Transexualism

A transsexual (sometimes transexual) person establishes a permanent identity with the opposite gender to their assigned sex. Transsexual men and women make or desire to make a transition from their birth sex to that of the opposite sex, with some type of medical alteration (gender reassignment therapy) to their body. The stereotypical explanation is of a "woman trapped in a man's body" or vice versa, although many members of the transsexual community, as well as some outside the community, reject this formulation. For the exact wording of formal diagnosis, see gender identity disorder.

Definitions
The minimum requirements for a person to be considered transsexual are debated. Some feel that hormone-induced changes, without surgical changes, are sufficient to qualify for the label transsexual. Others, especially health care providers, believe there is a certain set of procedures that must always be completed. The general public often defines "a transsexual" as someone who had or plans to have a "sex change" surgery. The current term in widest use for modification of sexual characteristics is sex reassignment surgery (SRS), a term which reflects the belief that transsexual people do not consider themselves to be changing their sex, but to be correcting their bodies. However, it is also often accepted (and is also evident in the Diagnostic and Statistical Manual) that to express desire to be of the opposite sex, or to assert that one is of the sex opposite to the one with which they were identified at birth, constitutes being transsexual. (This does not include delusions about ones current sex.) In contrast, some transgender people often do not identify as being of or wanting to be the opposite sex, but as being of or wanting to be another gender.

Transsexuality (also known as transsexualism) is one of a number of behaviours or states collectively referred to as transgender, which is generally considered an umbrella term for people who do not conform to typical gender roles. However, many in the transsexual community do not identify as transgendered. Some see transgender as subsuming and erasing their identity, rejecting the term for themselves because to them it implies a breaking down of gender roles, when in fact they see themselves as fitting a gender role -- just not the one they were assigned at birth.

Transsexual people are often construed as belonging to the LGBT or the Queer community, and many identify with the community; others do not, or prefer not to use the term. It should be noted that transsexuality is not associated with or dependent on sexual orientation. Transsexual men and women exhibit a range of sexual orientations just as non-transsexuals (cissexuals) do. They almost always use terms for their sexual orientation that relate to their target gender. For example, someone assigned to the male gender at birth but who identifies as a woman, and who is attracted solely to men, will identify as heterosexual, not gay; likewise, someone who was assigned female sex at birth, identifies as a man, and prefers male partners will identify as gay, not heterosexual. And, like everyone else, transsexuals can be bisexual or asexual as well.

Older medical texts often described sexual orientation in relation to the person's assigned sex, not their gender of identity; in other words, referring to a male-to-female transsexual who is attracted to men as a "homosexual male transsexual." Again, this dwindling usage is considered scientifically inaccurate and clinically insensitive today, and such a person would now be called and most likely identify herself as a heterosexual transwoman. However, some medical textbooks still refer to transsexual people as members of their assigned sex, or use terms that state both the individual's assigned sex and target sex. Many prefer the latter option, as it ensures that a given text is clear to whoever reads it.

A number of people outside the transsexual community maintain the usage of referring to transsexual people with terms associated with their birth sex (for example calling a male-to-female transsexual "him"). This usage, generally considered insensitive, has been (though not exclusively) based on biological arguments such as the unchanged karyotype, which is usually consistent with the sex assigned to the person at birth, or the absence of desired reproductive capability after transitioning in any form. The most common arguments, however, have been based on religious dogma.

Transsexuality should not be confused with cross dressing or the behaviour of drag queens, who can be described as transgender, but usually not transsexual. Also, transvestic fetishism has usually little, if anything, to do with transsexuality.

Terminology
Gender terms used to describe transsexual people always relate to the target. For example, a transsexual man is someone who was identified as female at birth owing to his genitals, but identifies as a man and who is transitioning, or has transitioned, to a male social gender role and a male-identified body (an alternative term is female-to-male transsexual or transman; compare also transwoman).

One common abbreviation used to clarify involves versions of "assigned-to-target", i.e. female-to-male, or male-to-female. This helps avoid confusion caused by outdated medical terminology. These terms are abbreviated with several variants, so female-to-male might be expressed as F to M, FtM, F2M, F-M, F>M, etc.

