Deciding What to Do About Your Gender Dysphoria (1991)

Notice: This booklet is published as a public service. AEGIS and the author are in no way responsible for any decisions made or actions taken by any individual. If you are feel that you might have gender dysphoria, we urge you to seek responsible professional help from a licensed mental health professional.

 

Introduction

 

This booklet is written for those of you who are severely conflicted about your gender identity. Its purpose is to inform you of your alternatives, and to help you make a reasoned and considered choice about how you will spend the rest of your life. It is not designed to encourage you to seek or discourage you from seeking sex reassignment, but to enable you to foresee areas of difficulty and hopefully avoid problems.

We live in a time in which medical science and social attitudes have made it possible for an individual to alter his or her physical characteristics and social role and live as a member of the opposite gender. This is a rare and extreme thing for a person to do.

Sex reassignment is not instantaneous, and it is not easy. It is a medical, psychological, and social process that can take years. It can disrupt every part of a person’s life. It should be done only after great deliberation about how it will effect not only the life of the individual with gender dysphoria, but the lives of family and friends.

Despite the difficulties in changing gender, thousands of men and women have done so successfully, and have found greater happiness and fulfillment in their lives. Some have experienced great adversity, and some have had few problems. You must weigh the pros and cons of sex reassignment and make the choice that is right for you.

AEGIS believes that one’s gender is a matter of informed personal choice. This series of booklets is designed to provide information which will help you to make competent and rational decisions about your gender.

 

You Have a Choice

 

The most difficult decision a pre-operative transsexual has to make is whether or not to go ahead with an irreversible mutilating series of surgical procedures. Having made that decision, or rather, having found life so completely untenable in the original gender that not having surgery can hardly be considered a viable option, the question then arises of how best to go about it with as little disruption and upset as possible.

—Hodgkinson, Bodyshock, p. 88

 

Your two basic options are to remain in the gender of original assignment or to switch gender. Both paths are fraught with difficulty and pain, and either choice will require considerable effort on your part and on the part of the significant others in your life. You may chose a third option, transgenderism, either cultivating androgyny or dividing your time between masculine and feminine roles. It is important to realize that it is not necessary to have surgery in order to live productively in the new gender role.

This may be the most important decision of your life. You should make it in a rational manner, after educating yourself as much as possible about transsexualism, and only after a great deal of introspection and self-analysis. You should be as aware as possible of the dangers confronting you. Above all, you should avoid making impulsive, poorly thought-out decisions.

You should seek the input of others. You may want to plumb the feelings of those to whom you are closest—your family and friends (who may have reasons for wanting you to remain as you are), and you may want to join a support group (the members of which may have reasons for wanting you to change), but you should seek unbiased, professional help also. You should view this booklet only as a vehicle to introduce you to some of the factors you should consider before making such a momentous decision, and not as a comprehensive guide to transition. To help you to locate additional information, we have included a brief reading and resource list at the end of this booklet. AEGIS publishes additional materials which may help you.

No matter what you decide, you will need understanding and support from others. But most importantly, you will need to understand yourself, for you are the one who will have to face yourself in the mirror when you get up every morning. Whatever choice you make, good luck. Have courage.

 

A Brief History of Sex Reassignment

 

Before the mid-20th century, transsexual people in Western society, with the exception of the very few who happened to possess a predominance of physical characteristics of the opposite sex, lived and died as men, if born male, and as women, if born female. Concomitant with the lack of medical procedures which would have allowed sex reassignment were rigid sexual attitudes and gender stereotyping which made sex reassignment socially impossible. The individual was locked into the gender of birth, and was powerless to do anything about it. In fact, the word transsexual was not coined until 1949, in an article by D.O. Cauldwell; the term was popularized by Dr. Harry Benjamin, who is often credited with its invention. Until the 1950’s, the populace, including transsexual people themselves, had no term and no mental template for transsexualism.

The synthesis of artificial gonadotropins (sex hormones) in the first half of the 20th century, advances in surgical procedures, and the advent of electrolysis have made it possible to alter one’s secondary sex characteristics and external genitalia to resemble that of the opposite sex. In fact, as Vern Bullough has pointed out, it is these hormones, rather than surgery, which make sex reassignment possible.

In the 1940’s, Lili Elbe (formerly Einar Wegener), a Danish painter, underwent surgical sex reassignment, but at a fatal cost. Laura Dillon, a British citizen, became Michael Dillon, having phalloplasty in 1948. But it was the case of Christine (formerly George) Jorgensen, a young American man who was severely gender dysphoric, and who received experimental hormonal therapy and vaginoplasty, and the ensuing publicity, which made the term sex change a household word in America. For the first time, the person on the street came face-to-face with the idea that such a dramatic course of action was possible. And for the first time, people who were transsexual considered that such a change might be possible for them.

Christine Jorgensen, as has every public transsexual person since, was deluged with letters and phone calls from anguished people, asking how they could change their sex.

During the late 1950’s and the 1960’s, men and women throughout the world began to actively seek sex reassignment. At first the numbers were small, but an accelerating trend was evident. Harry Benjamin, a New York physician who had supervised Jorgensen’s case, had a clientele comprised largely of transsexual persons. Surgeons were gaining expertise and developing new techniques, and endocrinologists were becoming more skilled at using hormones to masculinize females and to feminize males. Scattered articles began to appear in the medical and psychological literature.

In the early 1970s, the autobiographies of Renee Richards (formerly Richard Raskin), a physician who played professional tennis first as a man, and then as a woman, Jan (formerly James) Morris, a British journalist who had covered Sir Edmund Hillary’s successful assault on Mount Everest, Canary Conn, and others brought increased attention to transsexualism. Throughout the late 1970s and early 1980s, the number of persons actively seeking sex reassignment continued to increase. Not only were more female-to-male transsexual people coming forward, but female-to-males began to emerge in considerable numbers. A variety of university-affiliated gender clinics and other treatment centers sprang up, following the lead of Johns Hopkins University, which opened a center in the mid-sixties. By the late seventies, there were more than forty such gender clinics. By this time, the professional literature consisted of hundreds of articles.

