Trans Man, Female to Male Transgender: Sexuality

By and large, the transsexual condition is referred to, and often dealt with, as a sexual problem. Gender identity and sexuality are two separate aspects of our lives. Yet, it is amazing how many people have trouble conceptualizing the difference. Since transsexuals began approaching the medical community after W.W.II, the general view of those practitioners was one of taking a social deviant (socially embarrassing, “effeminate” men) and through chemical and surgical adjustments create a socially acceptable woman. Once it was discovered that a portion of these “new” women took female partners and identified as lesbians, the medical screening process was tightened up. Those who identified as anything other than heterosexual were forced to lie. If they mentioned any behavior that smacked of bisexuality or homosexuality, they were rejected from most gender programs. Those who felt they could not fight the system learned to lie. The medical community taught many transsexuals that their gender and sexual identity were inseparable.

One of the first people to challenge the gender programs and the medical professionals on this attitude was Louis Sullivan. He was the founder of the largest and longest-running FTM organization (to date) in the world, now known as FTM International, Inc. Lou identified not only as an FTM, but also as a gay man. He spent ten years of his life writing letters, personally visiting doctors, educating them, and persevering against the system. For ten years, he was denied hormone therapy or surgery. Finally, his persistence paid off and he was granted the right to pursue the treatment he felt he needed. He was the first FTM who openly led the way for others who identified as gay or bisexual.

Within the FTM experience, the entire gamut of the sexual spectrum is covered. A large portion of FTMs identify as heterosexual men who date and even marry women. There are those who identify as non-sexual and others who see themselves as asexual, choosing only self-stimulation. A large number of people identify as gay or queer, others identify as bisexual. There are those who identify as pansexual or simply sexual.

Of course with the exploration of sexuality comes the discovery and exploration of sex. And with sex, the specter of HIV/AIDS and STDs arises. Most of the FTMs on the street hustling for survival and money are fully aware of the risks they run. They face some of the tough problems that other male hustlers face on the streets. Most johns will pay higher dollar if they don’t have to use a condom. In San Francisco, $10 to $30 dollars will get you a blowjob. These are usually performed with condoms. To kick without a condom, the asking price is $75 to $150. Several of the young men have commanded prices of $500 or more for the john’s privilege to not use a rubber. It seems an awfully low price for their life. The chance of drug use, mostly intravenous, is high for these young men. To our knowledge, at this point in time, the number of young FTM men who work the streets is low.

The FTMs who are probably at the highest risk of transmitting or contracting STDs are those who identify as heterosexual. Many hetero FTMs feel they are immune to HIV/AIDS because it is still considered a gay disease, and not all FTMs emerge from the dyke community. Their biggest risk is their ignorance and lack of education. This is probably less so in urban areas, but the attitude is still alarmingly proliferant. Not surprisingly, those FTMs who identify as gay or bisexual are usually the most educated in regard to any STD as well as safer sex practices. This has not, however, kept FTMs from contracting HIV or other STDs. In both urban and rural areas, the number of FTMs who have sero-converted has risen in the past three years. Herpes is wide-spread if not epidemic. A large number of FTMs have spoken up about cases of gonorrhea as well. When asked why they choose not use condoms or other forms of protection, many state that they have felt pressured into not using them. Several have spoken of being told they won’t be seen as “real” men if they insist on protection. This kind of pressure has come from straight women, bisexual men and women, and gay men. Peer pressure seems to run the gamut in the sexual spectrum as well. More education is needed about safe sex that recognizes the unique conditions of FTM bodies and psyches.

Notes on Gender Transition

Revised September, 1997

FTM 101 — The Invisible Transsexuals

By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor

Female To Male Before And After Photos

Transsexuality is when a person adopts a different gender identity by not feeling belonging to their assigned gender. Transsexuality refers to a person’s gender identity, so it should not be confused with sexual orientation. A transgender person may have sexual orientations such as heterosexual, gay, lesbian, bisexual or asexual.

Transgender people, if they wish, can get medical help when making a permanent transition to the gender they define. During this transition period, practices such as hormone therapy and sex reassignment surgery aim to adapt their bodies to the gender they are defined.