Those researching the topic should be aware that older medical texts often referred to the person's original sex; in other words, referring to a M2F transsexual as a "transsexual male." This usage is now sharply deprecated and little-used.

Among the transsexual community, the short form trans is sometimes used, e.g. trans guy, trans dyke, trans folk. Some use the very controversial term tranny though many others consider this term to be highly offensive. Those who prefer this term claim that they are taking away the power of the term to insult. Others feel that the term is insulting regardless of the context.

Some people prefer to spell transexual with one s, in an attempt to divorce the word from the realm of psychiatry and medicine and place it in the realm of identity, but this trend is most common in the United States and, for example, is almost never used in the United Kingdom. Others think this usage is just silly.

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

It is also becoming clearer scientifically that transsex is simply a subset of intersex. Intersex previously referred only to those who are genitally intersexed, i.e., with genitals that don't look classically male or female (in spite of the fact that human genitals show an extremely wide variation in general). However, since sex in humans is composed of many different attributes, such as genes, chromosomes, regulatory proteins, hormones, hormone receptors, body morphology, and, most importantly, brain sex, any variation among any of those attributes falls under the rubric "intersex." Transsex then becomes simply neurological intersex.

Although not in the mainstream of terminology, some transsexuals who have successfully and completely changed gender prefer the term 'neo' as a prefix to their new gender. For example 'neo-woman' or 'neo-man'. This removes both 'trans' and 'sexual' which some people feel is misleading.

Causes of transsexualism
There is no scientifically proven cause of transsexualism. However, many theories have been proposed which suggest that the cause of transsexualism has its roots in biology. Because of this, the medical care profession is increasingly viewing transsexuality not as a psychological issue, but as a physical one. But many religious conservatives and others still believe that the causes of transsexualism are predominantly psychological.

Proposed psychological causes
In the past, many psychological causes for transsexualism have been proposed; including "overbearing mothers and absent fathers", "parents who wanted a child of the other sex", "repressed homosexuality", "emotional disturbance", "sexual abuse" or a variety of sexual "perversions". (Compare autogynephilia.)

None of these theories, however, were able to be applied successfully to a majority of transsexual people, and usually not even to a significant minority. Many theories also were developed in order to describe transsexual women, and when applied to transmen, they were even less useful. One such example was Ray Blanchard's theory that all transwomen could be divided into the categories of autogynephilic and homosexual. Many of these theories had also previously been applied to homosexuals, where they did not work out, either. This led to theories which consider physical reasons for transsexualism.

Experience with individuals who were surgically reassigned at birth, in order to correct deformities such as those caused by accidental castration or intersex conditions, suggests strongly that the mental gender identification is determined at birth - individuals born male but raised as female often show the same symptoms of gender dysphoria as transsexuals.

However, many religious conservatives and others still hold strong beliefs that the causes of transsexualism are psychological and/or emotional in nature.

"Curing" transsexualism
Psychological treatments aimed at curing transsexuality are historically known to be unsuccessful. As early as 1972, the American Medical Association Committee on Human Sexuality published the prevailing medical belief that psychotherapy was generally ineffectual for adult transsexuals and that sexual reassignment therapy was more useful. (Human Sexuality. The American Medical Association Committee on Human Sexuality. Chicago. 1972.) A number of other treatments have been used in the past that are now considered ineffective for people with significant and persistent cross gender identity, including aversion therapy, psychoactive medications, electroconvulsive therapy, hormone treatments consistent with the birth gender, and psychotherapy alone.

Reparative therapy aimed at gay or lesbian people has also been applied to transsexual and transgender people, since gender variant behaviour is seen by proponents of reparative therapy as an extreme form of homosexuality (a view that has long since disappeared from almost all scientific discourses). While the Kinsey scale expressed a similar view, the scientific community now rejects this part of Kinsey's theory, making reparative therapy useless to transsexual people as well as gay and lesbian people. Even though many of the major medical professional associations have repeatedly condemned reparative therapy as not only ineffective, but actually harmful, it continues to be advocated as a treatment for both homosexuals and transsexuals by several organizations with ties to the conservative Christian movement. However, in modern western medicine, reparative therapy generally is not considered to be good medical/psychological care.