In the late 1970’s, the increasing number of applicants for sex reassignment spurred The Harry Benjamin International Gender Dysphoria Association, a group comprised mainly of physicians and psychologists who provide services to transsexual people, to formulate Standards of Care, a set of minimal guidelines for provision of services to persons with gender dysphoria. These standards are regularly revised, and are used by most service providers. The Standards, which were first published in 1979 and are revised regularly, are an attempt to homogenize services and to safeguard both transsexual people and the people who work with them.

Also in 1979, an article by Jon Meyer and Donna Reter was published in the medical journal Archives of General Psychiatry. This article, which was titled “Sex Reassignment: Follow-up” found “no objective advantage” to the surgical treatment of transsexualism. The article stands in marked opposition to other follow-up studies, which have found high satisfaction rates and good results for sex reassignment surgery. Meyer & Reter (1979) has been roundly criticized for its methodological flaws, but it was nonetheless largely responsible for the closing of the gender identity clinic at the Johns Hopkins University.

The late 1980s were characterized by the strengthening of what has been called the Gender Community. Grassroots organizations popped up and linked up, providing support, information, and referrals to persons with gender dysphoria. Transsexual people and crossdressers increased their public visibility by having conventions and conferences. Television and radio talk shows began to feature transsexual people. A variety of books about gender issues were published and widely distributed. And a maturing literature of gender dysphoria has led to the emergence of a class of helping professionals who are more knowledgeable and empathetic than was the case in the past.

 

The Current Situation

 

At this time, a large number of transsexual persons are actively pursuing gender congruity. This has caused the number of service providers to increase. Although many areas remain unorganized, most major cities have support groups which maintain lists of competent and caring professionals, and there are at least a dozen full-service gender programs. Although it may require some traveling, it is possible for the transsexual individual to build a highly competent, experienced treatment team.

Social attitudes have relaxed in the past few decades, making it relatively safe for transsexual persons to pursue gender consonance. Sex reassignment has become common enough that most Americans know, or at least know of someone who has been reassigned. There has never been a better time to undertake sex reassignment, for never have more or finer services been available, and never have social attitudes been better.

Unfortunately, peer support and competent professional help can still be hard to find. Support groups maintain low profiles, and can be hard to locate, for their publications do not appear in bookstores and their advertisements, for the most part, are found in obscure and hard-to-find places. Listings are often out-of-date, and some groups are less than conscientious about returning phone calls and answering mail.

Many physicians, psychologists, social workers, ministers, legislators, electrologists, and aestheticians remain ignorant of the Standards of Care, and most are unaware of the unique needs of the transsexual person. Many refuse to provide services, and a few are openly contemptuous or hostile to the person requesting services.

As in the past, the vast majority of transsexual people are not sexually reassigned and will never be reassigned. They continue to live and die in the gender of birth. The psychic, social, and financial costs of changing gender are, quite simply, overwhelming. Many never come to terms with their feelings, denying them to themselves and to others. An unknown number commit suicide. Only a minority opt to begin the long and painful process of sex reassignment, and the majority of those who start do not finish.

While society has grown more tolerant, there is still a considerable social stigma attached to transsexualism. Those who are able to successfully blend into society in the gender of choice will be less at risk for ridicule or discrimination than those whose physical characteristics make them unduly conspicuous.

 

The Transgender Alternative

 

An alternative to sex reassignment—one which a considerable number of people are beginning to explore, but one with which many service providers and the general public are unfamiliar—is transgenderism.

Transgenderists have been described as persons who change gender roles, but do not plan to have sex reassignment surgery. They have alternatively been defined as persons who steer a middle course, living with the physical traits of both genders. Transgenderists may alter their anatomy with hormones and their features with plastic surgery, but they may purposefully retain many of the characteristics of the gender to which they were originally assigned. Many lead part-time lives in both genders; most cultivate an androgynous appearance. Some live full-time in the gender role opposite that assigned at birth, but do not desire surgical sex reassignment.

 

Making the Right Choice

 

You are the one who must make the choice of remaining in the gender of birth or of changing gender, or of steering an intermediate course. If you allow it to happen, others will make the decision for you, based on their needs, and not yours. You must make the determination that is right for you.

There are a variety of factors which must be weighed before a rational choice can be made. You must consider not only your innermost feelings, but your age, your state of health, your attitudes about men and women, your sexual preference, your emotional state, your financial status, your past history and legal and social entanglements, and your relationships with friends and family. You must think about the effect of what you will do not only on yourself, but on those who love you. You must think about how you will make a living. You must weigh the effects of sex reassignment on parents, siblings, spouse or other partner, children, friends, and co-workers. You must make a realistic assessment of the ways in which changing gender will impact these and other areas and decide if you are willing to face the disruption and strife that will likely occur.

You must consider the strength of your gender discomfort, and its nature, and decide whether you choose to live with those feelings, or whether they are powerful enough for you to embark on what will be a costly and time-consuming process of transition.

You must decide if the time is right for you to begin transition. Perhaps you will find it easier to wait until you graduate from college, or until your children have passed the critical early teen years. If you will be retiring from your job in a year or two, you may decide to wait before starting, so as not to jeopardize your retirement. You may want to adjust the pace of your transition to accommodate the other facets of your life.

While the decision is ultimately yours and yours alone, you will find it advisable to seek the input of a therapist to help you in weighing the benefits and risks of changing your gender. Psychiatrists, psychologists, and counselors help people to deal with areas of conflict in their lives, and your struggles will be similar to those of other, non‑gender‑conflicted persons. You should seek out someone with specific knowledge of gender dysphoria, but if such a person is not available, therapists with other specialties may be of some help, especially if they are willing to learn about transsexualism (this will generally be at your expense). You should avoid therapists who claim they can “cure” you of your transsexual feelings or who seem unsympathetic or biased.