Transsexuality is seeing and feeling as a different gender in the inner world rather than one’s behavior. Therefore, it is not possible to determine transsexuals by their appearance. Because they do not always reflect on their external appearance that they feel different sex. Unlike transvestism, other than clothing, physical appearance and behavior, some of the transsexuals undergo gender reassignment surgery and switch to different gender socially and legally.

Trans man, The term used for transgender men. It is the name given to people who were born female but identify themselves as male.

Many transgender people share their photos before and after the gender transition process.

I am sharing some of the before and after trans men photos I found on the internet.

 

Trans Man & Non-Binary Guide

In this article, I would like to talk about the products that make life easier for us as much as I can and the products we use / will use. I think it will be a little long but it is worth your reading.

Most of us have body dysphoria, and it is obvious that we have difficulties in our daily lives. The “binder” comes first among the items that facilitate this. There are those who suffer from severe posture disorders due to chest dysphoria. Many things are used in order not to reveal the breast, but the safest and healthiest of them is binder.

What should be considered when buying a binder?

First of all, the fabric quality of the binder that is not removed for a long time (actually this is wrong) is very important. It should be a breathable fabric, it should not cause allergies. Frankly, there is no place that produces locally produced products with very pleasant qualities. If your budget is not enough to buy from abroad, you can review and buy the products on the “fmtsmalls” page. “Underworks” and “gc2b” companies from abroad are among the best. Many trans people prefer these companies. Apart from that, there are many sellers’ products on Aliexpres, you can choose by looking at their comments here. When using binder, you should try not to wear it for a long time. This is important for your health, in order to avoid allergic reactions on your skin and to prevent serious deformations in the breast structure. In addition, you should not use methods such as bandaging.

If you are still hidden from your family and want to use binder, you can keep it safe by keeping it between your clothes when you are not wearing it.

Our second product, called packer, is used instead of under-pants penis. When you want to show yourself as a man among people on the street, if you don’t want feminine lines to stand out, you can use what is called packer. Before the products sold, you can get help from the videos of making a sock packer at home, which you can easily find on Youtube. When you write How to make a packer, you will see many videos. Even if you don’t speak English, you can easily learn while watching. In addition, domestic and foreign companies produce packers that are realistic. I recommend that you pay attention to the fact that it is not too big when choosing.

Another product after Packer is realistic penises. These are divided into two or three functions for standing peeing and for intercourse. I think there may be many more details, but I do not have very detailed information. Especially if you are going to buy it for a relationship, I recommend that you allocate a good budget and buy a quality product. In addition, if you use lubricant during contact with these products, you should be careful that it is water-based, others damage the product. Using condoms is beneficial for your partner’s health, again, it must be water-based. You can also find many review videos on Youtube, and you can find hint articles on foreign forums. Just start looking for a great paradise for us on Google and ask to learn. I have to say that in realistic products, if you want double-sided pleasure, which is an important thing, there is an apparatus called the pleasure rod developed abroad to enjoy not only your partner but also yourself. You can get an idea by looking at the company’s products and their Youtube reviews. Copies of this product were published recently as a domestic production, but I always favor the original purchase of such things. My first suggestion for Packer and realistics is Peacock firm, RealMagik, TransGuySupply and FTMShopping are others. In addition, many underwear manufacturing companies also sell packers and realistic products. In Turkey, “transfromturkey” account and the newly established tugrealistic I would recommend to you. You can also find many product recommendations on trans pages on Instagram.

Unfortunately, there are no local companies for packers and realistics, as well as comfortable underwear use in our daily lives. There is no sector for trans people in our country yet. The firm that I recommend and my favorite is Rodeoh. You can see all products on their own sites and instagram. It has really high quality and helpful products. Pocket compartment for packer, special hole for intercourse, convenient use. You can understand when you look at the models. Unfortunately, the prices are a bit high for us, but you can talk and request a discount coupon. Another company only for boxer is Woxer. It is a company that started out and manufactures on the female body. Unfortunately, there is no domestic counterpart, but you can look at the models for the relationship and find solutions yourself at home. I guess you can achieve this by buying a narrow boxer, making a hole the size of the penis and stitching the edges? In normal boxer use, I recommend the brands John Frank and Jack Jones, whose designs I like, in terms of comfort and quality. They are really comfortable and do not bother the fabrics.