However, for certain transsexual persons, therapies aimed at resolving gender conflicts, other than somatic treatments to reassign physical sex, may be effective and useful. Some people may have milder conflicts between gender identity and their physical sexual characteristics. These individuals may not actually wish to pursue gender reassignment therapy, but may seek care to help deal with the conflicts they face. If individuals express this desire for psychological care without SRS, supportive and psychoeducational counseling may be helpful. Additionally some transsexuals, who may have a significant lifelong conflict between gender identity and their sexed-body may present for care without requesting SRS. Their reasons for forgoing transition may include family or professional concerns, perceptions of difficulty of transition, fear of loss of social standing or role, firmly held religious beliefs, real or perceived inability to finance transition, and advanced age or chronic medical problems, which may, in some cases, be considered medical contraindications to hormone therapy or sex reassignment surgery. Regardless of their reasoning, if their decision is consistent, it should be respected. These individuals often seek alternative methods with which they can improve their functional status, promote acceptance of their gender identity as valid, and ameliorate mood symptoms caused by gender conflict through psychotherapy and sometimes medications. Additionally, these individuals sometimes benefit from partial somatic treatment. Low dose hormonal therapy only, validating patients desire to dress and live partially in the gender role appropriate to their gender, and even simply allowing the person a safe outlet to express themselves as a male or female can provide a great deal of comfort to patients who, for one reason or another, choose not to transition.

Physical causes
Many transsexual (and also many other transgendered) people have assumed that there is a physical cause of their transsexualism, because they claim to have had the feeling of being a girl or a boy for as long as they can remember. Several studies have shown evidence that there might actually be such a physical cause.

While the article by Zhou,, has been touted as strong evidence that transsexuality is based in structural and neurochemical similarities between the brain of transsexuals and brains typical of their gender identity, this article has been alleged to have numerous flaws. A second study by Kruijver, et al replicated the results of the first study, and included controls to help eliminate the alleged flaws.

Interesting evidence also comes from numerous animal studies demonstrating that exposure to cross-sex hormones during development can reliably produce cross-sex behaviors in animals. In addition twin studies have demonstrated a strong heritability for transsexuality. (Concordance for Gender Identity Among Monozygotic and Dizygotic Twin Pairs. Diamond, M and Hawk, S. American Psychological Association 2004 Annual Meeting. July 28 - August 1, 2004, Honolulu, Hawaii.) This research provides more suggestive evidence that transsexuality may be determined in part by genetics and in utero hormonal environment.

A recent study in Germany provides even more evidence for a physical basis for transsexualism. The study found a correlation between digit ratio and male to female transsexualism. Male to female transsexuals were found to have a higher digit ratio than control males, but one that was comparable to control females. Because digit ratio is directly related to prenatal hormone exposure, this tends to support theories linking such to male to female transsexualism. (Schneider, Pickel & Stalla 2005)

Many religious conservatives have criticized all of the studies suggesting physical causes of transsexuality as being seriously flawed due to methodological problems, erroneous conclusions, or both.

Objections against research of causes
Many scholars of gender theory, gender professionals and transsexual and transgender rights activists contest the very rationale of looking for a "cause" to transsexualism. The basic assumption behind this quest for "causes" is that gender dimorphism (the idea that there are only two discrete, well defined and dichotomous genders) is an established fact. The critics cite, among other things, historiographic and anthropological findings pointing to the fact that different cultures had diverse concepts of gender, some of them including three or more genders.

The main argument against the search for a "cause" to transsexualism is that it assumes a priori the legitimacy of normative gender identity, i.e. gender identity congruent with the external genitalia. This, affirm the critics, is an unproved contention. Historical research shows that the relation of genitals and gender identity changes across cultures. Assuming a priori that variant gender identity is anomalous (and therefore that its "causes" should be investigated) distorts science's view of gender and contributes to the stigmatization of gender non-conformists.

Closely related to the above argument is the belief of many people that transsexualism is not a disease or disorder and that no attempts should be made to cure transsexualism psychologically.