As the Standards of Care require periodic input from therapists, it will be to your advantage to maintain contact with your psychologist or psychiatrist. Remember: sex reassignment is one of the most disruptive and distressing things a human being can do. It is better to have a therapist on hand and not need one than to need one and not have one.

 

Your Gender Dysphoria

 

You should know that there is no cure for transsexualism. Feelings of inappropriateness in the gender of assignment and longings to change gender may wax and wane and may be successfully repressed for short or even long periods of time, but they are an integral part of your personality, and you should expect them to last for as long as you live. A decision to remain in the gender of original assignment must be periodically reaffirmed. For that matter, so will a decision to pursue gender consonance.

Psychotherapy will not cure transsexualism. Neither will medication. Nor will behavior modification. But by using these techniques on an ongoing basis, therapists can help you to deal with the problems of everyday life—whether or not you decide to change gender. Antidepressant medications can alleviate symptoms of depression which may be partially caused by transsexual feelings. Behavioral techniques such as contracts can help you to achieve compromise and balance in your life. Psychotherapy can help you to gain insight into yourself and others.

If you elect to remain in the gender of original assignment, periodic indulgence in crossdressing may or may not provide psychic relief. Likewise, you may find solace by occasionally attending conferences and activities in the gender of choice, or participating in a support group for crossdressers (a large percentage of the members of these groups are surprisingly gender‑conflicted).

Sex reassignment is not a “cure” in the traditional sense, for in no other “illness” is the body altered to match the mind. Sex reassignment is an unusual and only marginally socially acceptable procedure which can provide tremendous psychic relief to an individual who is gender‑conflicted‑‑ but it is not guaranteed to do so. Sex reassignment is not a magical cure for whatever ails you. You will end up with the same shortcomings and problems you started out with, but in the gender of choice.

Neither is transgenderism a cure, but for some persons, transgenderism may provide a compromise between traditional masculine and feminine roles. Transgenderists must be aware that they may be rendering themselves less than optimally effective in both genders.

 

Your Body

 

Although many things about your body can be changed, others cannot. You must take a hard look at what you have to work with.

You will not become taller or shorter as a result of sex reassignment. Your hands or feet will not become larger or smaller. A deep voice will not raise in pitch. Baldness in genetic males will not be reversed. A masculine brow, jaw, and nose will remain masculine. You must realize that you may be stuck with attributes that surgery, hard work, and hormones will not appreciably alter; you must face the fact that you will have those characteristics whether you are a man or a woman.

You should, of course, educate yourself about the changes that hormones, surgery, and hard work can bring about. You may find it helpful to develop a mental picture of yourself in the gender of choice (remembering to be realistic). You may find that dressing in the clothing of the desired gender can give you a basic idea of how you will look, and this may give you a rough gauge of your eventual ability to pass undetected in the gender of choice.

Bear in mind, however, that the characteristics which make passing difficult may be just those that are most amenable to surgical and hormonal modification. For example, a heavy beard can be removed by electrolysis, but can be a dead giveaway before its removal. For female-to-male persons, large breasts can be hard to disguise, but can be removed surgically. Of course, if you pass without trouble before hormonal therapy or electrolysis, things can only improve.

If you are inexperienced with presenting yourself in the gender of choice, you should seek out supportive locations for your initial tryouts. Support groups provide safe havens, and you will get useful suggestions about improving your appearance. You will need the practice in order to become comfortable in the unfamiliar clothing and social role.

You might find it useful to make a list of all your masculine and feminine features. Ask yourself which list is longer. Then change the list by factoring in the effects of gonadotropic hormones, surgeries, and electrolysis. Finally, ask yourself which characteristics can be changed by hard work (the voice is especially capable of modification). Look at the list a last time. You may be surprised how few really masculine (or conversely, feminine) traits remain on it.

It is of course your prerogative to change your gender no matter what your physical characteristics. You will be doing yourself a disservice, however, if you do not come to terms early with the possibility that even after sex reassignment you will have an unusual or even stigmatizing look. You must ask yourself if it is worthwhile to live in the gender of choice if your appearance continually broadcasts your original gender. You are the one who will have to live with what you become.

 

Your Sense of Gender

 

You must measure not only the strength of your feelings that you are or want to be a member of the opposite gender, but the intensity of your feelings about your current gender role and your body. It is not enough to want to be a woman; you must want not to be a man (and vice‑versa for female‑to‑male transsexual people). On the other hand, if your primary motivation is that you are dissatisfied with being a man or a woman without really identifying with the other sex, you probably should not seek sex reassignment. If you value components of either your present social life, your secondary sex characteristics, or your genitalia, then you probably should not seek sex reassignment; you might seek instead a transgenderal expression. If, however, you are totally alienated from your body and your social role, and this alienation is of long standing, then you will be a better candidate for sex reassignment.

If you are a genetic male, you must ask yourself whether your gender dysphoria is related to your sex drive. If you are strongly aroused by crossdressing or fantasies of crossdressing, and if your dysphoric feelings are strongest when aroused, you must consider that these feelings will likely fade or even disappear when libido is decreased because of estrogens.

It is not uncommon for transsexual individuals to have some sexual arousal when they cross dress, or when they imagine themselves to be of the opposite sex. It is important when seeking sex reassignment, however, that the primary motivation not be sexual, but a question of gender identity.

 

Your State of Physical Health

 

You must also give careful consideration to your state of physical well‑being—or lack thereof. Many of the physical procedures of sex reassignment are rigorous, involving risk even to those in perfect health. Those whose bodies are compromised by disease or disability must take note of the fact that they will face additional hazards, and that they may be physically unable to endure surgeries or withstand the deleterious effects of hormones. They must also consider the probability of facing professionals who will be at best reluctant to provide the services they desire—and who may well refuse. You should know that health considerations can raise the cost of certain procedures.

Those with health problems must especially consider the possibility that they will not be able to obtain sex reassignment surgery. They must ask themselves whether sex reassignment without such surgery is an acceptable alternative.