I want to say a few things about your relationships. Put ourselves in certain patterns

Article by @siriusea

Transgender Definition, Transgender Meaning

Transgender syndrome is a congenital medical condition treated by university hospitals around the world. It is a physical (organic) condition that takes shape in the mother’s womb. The initial sex of the offspring in all mammals is female. In the second month of development in the womb, the sex of the baby remains female or turns into a male with the hormones secreted by the fetus. During this period, the sexual structure of that tiny body and brain is determined. This explains why males also have nipples that remain as traces of the original female gender.

Something goes wrong at this stage of fetal development, and the sex of the baby’s body and the sex of the brain will not be the same, that is, the brain remains female while the body is performing sexual transformation, or while the brain is transforming, the body remains female before it transforms. Research on the brain confirms this explanation. Autopsies performed on people born transsexual have shown that the gender of the brain is not the same as the sex at birth. (Part of the brain is different in males and females.)

It is not medically possible to adjust the consciousness to the transgender body. The solution adapts the body to the brain / consciousness. This process is called gender redefinition or gender correction. The procedure takes many years (such as epilation, talking therapy, hormone therapy). Also, the financial source of this transaction must be provided. Surgery is not the last step of the procedure.

Transexuality has nothing to do with transvestism. Transvestites are men who like to look like a woman, even though they are happy and content to be men.

Transsexuality is not linked to homosexuality. A gay man gets together with a homosexual man, and a homosexual woman gets along with a homosexual woman. They are proud of their gender and oppose surgical removal of their genitals unless they encounter cancer or another disease. Homosexuality refers to a relationship. Transsexuality indicates identity anxiety, not sexual orientation. Like other people, the transgender-born person can have a relationship with a man, a woman, both, or neither.

Transsexuality is not a mental illness. Psychiatrists and psychologists saw it as an illness and tried to treat it for years. But since this is not a mental illness, it has now been understood that it is not possible to be cured by psychiatrists. In fact, it has been observed that a transgender is more balanced in terms of mental health than other people.

Clothing and appearance are not a matter of taste for transsexuals The transgender person dresses up and dresses up specifically to be seen as a natural member of the opposite sex. This is a necessary part of the treatment and the person has to live in this role for at least 1 year like a member of the opposite sex until the operation is allowed.

A transgender is not a man who wants to be a woman, or a woman who wants to be a man. Although the identity card says that he is a member of a gender, before the treatment the person is neither male nor female, he / she is transgender. Because there is a discrepancy between the gender in the brain / consciousness and the gender in the identity document.

There is no cure for the syndrome other than gender reassessment. Until the gender re-determination stage, the person is considered to be medically transsexual, but after the procedure, he is no longer a transsexual, but simply a woman or a man.

It is unpredictable to what family a transsexual can be born into. You cannot know if your child or grandchild is transgender. The majority of sufferers spend unhappy decades trying insistently to live in the gender they were born with, like everyone else. So, when these people are questioned, they may even persistently refuse to be of the opposite sex. As the years pass and mature, they begin to understand what is wrong and with great courage they can attempt to change everything radically. Because no one becomes transgender over time, you personally know whether you are transgender or not. If not, you’d be grateful for that.

Untreated, transsexuals can go mad or even commit suicide as a result of the anxiety and depression they can’t handle, because no one can suppress their existing identity for a lifetime. Before surgery, 80% of these people seriously intend to kill themselves, try or actually commit suicide. After surgery, this rate falls to the level of suicide rates in the community.

Transsexuality is not a negligible situation. Often, he may lose his family, friends, job, home, savings and reputation for the sake of this treatment. It should not be forgotten that

Nothing costs more than their lives.

These losses are the result of society’s indifference to the issue. Being born transsexual is not their choice. This is not a problem created by him.

If you change your gender by surgery, you will fall into a transgender’s pre-treatment state. No one can be forced to live in the wrong sex, even a day!.

FTM Related Books

Here Is A List of Female to Male Related Books…

Bornstein, Kate. Gender Outlaw: On Men, Women, and the Rest of Us. Vintage Books, 1995.