Gender reassignment therapy
Most transsexual men and women suffer from great psychological and emotional pain due to the conflict between their gender identity and their original gender role and anatomy. They often find that their only recourse is to change their gender role and undergo gender reassignment therapy. This may include taking hormones to modify their secondary sex characteristics or having sex reassignment surgery to change their primary sex characteristics.

Psychological treatment
Mental health approaches that attempt to change gender identity to one considered appropriate for the person's assigned sex have almost universally been shown to be ineffective. Therefore, it is generally accepted that the only effective course of treatment for transsexuals is gender reassignment therapy.

The need for physical treatment is emphasized by the high rate of mental health problems, including depression, anxiety, and various addictions, as well as a much higher suicide rate among untreated transsexual people than in the general population. Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role.

Many transgender and transsexual activists, and many caregivers, point out that these problems usually are not related to the gender identity issues themselves, but to problems that arise from dealing with those issues and social problems related to them. Also, many feel that those problems are much more likely to be diagnosed in transsexual people than in the general population, because transsexual people are usually required to visit a mental health professional to obtain approval for hormones and sex reassignment surgery. These professionals routinely evaluate their patients for these and similar problems.

A growing number of transsexual and transgender people therefore resent or even refuse psychological treatment which is mandated by the Standards of Care, because they believe that gender dysphoria itself is untreatable by psychological means, and that they have no other problems that need treatment. This, however, can cause significant problems when they try to obtain physical treatment.

Therapists' records reveal that most transsexuals do not believe they need psychological counseling, but acquiesce to legal and medical demands in order to gain rights which are granted through the medical/psychological hierarchy. Legal issues such as a change of sex on legal documents, and medical issues, such as sex reassignment surgery itself, are usually impossible to obtain without a doctor's and/or therapist's approval. This leads to the inevitability that many transsexuals feel coerced into confirming pre-ordained symptoms of self-loathing, impotence, and sexual-preference, in order to see simple legal and medical hurdles overcome. Transsexuals face the unattractive option of remaining invisible with no legal rights and possibly incongruent identification, or submitting to a medical hierarchy which alone has the ability to grant legal gender status.

Requirements for gender reassignment treatment
Main article: Standards of Care for Gender Identity Disorders

The requirements for hormone replacement therapy vary greatly. Often a minimum time period of psychological counseling or a time spent living in the desired gender role in order to ensure they can function psychologically in that role is required. This time period of "cross-living" is usually known as the Real-Life-Test (RLT) or Real-Life-Experience (RLE). This is not always possible; transsexual men frequently cannot "pass" this period without hormones. Transsexual women may also require hormones to pass as women in society. Most transwomen also require things such as facial hair removal, voice training, and sometimes, facial feminization surgery, to be passable as females. Many feel that these things are more important than hormones to the passability of most transwomen. The most recent revision of the HBIGDA Standards of Care recognize this limitation for some transgender people. Therefore, the SOC state that patients may be approved for treatment after either a period of successful cross-living or a period of diagnostic psychotherapy - generally at least three months. Some doctors may prescribe hormones to any patient who requests them; however, most physicians are extremely reluctant to do so, especially for FTM transsexuals. In FTM transsexuals, some hormonally-induced changes may become virtually irreversible within a matter of weeks, whereas MTF transsexuals usually have to take hormones for many months before any irreversible changes will result. Some transsexual men and women are able to avoid the medical community's requirements for hormone therapy altogether by obtaining hormones from black market sources, such as internet pharmacies which ship from overseas.

Some surgeons who perform sex-reassignment surgery may require the patient to live as the opposite gender in as many ways as possible for a specified period of time, prior to the start of surgery. However, some surgeons recognize that RLT for FTM transsexuals, without at least chest reconstruction may be difficult. Some surgeons also recognize that the RLT may be difficult for some MTF transsexuals without facial feminization surgery. Therefore, many surgeons are willing to perform some or even all elements of SRS without an RLT period. This is especially prevalent amongst surgeons who practice in Asia. However, almost all US surgeons who perform vaginoplasty on MTF transsexuals require a minimum one-year RLT as well as recommendation letters from two psychotherapists.