Many physical conditions will not significantly impact upon the actual process of transition, especially when controlled. It is important to realize, however, that sex reassignment will not be a cure for anything other than your gender dysphoria. Whatever your physical condition, sex reassignment will not improve it. If you are wheelchair‑bound as a man, you will be wheelchair‑bound as a woman. If you are a diabetic, you will remain a diabetic. You must not allow yourself to see sex reassignment as a magical process that will cure any ill other than your sense of gender discomfort.

 

Your Emotional State

 

You should take careful inventory of your mental and emotional condition and personality traits, and your level of maturity, considering how they will effect your transition. For example, if you are a stable and calm individual and react well to stress, your prognosis is better than if your past has been characterized by acting‑out and hysterical behavior. If you are mentally ill, indecisive, or unstable, you may find those traits exacerbated by the considerable demands of transition. If you suffer from depression, you should realize that the stress of transition may aggravate your condition.

You should know that if you are in great distress, your ability to make decisions (including whether to seek sex reassignment) may be negatively affected. If you are in doubt, and especially if you are having self‑destructive feelings or thoughts of suicide, you should seek professional help. Certainly, the decision about or not whether to undergo sex reassignment should be made only after careful and calm deliberation, and after consulting a therapist.

You should also consider the feelings you have about transsexualism. If you have excessive guilt, anger, or fear, you will need to work through those feelings (with a therapist) so that they will not interfere with your functioning during the transitional period.

 

Your Age

 

If you are under eighteen years of age, you will in all likelihood be unable to obtain hormonal or surgical help, unless your parents intervene in your behalf. With the help of your parent or guardian, you may be able to obtain hormones, but surgery is very rare before the age of majority. It can be frustrating to see the effects that gonadotropins are having on your body and be unable to do anything about it because you are unable to obtain hormones. But age 18 does come. At least, it has for everyone in the world up until now.

In general, the younger you are when you begin sex reassignment procedures, the fewer physical problems you will have. The gonadotropins your body naturally produce will have had less time to work, and there will be less to undo. More importantly, the opposite‑sex hormones seem to have a more dramatic effect in the earlier years, while they can still have an effect on skeletal structure.

Young people are less likely than their elders to have as much emotional and social baggage of the gender of birth: marriage, children, career, military history. They are less likely to have a life characterized by activities and relationships which clearly indicate the gender of original assignment. They will be less likely to have engulfed themselves in hypermasculine or hyperfeminine activities, and will have less of a history to rearrange and live down.

On the other hand, young people may have relatively strong relationships with their parents, who, even in young adulthood, can exert considerable influence and exercise significant control. They are likely to be significantly affected by peer pressure. Young people often have more difficulty in asserting themselves and less experience in the rigid self‑discipline that sex reassignment requires. They have avenues which are untried, and may opt to remain in the gender of birth in order to explore such avenues, in particular marriage, career, and the military. They will have had less time to come to terms with their gender dysphoria than those who are older.

The elderly person will be more at risk for health problems, and may face additional obstacles because of age. For example, sex reassignment surgery will be more difficult to obtain after age fifty, and may difficult to obtain after age 60.

On the other hand, the elderly may have lost some of their social obligations. Retirement, the empty nest syndrome, and even widow or widowerhood can reduce the number of social responsibilities which may be negatively impacted by sex reassignment. Additionally, elderly people may have fewer problems in passing in the gender of choice, for the aged frequently develop a certainly androgyny; for example, a deep voice is much less unusual for a woman in her sixties than it is for a woman in her twenties.

Age is not an absolute contraindication for vaginoplasty or phalloplasty. Reassignment sex surgery has been successfully performed on persons in their seventies.

 

Your Sexual Orientation

 

Sexual orientation is a complex subject, and when compounded by the issues of gender, and especially with changing gender, the matter of partner preference can become very complicated.

Whether you identify as a man or a woman, sexual preference (favoring men or women for your partners) is distinctly different from gender identity. In the gender of original assignment, you may have led any of a number of sexual lifestyles, being heterosexual, homosexual, bisexual, or celibate. Your sexual preference may have changed over the course of your lifetime.

Your sexual relationships will change with sex reassignment. It will not be possible to have either heterosexual or homosexual relationships in the sense that you have had them before, for you will be changing your gender role. Even if you maintain the same partner, what was formerly a heterosexual relationship will now be publicly perceived as homosexual, and vice‑versa. With pre‑ operative status, the mechanics of lovemaking may remain much the same, but your gender role will have changed.

Sex reassignment is stressful for partners, and it is advisable for the partner to have a therapist. Many therapists can provide marital or relationship counseling.

If your partner valued your masculinity or femininity, he or she may react poorly to the loss of those characteristics. To the partner, it may seem that a stranger has replaced the loved one. Your partner may flee, or, if he or she stays, may exhibit a variety of psychological defenses, including but not limited to guilt, denial, hostility, ridicule, self‑doubt, and feelings of homosexuality or inadequacy. Maintaining the relationship will take all of the partner’s coping ability, and even then the partner may be simply unable to deal with the way you are changing. Such relationships occasionally survive transition, but it is probably unrealistic to count on yours being one of the very few that do persist.

Some partners may prefer you in the gender of your choice, and will feel less dissonance as you change. Some, however, may find that they have had unrealistic expectations about your transition, and may actively work to convince you to abandon your plans for sex reassignment. Others, although happy with you in your new social role, may have a definite preference for the genitalia of your original gender. Or, they may like your new physical appearance, but be unhappy with the social aspects of transition. More than a few transsexual people have found their plans for surgery subtly sabotaged or have been abandoned by their lovers on the eve of surgery. You should count on your partner for support, but you must remember that he or she is human, and subject to the usual human failings. Your transition will be perhaps more stressful for your partner than it is for you.