Bornstein, Kate. My Gender Workbook: How to Become a Real Man, a Real Woman, the Real You, or Something Else Entirely. Routledge, 1998.

Brown, Mildred L. & Chloe Ann Rounsley. True Selves: Understanding Transsexualism-For Families, Friends, Coworkers, and Helping Professionals. Jossey-Bass Publishers, 1996.

Burke, Phyllis. Gender Shock: Exploding the Myths of Male and Female. Anchor Press, 1997.

Califia, Pat. Sex Changes: The Politics of Transgenderism. Cleis Press, 1997.

Cameron, Loren. Body Alchemy: Transsexual Portraits. Cleis Press, 1996.

Colapinto, John. As Nature Made Him: The Boy Who Was Raised As A Girl. Harper Collins, 2000.

Devor, Holly. FTM: Female-To-Male Transsexuals in Sciety. Indiana University Press, 1997.

Devor, Holly. Gender Blending: Confronting The Limits Of Duality. Indiana University, 1989.

Feinberg, Leslie. Trans Liberation: Beyond Pink or Blue. Beacon Press, 1998.

Feinberg, Leslie. Stone Butch Blues: A Novel. Firebrand Books, 1993.

Feinberg, Leslie. Transgender Warriors : Making History from Joan of Arc to Dennis Rodman. Beacon Press, 1997.

Halberstam, Judith. Female Masculinity. Duke University Press, 1998.

Hewitt, Paul. A Self-Made Man: The Diary Of A Man Born In A Woman’s Body. Headline, 1995.

Israel, Gianna E. Transgender Care: Recommended Guidelines, Practical Information, and Personal Accounts. Temple University Press, 1997.

Jones, Aphrodite. All She Wanted. Pocket Books, 1996.

Kirk, Sheila M.D. Masculinizing Hormonal Therapy for the Transgendered. Together Lifeworks, 1996.

Middlebrook, Diane Wood. Suits Me: The Double Life Of Billy Tipton. Houghton Mifflin, 1998.

Morpurgo, Michael. Joan Of Arc. Harcourt Brace, 1999 (Children’s Book)

Nataf, Zachary I. Lesbians Talk Transgender. Scarlet Press, 1996.

Nestle, Joan. The Persistent Desire: A Femme-Butch Reader. Alyson Publications, 1992.

Pratt, Minnie Bruce. S/he. Firebrand Books, 1995.

Queen, Carol and Lawrence Schimel. Pomosexuals: Challenging Assumptions About Gender and Sexuality. Cleis Press, 1997.

Ramsey, Gerald, Ph.D. Transsexuals: Candid Answers To Private Questions. The Crossing Press, 1996.

Rees, Mark Nicholas Alban. Dear Sir or Madam: The Autobiography of a Female-To-Male Transsexual. Cassell Academic: 1996.

Reit, Seymour. Behind Rebel Lines. Odyssey, 1988. ( Children’s Book about a girl who enlisted in the Union Army as a boy.)

Stringer, Joann Altman. The Transsexual’s Survival Guide: To Transition & Beyond. Creative Design Services, 1990.

Sullivan, Louis. From Female To Male: The Life Of Jack Bee Garland. Alyson Publications, 1990.

Thompson, C.J.S. Ladies Or Gentleman: Women Who Posed As Men, And Men Who Impersonated Women. Dorset Press, 1993

Valerio, Max Wolf. A Man: The Transsexual Journey of an Agent Provocateur. William Morrow & Company, 1998.

Volcano, Del LaGrace & Halberstam, Judith “Jack”. The Drag King Book. Serpent’s Tail, 1999.

Wilchins, Riki Anne. Read My Lips: Sexual Subversion and the End of Gender. Firebrand Books, 1997.

What is FTM?

The border between intersex (hermaphrodites) and transsexuals is very fluent. In fact it can be argued that both are two sides of the same phenomena: during the early devellopment of the fetus the body develloped in a nonstandard way, making it difficult for third persons to guess the gender of the baby after birth.

In the FTM case a child has mistakenly (if the psychological identity is used as defining standart) been labeled and assigned as female at birth.