Generally, both physicians who prescribe hormones and surgeons who perform SRS may request letters of diagnosis and recommendation for treatment from the patient's therapist. However, experienced physicians and surgeons, especially outside the United States, sometimes waive this requirement with patients who, by their evaluation, are obvious candidates for treatment.

Hormone replacement therapy
Main article: Hormone replacement therapy (trans)

For both transsexual men and women hormone replacement therapy (HRT) causes the development of many of the secondary sexual characteristics of their desired gender. However, many of the already existing primary and secondary sexual characteristics cannot be undone by HRT though. For example breasts will grow in transsexual women but they will not regress in transsexual men. Facial hair will grow in transsexual men, but usually will not regress in transsexual women. However some characteristics like distribution of body fat and muscle as well as menstruation in transsexual men may be reversed by hormonal treatment. Generally, those traits that are easily reversible will also revert on cessation of hormonal treatment unless surgical castration has occurred. For many transsexual people, surgery is required to provide a satisfactory physical body.

Sex reassignment surgery
Main article: Sex reassignment surgery

Sex reassignment surgery consists of procedures transsexual women and men undergo in order to match their anatomical sex to their gender identity. While genital reassignment surgery (GRS) refers only to surgeries that correct genital anatomy, sex reassignment surgery (SRS) may refer to all surgical procedures undergone by transsexuals.

Generally, SRS is very expensive and often not covered by public or private health insurance. There are also significant medical risks associated with SRS that should be considered by transsexuals who are contemplating the surgery.

Prior to surgery, transsexual men and women are often referred to as pre-operative (pre-op); those who have already had the surgery may be referred to as post-operative (post-op) or simply identified by the sex and sexual status they have chosen. Not all transsexual people undergo sexual reassignment surgery (either because of the high cost of such surgery, medical reasons, or other reasons), although they live constantly in their chosen gender role; these people are often called non-operative (''non-op).

A more modern idea suggests the notion that the focus on surgery status is misplaced, and therefore, more and more people are refusing to define themselves in terms of operative status, often defining themselves based on their social presentation instead. This goes with the belief of many transsexual people that SRS is only a small part of a complete transition.

Legal and social aspects
Main article: Legal aspects of transsexualism

Many Western societies, nowadays, have some sort of procedure whereby an individual can change their name, and sometimes, their legal gender, to reflect their gender identity. Medical procedures for transsexual and transgender people are also available in most Western countries. However, transsexual and transgender people make strong challenges to the prevalence of gender roles in many cultures and often face considerable hatred and prejudice. The film Boys Don't Cry chronicles such a case.

Some people who have undergone a change of gender role will adopt or provide foster care for children, sometimes for children who are also transsexual or transgender so they can live according to their gender identity. Societies are, in some instances, challenged to assimilate these men and women into their social institutions such as marriage and the role of parenting. Often, children exist from before transition. Many of these children stay with their transitioning/transitioned parent. Recent research shows that this does not harm the development of these children in any way. Much to the dismay of many transsexuals, older children frequently reject their transsexual parents and refuse to live with them. Equally distressing to transsexual parents, many younger children are barred from visiting their transsexual parents by family members or court order.

The style guides of many media outlets prescribe that a journalist who writes about a transsexual should use the pronoun and name used by that person. Family members and friends, who are often confused about pronoun usage or the definitions of sex, are frequently corrected by either the transsexual or the professionals who assist them as they approach that point at which they begin to "pass" as a member of their target sex.

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

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

The equation with "coming out", whereby a lesbian or gay person, or a transsexual person who has hidden their true gender identity maintaining their originally assigned gender role, feels they reveal their true self, has been countered by the explanation that, in contrast, because of prejudice, sensationalism, and how it can trigger unconscious personal feelings and emotions, knowledge of someone's transsexual past can too easily prevent the average person being able see the transitioned person's true self. So the knowledge obscures, instead of reveals, the truth.