You must also consider your own sexuality. What is your preference in partners? Do you think it will change with sex reassignment? If you think you will continue to accept the same partner or types or partners, and you were formerly heterosexual, are you wiling to accept the difficulties inherent in a homosexual lifestyle? And if you were formerly homosexual, you must ask yourself if you are willing to give up the camaraderie and other advantages of the gay lifestyle for the straight world.

You should consider that changes in sexual habits call for increased precautionary measures. AIDS is a very real danger for both homosexual and heterosexual people. The sex acts you find yourself engaging in, especially pre‑operatively, may entail a level of risk higher than your previous sexual behavior. You should learn and practice safe‑sex techniques.

You must also be willing to face the possibility that you will be in for a long period of celibacy while you are in transition. Before you begin living in the gender of choice, you will have an androgynous appearance, coupled with loss of sex drive and inability to perform (if you are a male‑to‑female transsexual person). Even when living full‑time, you will have genitalia which are not what a partner will expect, and you may not feel comfortable in informing prospective partners of the problem with your plumbing. Additionally, although you may feel you are beautiful in the gender of choice, there is every possibility that you will be less attractive than you were in the old. Suitable partners are always difficult to come by, and may be even more so when you are in transition.

Sex reassignment surgery will render you permanently sterile. You must face the fact that you will lose your reproductive fitness, and will not be fertile in the new role.

Sex reassignment surgery is not risk‑free. For the male‑to‑female transsexual person, there is danger of vaginal stenosis (closure), incontinence, infection, and vagino‑rectal fistula (rupture), especially when the surgeon is inexperienced. For the female‑to‑male transsexual person, there is risk of rejection of tissue after phalloplasty. In all surgery, there is the possibility of hemorrhage, infection, scarring, pulmonary embolism, and infections; sex reassignment surgery is no exception.

Finally, you must consider that with surgery, the mechanics of sex will be permanently altered. There is the possibility (and a near certainty, for female‑to‑male transsexual people who have phalloplasty) that your new sexual apparatus will not give you the same level of sensation and physical pleasure that you had pre‑operatively. Functionality may not be as you anticipated. Certainly, the sensations and your role in lovemaking will change. If you are fond of your sexual organs and take pleasure in their use, you should consider that surgery is irreversible. You will be stuck with your new genitalia, whether they please you or not.

 

Your Friends and Family

 

You must realize that sex reassignment is very disruptive to human relationships. Those who know and love you have a strong sense of you in your original gender, and many of them will be unable to ever accept you in your new role. Some‑‑ and this includes parents, spouses, and children‑‑ may choose to totally break off contact. You must be prepared to lose those whom you love. And you must realize that your relationships with those who stand by you will be irrevocably altered.

Even those who support you will have trouble relating to you in your new gender, if they have known you in your original role. Some people may be unwilling to call you by your new name or to use gender‑appropriate pronouns. Some may tend to see gender‑dissonant components in your behavior and appearance, and may offer unneeded and perhaps superfluous criticisms and comments.

The manner in which others find out about your gender dysphoria is of critical importance. You should tell them in as straightforward a manner as possible, during a quiet time in which there is little stress. Your therapist will probably be willing to help explain things to your friends and family.

No matter how convincing you may be in your new role, those who have known you before will have difficulty in seeing you as you now are. Some will show more “inertia” than others, but you should expect unintentionally references to you with the wrong pronoun, difficulty in using your new name, and other behaviors as the individual tries to adjust. It will be better if you gently prompt, rather than angrily confronting, the individual. A well-developed sense of humor will help, not only in dealing with such inertial effects, but throughout the process of sex reassignment.

 

Your Personality After Sex Reassignment

 

You should give considerable thought to the personal changes you expect from changing gender. For example, you should not expect for there to be dramatic differences in your personality. Although hormones may cause some subtle behavioral changes, and although there may be some relief and alleviation of depression caused by living in the gender of choice, you will be the same person, with the same strengths and the same weaknesses. If you are hostile and distrustful before reassignment, you will be hostile and distrustful afterwards. If you have trouble making friends, you may still have trouble making friends. If you have a bad temper, you will still have a bad temper.

Sex reassignment will not magically teach you how to talk or walk in a feminine or masculine manner, or to make gender‑appropriate gestures. Unless you already have the behaviors in your repertoire, it will take lots of hard work and study to learn the rudiments of masculine and feminine deportment, and to learn to control what will then be gender‑inappropriate conduct. For example, an appropriate sitting posture for a man is not appropriate for a woman in skirts.

Although you will be free to cultivate gender‑appropriate interests after reassignment, you will not automatically become attracted to things masculine or things feminine. Nor will your old interests necessarily go away. It is fortunate that we live in a time in which men can collect dolls and women can drive race cars, but such behaviors are hardly the norm, and can excite curiosity and comment.

 

Your New Social Role

 

You should look closely at the roles of men and women in contemporary society, and at your idealization of yourself in the gender of choice. What kind of man or woman will you be? Does your picture of yourself gibe with reality, or do you have romanticized notions that may be difficult or impossible to realize? Are your ideas of the roles of men and women, in fact, an accurate reflection of what men and women are really like? You may want to be a housewife‑‑ but housewives are rare in contemporary American society, where it often takes two salaries in order to survive. You may see yourself as happily married, but you must consider that many nontranssexual men and women in their thirties and forties are unable to find suitable mates. You may see yourself as young and sexy, but at age forty, you will certainly not be young, and perhaps you will not be sexy. Your picture of yourself should be consistent with your age, body type, level of education, work history, and social status.

 

Your Career and Employment

 

Transition will most certainly not have a positive effect on your financial situation. At best, you may be able to retain the position you have. At a time when you will have considerable gender‑related financial obligations, you may well find yourself without a job and without prospects of one. You may be able to keep your present position. You should know, if you do so, that you will be the subject of curiosity, gossip, and perhaps ridicule. You may find arbitrary and unreasonable limitations on the expression of your gender. Coworkers who were initially supportive may become critics. Your employer, who may have initially endeavored to support you in your transition, may suddenly reverse position; this is especially likely if problems with productivity or employee relations arise as a result of your transsexualism. There will be no legal recourse if you are fired for transsexualism. The record in the courts has been dismal, and there are a number of legal precedents finding against transsexuals. For example, Karen Ulane, an airline pilot, fought a discrimination case all the way to the U.S. Supreme Court, and eventually lost. If you lose your job, you have just lost it. Reinstatement or financial compensation by the courts is unlikely; even if you are successful in litigation, there will be great psychic and financial burdens.