During childhood, adolescence but usually only as an adult the FTM corrects this mistake and lives as a man.

This can be a disruptive process as parents, friends, employers are often relucutant to aceept that their perception of this person was incorrect. Usually after some time most people do adapt, also because it is easier to relate to a FTM as a man.

Hormones, surgery or a legal court order are usually nessesary to achive a complete recognition by society. Many countries, smore health organisations unfortunately still discriminate against FTMs, and intersex and transgendered people in general.

Many FTMs have started to explore ways which lead to a recognition without surgery, especially FTMs who pass as boys or young men without any medical intervention. Others have explored bi-gendered ways, bluring the border between the gay/lesbian and transgender population.

The abreviation FTM is derived from the medical term female to male (transgender, transsexual, etc.). As most FTMs have no serious medical disorders related to their condition, FTM and intersex people who match this statement should however rather seen as a part of the rich heritage of human diversity, which has produced differnt races, bodyshapes, and on a higher level ethinically diverse cultures.

Transgender Voice Therapy and Treatment

For the male to female transsexual acquiring a female voice which is convincing, even over the telephone, can be one of the most difficult aspects of changing gender role. Speech therapy is a very important part of the gender reassignment package and may or may not be available through medical referral. This information sheet does not make any recommendations or comments on the relative benefits of different ways of changing the voice such as surgery and re-education through speech therapy. The following three articles report on different approaches to the subject.

1) Voice Surgery for Male to Female Transsexuals by Selina of Newcastle upon Tyne (575). First Published in GEMSNEWS No. 24

This is an area of treatment which is sadly neglected and lacking in the UK and about which there is very little reliable information even amongst professional advisers. I am very surprised that so little priority and importance is placed on having a really acceptable female voice. I have found that whilst I can be accepted as female in personal contact (people generally accept what they see) the telephone is the big problem. As I use the phone a great deal for my business, it is a thorough nuisance having to correct wrong gender assumption umpteen times every day.

After much research I discovered two places where the procedure known as “cricothyroid approximation” is undertaken. One is in Beverly Hills, California, USA and the other is Amsterdam, Holland. I know people who have been to both places. The biggest problem with California is the expense both of the treatment and of travel, hotels, etc. Dr Toby Mayer who does this work has been doing it for a considerable number of years and is thus very experienced. I was quoted $7,000 (approx £4,600) for the surgery which included a reduction of the thyroid cartilage (Adam’s Apple). In Amsterdam a consultation with Prof. H.F. Mahieu to see if surgery was feasible cost approx 200 Guilders (£180) and surgery about 3,000 guilders (£1,200). Having decided on this route and having undergone surgery there, I am in a position to describe what happened to me.

”The initial consultation took most of one day and included meeting with Prof. Mahieu to find out about the procedure and for him to find out about me. He told me that it was an inexact science and that everyone responded differently. Very much in my favour was that I have never smoked and I drink very little. On the deficit side was my age but Prof Mahieu said that I seemed very good for my years and so this was hopefully not a problem. In laymen’s terms what is done is that the hard sections of cartilage, which are separated by soft tissue, are pulled together with stitches thereby putting extra tension on the vocal chords and producing a higher pitch than before.

This causes the thyroid cartilage (Adam’s Apple) to become more prominent and therefore necessitates its reduction, known as a tracheal shave. This is still done at the same time as the pitch raising surgery. Physical examination of ears and throat was followed by photographs of throat, X-ray of throat, blood tests (both for blood group and to check for HIV). Also a phonetogram was taken to record my vocal pitch prior to treatment. It was explained to me that patients must have completed their gender re-assignment before voice surgery can be considered. I was then given an appointment for surgery some months ahead of the consultation date. This interval is usually about six months. The surgery is done on an out-patient basis with return for check-up two days later and again at three months and one year later to monitor results. If at check up it is found that insufficient pitch rise has been maintained, apparently a11 is not lost.