The choice to live completely stealth is believed to present its own psychological difficulties. Many believe that without anyone in which to confide, there may be tendencies towards anxiety and depression. The term deep stealth is sometimes used for those that have completely isolated themselves from their past, their birth families, the medical professionals directly involved in their treatment process, and from the support structures that may have helped them through transition. Several examples exist of people who have gone deep stealth whose status was only discovered at their death. For example, the jazz musician Billy Tipton was deep stealth and his status was not even known by his wife and (adoptive) children. Moreover the tragedy of Mr Tipton's death illustrates just one of the dangers of going deep stealth. The fear of discovery as being transsexual often may keep people from seeking needed medical care. Mr Tipton bled to death from an ulcer that could have been readily treated at the time had he been able to seek medical care without fear of discovery.

However, many believe that fear of discovery as mentioned above is justifiable. Several examples also exist of people who have been denied medical treatment upon discovery of their trans status, whether it was revealed by the patient or inadvertantly discovered by the doctors. For example, Leslie Feinberg was once turned away from a hospital emergency room where s/he had sought treatment for encephalitis. Like Tipton, Feinberg was presenting as a man but had female genital anatomy. S/he nearly died after being denied treatment. Feinberg's case demonstrates one of the many dangers of actually being discovered.

The majority of the transsexual and transgender community has learned to accept that people choose, for many reasons including political beliefs, religion, family responsibilities, career, perception of how well they will be accepted by others, and personal psychology, to live at a certain place on the spectrum from 'out and proud' to 'deep stealth.' Billy Tipton's decision to be deep stealth was no more or less valid than Jamison Green's decision to be out and politically active, as detailed in his book 'Becoming a Visible Man.' There are risks and benefits to any place on the spectrum and the decision is widely considered a personal one.

Transsexual youth
Different individuals begin to come to terms with their gender identity during many different stages in their life. In most cases, the transsexual condition becomes apparent at some time in childhood, sometimes in very early childhood, where the child may be expressing behaviour incongruent with, and dissatisfaction related to, his or her assigned gender.

Most of the time, though, these children try to hide their being different as soon as they experience rejection resulting from their differences.

Coming out
Since transsexualism is still not widely accepted in many regions and "circles", transsexual youths may feel they need to remain in the closet until they feel that there is a time appropriate to reveal their gender identity to their parents and others -- understandably so, as parents have a great deal of influence in their children's lives. Some parents can react negatively towards such news. Other parents can be very supportive when such news is broken to them. It is often impossible to predict how parents will react to such news, and the process is fraught with tension for many transsexual youths. Reactions of parents to transsexual children can also change over time. For example, parents who initially reacted with negativity and hostility may eventually come around to support their transsexual children. And parents who were supportive at first may later develop hostility toward their child's gender identity.

Transsexual youths also face many hardships when it comes to obtaining medical treatment for their condition. Psychiatrists and endocrinologists are very reluctant to give hormone treatment to transsexual youths under 16, and getting surgery, prior to the age of 18, is almost completely impossible. The latest revision of the Standards of Care has addressed the needs of transsexual children. According to the SOC, intensely transsexual youths can begin taking puberty-preventing medications as soon as the first signs of puberty become apparent.

Puberty
Puberty is especially difficult for trans youth. Many people consider puberty to be difficult for everyone in many ways. But unlike their peers, who may be excited about bodily changes and thrilled with growing up, trans youth are put into an extremely bad position in their lives. While everyone around them may seem to be happy about going through puberty, the changes that are happening to them are the opposite of what feels right. The androgyny of childhood melts away, and to their horror, they see changes in their body that only make them more uncomfortable and put them through considerable agony.

And to make it worse, many endocrinologists insist on youths going through the puberty of their genetic sex before they prescribe hormones that could have prevented the masculinization or feminization of an MTF or FTM, respectively. Because of this, transsexual people must often undergo expensive, risky, time-consuming, and painful procedures to reverse pubertal changes that could have been prevented with early intervention. During this time, some MTF trans youth attempt self-castration, but often, they are not successful, and self-castration is widely considered to be extremely dangerous for anyone to attempt.

Ensuring the child's security
Only in recent years have some transsexual or transgendered children received counseling and, in some cases, medical treatment, as well as the possibility to change their social role.