If you own your own business, you may find that you can maintain it through transition. You may elect to keep a low profile, or you may continue to deal directly with your customers. You should not be surprised if you lose business, but you may find that you do well. You are more likely to find work if your transsexualism is unknown than if it is common knowledge. If your appearance or paper trail send up warning flags, getting employment will be difficult. Past references, no matter how good, will be useless if gender‑inappropriate pronouns are used. Even with an excellent work history and good work skills, you may spend years re‑establishing yourself. If your job was one not normally done by persons of your new gender (as was Karen Ulane’s), you will find additional difficulties. You may likewise have difficulties if your field is small or nepotistic, for you will be well known in your original gender. You may find that your military experience, formerly an asset, is now a liability. You may choose to omit it from your resume or vita. If you are unfortunate enough to have gone to a college which was not coeducational at the time you attended, you may find that your degree has become unusable. However, some segregated schools have coeducational day programs, and most are not well known out of their home states. Even if you are highly trained and well educated, you may find it advisable to go back to school or to pursue a totally different career. Even so, you may find that you have traded a high‑flying and prestigious career for a low‑paying and unglamorous job. Male‑to‑female transsexual persons may find discrimination from which they were formerly immune. Women often make lower salaries and are passed over for promotions more than are men. You may find some categories of work denied to you, and may find yourself treated as a social inferior or a sex object by those who formerly considered you their equal. You may find yourself channeled into dead‑end or unrewarding career paths. You may find yourself the victim of sexual harassment. Female‑to‑male transsexual persons may be expected to do mechanical work, lift heavy weights, or work in cold or hot or otherwise uncomfortable locations. They may find less sympathy and emotional support than before, but this may be offset by increased status and salary.

While you may find that your difficulties in obtaining employment make you eligible for vocational training or disability payments, you well may not. Some areas specifically exclude gender‑ conflicted people from consideration for such benefits. The Americans with Disabilities Act of 1990 specifically excludes transsexual persons from handicapped status.

Without the support of family and friends, without a job, and without eligibility for benefits, you may literally find yourself on the streets. While most transsexual persons avoid this, you should be aware of the possibility.

 

Your Expenses

 

In addition to the direct costs of your transition, there will be considerable hidden costs. Your income may decrease because of employment difficulties. If you lose a partner, you may find yourself with a single income where before there were two. Especially if your transsexualism becomes an issue in a divorce or other settlement, you may find yourself losing a disproportionate share of community property. You may face alimony and child care payments.

If you find yourself unemployed or underemployed, you may find it difficult to pay the direct costs of transition. Many transsexual persons live in the gender of choice, never having sex reassignment surgery, simply because they cannot afford it. If you change gender roles prematurely, you may find yourself unable to afford procedures to correct deficiencies in your appearance which make it difficult for you to make more money. If you have a beard, for example, it will be difficult for you to find work as a woman‑‑ yet electrolysis is expensive, and you may find that you cannot afford it at your present level of income.

You will have many direct expenses. For example, the Standards of Care periodically require the input of a psychologist or psychiatrist. You must have a letter from a therapist before starting hormones, and letters from two therapists before reassignment surgery. Fees can be quite high, and there is no guarantee of how many or few visits your therapist will require. You may find that you have your letters after only two or three visits, but you may find yourself going to regular sessions for a year or longer; the number of visits will depend upon you, your life situation, and your particular therapist.

Electrolysis can cost as much as $60 an hour (1993 prices), and it may take as many as 200 hours of treatment to get rid of your facial hair. If your body hair is especially thick, you may need additional electrolysis on your torso, arms, or legs. Hormones can cost as much as $150 a month, and it will be necessary to see your endocrinologist regularly. You may need or desire ancillary surgeries such as hair replacement, rhinoplasty (nose surgery), tracheal shave, breast augmentation, or cheekbone, hip, or chin implants. These procedures are performed by plastic surgeons and are expensive. You may find you must provide money up front to service providers who have been repeatedly shorted by their patients, transsexual and otherwise.

You may find it necessary to travel long distances to obtain services; this can entail airfare, fuel expenses and automobile maintenance and repairs, hotel and motel bills, and meals. You will additionally find that maintaining two wardrobes is an expensive proposition.

Sex reassignment surgery can cost as much as $50,000 for female‑to‑male transsexual persons, and as much as $40,000 for male‑to‑female transsexual persons. Some prices are considerably cheaper, but even an inexpensive surgery costs thousands of dollars. There is not necessarily a direct relationship between price and quality of surgery, however. Selecting a surgeon should be done primarily on the basis of experience, complication rates, and quality of work, with price being a secondary consideration.

By being a good consumer, you will find that you can save a great deal of money. For example, at the time of this writing, competent sex reassignment surgery is available for male‑to‑female transsexual persons for considerably less than $5000. Electrologists vary in rates, and sometimes offer volume discounts, but cost is not the only deciding factor, for some electrologists seem to have a higher kill rate for hairs than do others; the more expensive electrologist may actually cost you less money in the long run. Ancillary procedures such as breast implants are often not necessary, and are undertaken more as matters of personal vanity than because they are necessary in order to live a fulfilling life in the gender of choice. You will probably find that by compromise, saving, and setting of priorities, you can free enough money to pursue transition (provided that you remain employed). For example, three or four hundred dollars a month, earned by working a second job, would easily pay for an occasional visit to a therapist, hormones, and weekly or biweekly electrolysis. Driving an older car, moving to a smaller house or apartment, or taking a paying roommate may free up several hundred dollars a month.

