group into two 10-year periods. As can be seen from Table 1, not only do our results agree with the Swedish incidence data published in the 1970s, but also they remain remarkably stable over time. Separating from all applications the group with primary transsexualism yielded 188 cases, i.e. 9.4 cases annually. As is shown in Table 2, this corresponds to an incidence of primary transsexualism of 0.14 per 100,000 inhabitants over 15 years of age. It should also be noted that primary transsexualism is equally common in women and men..." in Incidence and sex ratio of transsexualism in Sweden from Acta Psychiatrica Scandanavica, Volume 93, pages 261-263. Retrieved on 2007-09-22.
123. Reed, Bernard; Stephenne Rhodes (2008). Presentation on prevalence of transsexual people in the UK.
124. Benjamin, Harry; Green, Richard (1966). The Transsexual Phenomenon, Appendix C: Transsexualism: Mythological, Historical, and Cross-Cultural Aspects. New York: The Julian Press, inc. Archived from the original on 2007-07-17. Retrieved 2007-08-03.
125. Godbout, Louis (2004). "Elagabalus". GLBTQ: An Encyclopedia of Gay, Lesbian, Bisexual, Transgender, and Queer Culture. Chicago: glbtq, Inc. Retrieved 2007-08-06.
126. Gilley, Brian Joseph (2006: 8). Becoming Two-Spirit: Gay Identity and Social Acceptance in Indian Country. ISBN 0-8032-7126-3.
127. "Anna Grodzka". Sejm Rzeczypospolitej Polskiej. Retrieved December 2, 2011.
128. Świerzowski, Bogusław. "Wybory 2011: Andrzej Duda (PIS) zdeklasował konkurentów w Krakowie". Info Kraków 24. October 10, 2011.
129. "The Transgender Law and Policy Institute: Home Page". Transgenderlaw.org. Retrieved 2011-07-06.
130. Remembering Our Dead – a memorial to transgender people who have been murdered
131. Don't Forget Transgender Day of Rememberance (sic) by Jamie Tyroler, January 18, 2008, Kansas City Camp
132. The Age, Dec 28 2014, "When Albert met Ann: 'Ridiculous' marriage laws force transgender divorce", http://www.theage.com.au/victoria/when-albert-met-ann-ridiculous-marriage-laws-force-transgender-divorce-20141210-124b8q.html
133. Glicksman, Eve (April 2013). "Transgender terminology: It's complicated". Vol 44, No. 4: American Psychological Association. p. 39. Retrieved 2013-09-17. Use whatever name and gender pronoun the person prefers
134. Sponsored by the American Medical Association and The Fenway Health with unrestricted support from Fenway Health and Pfizer. "Meeting the Health Care Needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) People: The End to LGBT Invisibility" (PowerPoint Presentation). The Fenway Institute. p. 24. Retrieved 2013-09-17. Use the pronoun that matches the person’s gender identity
135. "Glossary of Gender and Transgender Terms" (PDF). Preface: Fenway Health. January 2010. p. 2. Retrieved 2013-09-17. listen to your clients – what terms do they use to describe themselves
136. Julia Serano, "Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity", Seal press, 2009
137. "Americans with Disabilities Act of 1990 - ADA - 42 U.S. Code Chapter 126". find US law. Retrieved 2011-07-06.
138. "Americans with Disabilities Act of 1990 §512. DEFINITIONS.". United States Access Board, a Federal Agency. 2009-01-01. Retrieved 2013-06-05.
139. Work transition for transsexual women – TS Road Map
140. Making a successful transition at work – helpful guide by Jessica McKinnon and sample transition-related documents
141. Pepper 2008
142. Weiss, Jillian Todd (2001). "The Gender Caste System: Identity, Privacy and Heteronormativity" (PDF). Tulane Law School. Retrieved 2007-02-25.
143. Workplace Discrimination: Gender Identity or Expression – Human Rights Campaign Foundation
144. Judgment of the Court of 30 April 1996. – P v S and Cornwall County Council. – Reference for a preliminary ruling: Industrial Tribunal, Truro – United Kingdom. – Equal treatment for men and women – Dismissal of a transsexual. – Case C-13/94 – European Court reports 1996 Page I-02143
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146. http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf
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148. "Medicine: Change of Sex". Time. 24 Aug 1936. Retrieved 23 December 2010.
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150. Aleshia Brevard at the Internet Movie Database
151. Aleshia Brevard (2001). The Woman I Was Not Born to Be: A Transsexual Journey. Philadelphia: Temple University Press. ISBN 1-56639-840-1.
152. Silence of the Lambs at the Internet Movie Database
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155. TransGeneration at the Internet Movie Database
156. Beautiful Daughters – LOGO (TV channel) Documentary
157. Calpernia Addams at the Internet Movie Database
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Bibliography

• Brown, Mildred L.; Chloe Ann Rounsley (1996). True Selves: Understanding Transsexualism – For Families, Friends, Coworkers, and Helping Professionals. Jossey-Bass. ISBN 978-0-7879-6702-4.
• Feinberg, Leslie (1999). Trans Liberation : Beyond Pink or Blue. Beacon Press. ISBN 978-0-8070-7951-5.
• Standards of Care for Gender Identity Disorders, Seventh Version. – World Professional Association for Transgender Health (2012)
• Kruijver, Frank P. M.; Jiang-Ning Zhou, Chris W. Pool, Michel A. Hofman, Louis J. G. Gooren and Dick F. Swaab (2000). "Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus". Journal of Clinical Endocrinology & Metabolism 85 (5): 2034–41. doi:10.1210/jc.85.5.2034. PMID 10843193.
• Rathus, Spencer A.; Jeffery S. Nevid, Lois Fichner-Rathus (2002). Human Sexuality in a World of Diversity. Allyn & Bacon. ISBN 978-0-205-40615-9.

• 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 Health Care Providers". The Career Development Quarterly 56 (4): 330–343. doi:10.1002/j.2161-0045.2008.tb00098.x.

External links

• Full service information and interactive dialogue for transsexual people
• 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 – US-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)
• The International Journal of Transgenderism – The Official Journal of the World Professional Association for Transgender Health (formerly HBIGDA). An archive of IJT Volumes I through V is available, as are several books on transsexualism, including Harry Benjamin's "The Transsexual Phenomenon"
• TransParentcy – supports transgender parents and their advocates (lawyers, mental health professionals, friends, family) by providing information and resources.
• Transsexual Road Map – consumer information and advice for transsexual women.
• Lynn Conway's transsexual resources pages
• "Dr. Anne Lawrence On Transsexualism and Sexuality" - detailed information on medical aspects of transition
• The Gender Identity Research and Education Society