Families with a young child, who may identify already as a member of "the other" sex, and who chooses to change their gender roles through dress and behaviors, may respect their child's decision, and may even decide to relocate this child's home to another area in order to afford the young person the best opportunity to live in the desired gender role among a novel set of peers and community. This helps to protect trans children from peer rejection, bullying, and harassment.

Choosing to remain and live within an intolerant society where the local community has had previous experience of the child's assigned sex may raise many challenging issues. Gwen Araujo of Newark, California was a young person who had lived as female, a gender opposite to the male gender assigned her at birth. She became the victim of violent crimes that resulted in her death after she attended a party where her birth sex was revealed.

The film Ma Vie en Rose (1997), by Alain Berliner, depicts a similar scenario: Ludovic is a young child who is assigned male but who identifies as a girl and tries to make others agree with this identification. Ludovic's gender play incurs conflict within the family and prejudice from the neighbours; in the end the family has to relocate to a new community.

The 1999 documentary film Creature directed by Parris Patton, tells the story of Stacey "Hollywood" Dean, a young transsexual woman who grew up in rural North Carolina. It follows her through four years and includes interviews with her conservative Christian parents.

The decision to relocate, however, depends very much on the social environment and the handling of the situation by caregivers and other adults. There are also several cases where it was not felt that there was such a need to relocate, particularly in Western Europe.

Retransitions
While rare, transsexuals sometimes choose to retransition to their original sex. However, every recent study done on the number of these cases states that their number is well below 1%, and that the reasons for retransitioning are very diverse. See this article in the International Journal of Transgenderism for examples.

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

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

Depictions of transsexuality in the media
Male-to-female transsexuals are commonly featured in pornography. When depicted without having undergone vaginoplasty, they are usually referred to as "shemales". While some pre-op transwomen call themselves and others like them "shemales," the term is regarded as offensive by many transsexuals.

Transsexualism is often presented in popular media as a joke. Films containing serious depictions of transgender issues include The World According to Garp and The Crying Game. The film Different for Girls is notable for a sensitive depiction of a male-to-female transsexual who meets up with, and forms a romantic relationship with, her once best friend from her all-male boarding school. Ma Vie en Rose is a sensitive portrayal of a six-year-old child who is gender variant. Two notable films depict transphobic violence based on real events: Soldier's Girl (about the relationship between Barry Winchell and Calpernia Addams, and his subsequent murder) and Boys Don't Cry (about Brandon Teena's murder).

Transsexuals have also been depicted in a more serious light in some popular television shows. In Just Shoot Me, David Spade's character meets up with his childhood male friend, who has gone MtF. After initially being frightened, he eventually becomes sexually attracted to his friend, but is scorned as he is 'not her type'. The series Law & Order and Nip/Tuck, have had transsexual characters, but they were played by non-transsexual women, or professional cross-dressers. The series Without a Trace featured an episode in which an MtF transsexual went missing and is almost killed by her ex-wife's husband after visiting her family, which she abandoned before transtioning. CSI: Crime Scene Investigation had an episode dealing with a transsexual victim, Ch-Ch-Changes. Many transsexual actresses and extras appeared on the episode, including Marci Bowers and Calpernia Addams. The MTF transsexual victim, Wendy, was played by Sarah Buxton, a cisgender woman. Addams has appeared in numerous movies and television shows, including the 2005 comedy Transamerica.

Transsexuals in non-Western cultures
Transsexuals enjoy varying degrees of acceptance in non-Western societies.

In 1976, the supreme leader of Iran, Ayatollah Ruhollah Khomeini, issued a fatwa to allow people with hormonal disorders to change sex if they wished, as well as change their birth certificates. Before the Islamic Revolution in 1979, there was no particular policy regarding transsexuals. Iranians with the inclination, means and connections could obtain the necessary medical treatment and new identity documents. The new religious government, however, classified transsexuals with gays and lesbians, who were condemned by Islam and faced the punishment of lashing under Iran's penal code. One early campaigner for transsexual rights is Maryam Hatoon Molkara, who formerly lived as a man known as Fereydoon. Before the revolution, under the shah, she had longed to become a woman but could not afford surgery. Furthermore, she wanted religious guidance. In 1978, she wrote to Ayatollah Ruhollah Khomeini, who was to become the leader of the revolution but was still in exile, explaining her situation. The ayatollah replied that her case was different from that of a homosexual, and therefore, that she had his blessing. This stance might be seen as liberal from an American or European viewpoint, but it is due to a stressing of heteronormativity on the the part of Iranian and Islamic society, not a growing acceptance of homosexuality. Homosexuality is still forbidden in Iran, and the viewpoint is that males who are attracted to other males should become women.