Still, sex reassignment is at best a very expensive process. If you live hand‑to‑mouth, you may find it difficult to set and follow a timeline for transition. You may want to save as much money as possible during the initial stages of your transition, or even before you start. This will act as a buffer in case you find yourself out of work during mid‑transition. Medical insurance will usually pay a percentage of therapy costs. Similarly, visits to an endocrinologist will probably be covered, especially is you do not specifically reveal your intentions to the insurance company. Even money spent for hormones may be reimbursed. On the other hand, electrolysis, plastic procedures, and sex reassignment surgery are considered elective and are almost always excluded from coverage, although some insurance companies have been known to pay.

Treatment of transsexual persons by insurance companies is often arbitrary and inconsistent. Even if your policy has paid for the reassignment surgery of others, you should not count on it paying for your own surgery. If you fear that your insurance company may provide your employer with information you do not wish shared, you may elect to shoulder the entirety of your transition‑related medical expenses. However, most service providers will be willing to bill you in a manner which will not indicate that you are being treated for transsexualism. Sex reassignment imposes a considerable financial commitment and sacrifice. If you are chronically indigent or unemployed, unwilling to commit the funds, unable to realistically earn enough money to pursue electrolysis or pay for hormones, or if you expect for society to somehow pay for your transition, you probably should not begin with seeking medical procedures, but by structuring your life so that they can pay for those procedures. On the other hand, you should remember that it is possible to live a fulfilling role in the gender of choice without ever having sex reassignment surgery.

 

Legal Matters

 

The legal status of transsexual people is vague; often, they have the worst of both worlds. Discrimination is rampant, and is very difficult to fight. Some localities will not change birth certificates or other records to reflect the new gender. Name changes are at the discretion of local judges, and may be refused. Those who do not pass in the gender of choice or are known to law enforcement officials may find themselves harassed or arrested, especially if appearing in the dress of the preferred gender. Marriage to the same biological sex is illegal before sex reassignment surgery, and previous marriages must be ended before surgery. In the United States (although not in Great Britain), post‑operative transsexual people can legally marry, but such marriages may be annullable, even years later, on the grounds that the transsexual person is “really” a member of the same sex; this is especially likely if the partner was not informed of the individual’s transsexual status before the marriage ceremony.

The transsexual person is subject to discrimination in the workplace, in the community, and indeed in every area of life. If transsexual status is known or suspected, adoption can be difficult. If you are incarcerated and expect to be incarcerated for a long time, you will find additional burdens imposed by the penal system. Especially if you have not achieved a viable appearance in the gender of choice, you will probably have trouble in obtaining hormones or electrolysis. Certainly, it is unlikely that you will be able to have reassignment surgery before your date of release. If you have a diagnosis of transsexualism, you will be more likely to receive services than if you do not have a diagnosis, but diagnosis may be difficult or impossible to obtain while you are incarcerated.

If you are in the military, you may be able to hide your transsexualism for some time. The armed services, however, have historically dealt harshly with both gender and sexual minorities; if discovered, you may be subject to harassment and punitive measures, up to and including court‑martial. It will be very unlikely that you will be able to successfully fight any actions that are taken against you. Rather than risk such treatment, it might behoove you, if you are in transition, to resign before you are discovered. This will leave your privileges intact. If your gender dysphoria is discovered and the military is taking steps to get rid of you, you still might be able to escape stigmatization by agreeing to resign with an honorable discharge, leaving you with a variety of benefits, including services from the Veteran’s Administration and eligibility to pursue education or retraining under the G.I. Bill.

 

Other Considerations

 

If you live in a location which is far from the gender‑related services you will need, you might, other things considered, think about relocating. Of course, you should not give up a lucrative business or position to save an occasional drive to the city, but if you are on a tight budget, moving closer to the locus of services may enable considerable savings and accelerate the pace of transition.

It will be difficult to predict the reaction of your church and any organizations of which you are a member. Reactions may vary from total acceptance to complete rejection. There have been instances of the religious right “de‑programming” transsexual persons. You should not be surprised if your fellow members are less than enthusiastic about your plans or attempt to persuade you to abandon them.

If your community is especially biased and closed‑minded, or if you are especially well‑known there, you might consider relocation. Small and rural are not synonymous with backwards, however; nor are big and urban synonymous with toleration and acceptance. You may choose to remain in your neighborhood, working at your old job, or you may decide to make a clean start in another city.

If you are fortunate enough to have been given a name at birth that works in your new gender, you might consider keeping it. There will be a greater chance of you being recognized because of your name, of course, but you will find that there are many fewer records to change. You will not need to alter books, diplomas, licenses, or other documents which bear your name. Additionally, you will not find it necessary to learn to respond to a new and unfamiliar name.

Choosing a name which works in both genders (some examples are Kim, Leslie, and Shannon) may help you during the time of greatest androgyny; whether those who meet you assume you are a man or a woman, your name will not provide a discordant cue. Another way of bridging the gap is to choose a new name with the same initials as your old one. You can have your credit cards and other records put in those initials and use them whether you are presenting yourself as a man or a woman.

 

CONCLUSIONS

 

Despite the difficulties inherent in changing gender, thousands of people have successfully undergone sex reassignment. Unfortunately, there are no guarantees in this life. Achieving a viable situation in the gender of your choice will require money and lots of hard work, and no matter how supportive your friends and family may be, there will be considerable psychic costs.

There is no law or rule that says you must conform to gender stereotypes. Reassignment surgery need not be your final goal; you can stop anywhere along the path of transition. You should pursue a course that will make you content. Your goal should be to be at peace with yourself. You will know when you find your level. Whether you find your peace in cultivating an androgynous appearance, by structuring your life to give you freedom to crossdress, or by totally and irrecoverably crossing the gender line, it is your life, and you can live it as you see fit.

 

GLOSSARY

 

Androgyny: Possessing both masculine and feminine traits.