This heteronormative stance is also seen in countries such as Brazil and Thailand. Thailand seems to have the highest prevalence of transsexuality in the world. In Thailand, khatoey (who are often, but not always, transsexual) are accepted to a greater extent than in most countries, but are not completely free of societal stigma. Feminine transsexual khatoey are much more accepted than gay male khatoey; this may be seen as an example of heteronormativity. Due to the relative prevalence and acceptance of transseuxality in Thailand, there are a large number of highly accomplished Thai surgeons who are specialized in sex reassignment surgery. In addition to generally favorable exchange rates, this makes the Thai surgeons a popular option for Western transseuxals seeking surgery.

See also Transgender in non-Western contexts.

Specific to trans women

 * Mom, I Need to Be a Girl - a book by the mother of a transsexual child
 * Transsexual Road Map - practical and medical information
 * Lynn Conway - her goal is to "illuminate and normalize the issues of gender identity and the processes of gender transition."
 * Annelawrence.com Medical and Other Resources for Transsexual Women - often considered to be a controversial figure within the community due to her support for the autogynephilia theory
 * Brenda Make's Genderrain Project - contains the web version of Saving Throw. Saving throw is a transsexual person's autobiography which also touches on bisexuality, abuse, recovery, drug abuse, gender ethics and politics.
 * Older Tees Medical, support and general articles for the transsexual community.

Specific to trans men

 * FTM International - Female To Male International: practical and medical information
 * FTMA Network - Australian-wide network providing up to date contact, support and information.
 * Transster - A photo repository of female-to-male surgery, with patient surveys on quality of care experiences with different surgeons.
 * Medical Therapy and Health Maintenance for Transgender Men: A Guide For Health Care Providers - Guidebook available free online.
 * The Transitional Male - a Comprehensive, Educational Personal Website for Transmen, FTM's, Spouses, Family & Friends.
 * Why Don't You Tell Them I'm A Boy? - Raising a Gender- Nonconforming Child, by Florence Dillon. A mother's experience with raising a transgender (FtM) son.
 * Hudson's FTM Resource Guide - A basic guide including information about testosterone, health, surgeries, binding, packing, shaving, acne, hair loss, STP/bathrooms, clothing and shoes, and other topics, as well as FTM-related product links.

Specific to trans youth

 * Antijen - Support site for transexual youth. Includes sample letters to parents, articles, and links.
 * TransProud - OutProud's website for transgender youth. Headline news, links to other transgender sites for trans youth, loads of resources and information, stories of other transgender teens, message boards, as well as resources for parents of transgender children.
 * Mermaids - A UK based family support group for children and teenagers with gender identity issues. Includes useful resouces for international transgender youth.
 * Gender Public Advocacy Coalition Youth - National network of students combating bullying and discrimination caused by gender stereotypes through peer to peer mentoring, grassroots organizing and community education. Youth branch of GPAC.
 * I Think I May Be Transgender, Now What do I Do? - A brochure by and for transgender youth.
 * Canadian Transexuals Fight For Rights Youth - A considerable collection of links for transexual youth, both Canadian and international, compiled by the CTFFR.
 * Our Trans Children - A Publication of the Transgender Network of Parents, Families and Friends of Lesbians and Gays (PFLAG)

Media treatment of transsexuality

 * spectator.net article: Embracing the Transsexual Menace: Another Radical Idea Whose Time Has Come?
 * GLBTQ article: Pornographic Film and Video: Transsexual

Транссексуалност Transseksualnost Transsexualitat Transsexualität Transseksulo Transsexualisme טרנסקסואליות 性同一性障害 Транссексуалност Transseksualiteit Transseksualizm Transexual Транссексуальность Transsexual Transsexuell