Crossdresser: The word crossdresser has largely replaced the word transvestite. Most crossdressers are male and heterosexual and do not desire to permanently change their gender. They dress in the clothing of the opposite sex for reasons of personal satisfaction.

Electrolysis: A process of permanent depilation produced by introduction of galvanic current to the hair root.

Gender: Being a woman or a man, a boy or a girl. Gender is a social construction, and is distinct from sex, which is the individual’s state of maleness or femaleness (a biological quality).

Gender Conflict, Gender Confusion, Gender Discomfort, Gender Dysphoria: A sense of discomfort and unhappiness in the gender of assignment.

Gender Identity: One’s sense of being a man or a woman, a boy or a girl.

Gonadotropins: The hormones, androgens (in males) and estrogens (in females), which cause the development of secondary sex characteristics.

Sex: The biological quality of maleness or femaleness, as opposed to gender, which is a social construction.

Sex Change; Sex Reassignment (Gender Change; Gender Reassignment): Modifying the body to make it as much as possible like that of the opposite sex, and permanently living in the social role that is associated with that sex.

Standards of Care: A set of minimum guidelines formulated by the Harry Benjamin International Gender Dysphoria Association, Inc., and designed to safeguard both transsexual persons and those who provide professional services to transsexual persons. By imposing various requirements on both the service provider and the transsexual person, the Standards minimize the chance of an individual regretting the decision to change gender.

 

Therapist: An individual who provides counseling and/or psychotherapy. Includes psychologists, psychiatrists, counselors, psychiatric social workers, and some ministers.

Transgenderist: An individual who incorporates portions of the opposite gender role, but retains elements of the original gender.

Transsexual: An individual who is profoundly unhappy in the gender of original assignment. The transsexual person wishes to change the body to be as much as possible like that of the opposite sex and to live in the gender normally associated with that sex.

READING AND RESOURCE LIST

 

Blanchard, R., & Steiner, B. (Eds.). (1990). Clinical management of gender identity disorders in children and adults. Washington, DC: American Psychiatric Press.

Bolin, Anne. 1988. In search of Eve: Transsexual rites of passage. MA: Bergin and Garvey Publishers, Inc.

Bullough, V.L., & Bullough, B. (1993). Cross-dressing, sex, and gender. Baltimore: University of Pennsylvania Press.

Cossey, C. (1991). My story. Boston: Faber & Faber.

Denny, D. (In Press). Gender dysphoria: A guide to research. Garland Publications.

Denny, D. (1992). An annotated bibliography of gender dysphoria. Decatur, GA: AEGIS.

Denny, D. (1991). Dealing with your feelings: A guide to coming out for persons with gender dysphoria. Decatur, GA: AEGIS.

Denny, D. (1991). Discovering who you are: A guide to self-assessment for persons with gender dysphoria. Decatur, GA: AEGIS.

Devor, H. (1989). Gender blending: Confronting the limits of duality. Bloomington: Indiana University Press.

Docter, R.F. (1988). Transvestites and transsexuals: Toward a theory of cross-gender behavior. London: Plenum Press.

Elizabeth, Sister Mary. 1990. Legal aspects of transsexualism—1990 edition. J2CP: San Juan Capistrano, CA. (This book is presently out of print, but there are plans to issue a new edition).

Epstein, J., & Straub, K. (Eds.). (1992). Bodyguards: The cultural politics of gender ambiguity. New York: Chapman & Hall.

Garber, M. (1991). Vested interests: Cross-dressing and cultural anxiety. New York: Routledge.

Hodgkinson, Liz. 1987. Bodyshock: The truth About changing sex. London: Columbus Books.

Kirk, S. (1991). Hormones: 1991 edition. International Foundation for Gender Education, Box 367, Wayland, MA 01778.

Rudd, P. (1990). Crossdressing with dignity: The case for transcending gender lines. Katy, TX: PM Publishers.

Stringer, J.A. (1990). The transsexual’s survival guide: To transition and beyond. Creative Design Services, P.O. Box 1263, King of Prussia, PA 19406.

Stuart, Kim Elizabeth. 1983. The uninvited dilemma: A question of gender. Portland, OR: Metamorphous Press.

Sullivan, L. Information for the female-to-male cross-dresser and transsexual. International Foundation for Gender Education, P.O. Box 367, Wayland, MA 01778.

 

Many of these books are available from the American Educational Gender Information Service, Inc. (AEGIS)

P.O. Box 33724, Decatur, GA 30033

And from International Foundation for Gender Education

P.O. Box 367, Wayland, MA 01778

 

The American Educational Gender Information Service (AEGIS) is a not-for-profit business which disseminates information to persons interested in issues of gender. AEGIS provides free referrals to support groups and gender clinics, and free referrals to physicians, psychologists, psychiatrists, social agencies and private social workers, ministers, attorneys, and gender clinics and support groups to those not within range of a gender clinic or support group. We maintain a worldwide database of helping professionals, including surgeons who perform sex reassignment. Our magazine, Chrysalis Quarterly, is published four times a year, and we will be offering other publications as they are readied. We work actively with our sister organizations, exchanging newsletters, information, and referrals, and helping to organize cooperative projects and events.

AEGIS supports the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc., and makes referrals contingent upon documentation of adherence to these standards. We actively support the professionalization and standardization of services for transgendered persons. We promote nonjudgemental and nondiscriminatory treatment of persons with gender dysphoria, and advocate respect for their dignity, their right to treatment, and their right to choose their gender.

AEGIS was founded and is managed by a licensed human service professional with knowledge of the professional literature of gender issues and more than a decade of experience in the delivery of psychological services.

The word AEGIS means, variously, shield, protection, and sponsorship. We will strive to live up to our acronym by at all times maintaining confidentiality and by helping transgendered persons make reasoned and informed decisions about the ways in which they will live their lives.

aegis (e’jis), n. 1. in Greek mythology, a shield or breastplate used by Zeus and, later, by his daughter Athena; hence, 2. a protection. 3. sponsorship; auspices.

Webster’s New World Dictionary of the American Language