There is a second stage procedure and even a third stage which can be applied should it be deemed necessary. The second stage consists of an endoscopical laryngeal procedure creating a web in the anterior or front part of the glottis. This procedure results in a reduction of the length over which the vocal folds can vibrate so the vocal folds form the web. Negative side effects such as hoarseness and breathiness are said to be possible in patients with a laryngeal web. The stage three procedure which is regarded as only to be undertaken as an absolute last resort consists of scarification and mass reduction of the vocal fold mucosa by CO2 laser vaporisation. This can result in a deterioration of the voice quality which is why it is a last resort.

Before describing the actual treatment I received, let me say that there is nothing to be afraid of. Dr Mahieu and his staff were extremely efficient and kind using most impressive up-to-date facilities. I really suffered nothing that I would describe as pain – only discomfort and no hint of sickness. At this point, I should say perhape that I seem to have a fairly high pain threshold; my GRS surgery was not a problem to me and I never have injections at the dentist. Half an hour before surgery I was given a jab of morphine and atropine in my thigh to dull the senses and give a dry mouth so that I would not want to keep swallowing. Immediately prior to surgery I was given a local anaesthetic to the anterior side of my neck with xylocaine and adrenaline.

My view of what took place was most effectively hidden by a blue plastic sheet which was draped over a bar running horizontally 12″ above my face and the plastic was securely taped around my jawline. From then on I had to lie very still and could hear (but not feel) various sounds from the tools used. From time to time there were scratching, clipping and sizzling sounds and a slight smell of hot flesh as, I assume, various things were cauterised.

After about half an hour Dr Mahieu told me that my cartilage had calcified to a certain extent and that he could not push a needle through (not unexpected) and he would have to drill holes for the thread to pass through. This was done with a dentist’s type drill. The nylon thread was then inserted and initially tightened. I was asked to make an extended ee… sound whicb to my amazement was really high pitched. As Dr Mahieu released the tension my pitch dropped back down to its former level. He said that he was very satisfied and would now pull it up again and tie it off permanently. When he had finished his work he inspected it internally by pushing an endoscope up my nose and down my throat to see that no stitches were visible and that the vocal folds were as they shou1d be. Again he said that it looked fine and he would now reduce what he called “the notch” (Adam’s Apple) with a rotary burr. He then handed over to his aasistant to stitch up the incision in my throat.

The endoscopy was probably the worst part as it made me feel I was choking but it was only quite brief. I was actually on the operating table for one and three quarter hours in total and was then put to bed far a couple of hours to recover. I was brought some light lunch (somewhat late in the day at 2.30pm} and then allowed to leave by taxi for my nearby hotel.

1 was told that I must not try to speak or even whisper for two days and then return to hospital far a check-up. If all was well, which fortunately it was, I could then go home to the UK. On the day of surgery I had great difficulty in swallowing but, nevertheless, managed some soup, a hot cross bun with jam and a dish of ice cream. I slept well and next morning was able to eat a good breakfast with swallowing much improved. I kept my neck covered with a chiffon scarf to avoid frightening Joe Public with the initially rather angry looking bruising and swelling: the bruising faded quite quickly although I still have some swelling.

The stitches came out after eight days at the hands of my own GP’s nurse. It was actually one continuous thread and I was told that it had to be mobilised by pulling at alternate ends and then withdrawn in one piece. The suture came out quite easily and painlessly and the scar is neat and unobtrusive. At this time it gives every indication that it will fade very quickly and hopefully be virtually invisible.

The average male frequency range is quoted by Dr Mahieu as being approx 98 to 131 Hz and the average female range 196 to 262 Hz. Prior to surgery my rnean pitch was measured at 133 Hz which is at the top of the male range. I am writing this article only ten days after surgery while it is still fresh in my mind. It is early days yet for me to know how my voice will be at the three months checkup. For two days following surgery I communicated with masses of little notes and on the third day I tried out my new voice. That is actually too exotic a description for the croaky frog noises that I could make. It sounded like the worst case of laryngitis ever recorded. However, I had fortunately been forewarned what to expect so it came as no real shock, (at least to me!)

In the intervening few days the voice has gradually grown stronger but at this time of writing is still a miserable monotone. I was told that anything from three to twelve months is usually needed for full recovery. I am under no illusions about the surgery being a magic wand and I know that patience and further speech therapy will be needed.

2) Voice Therapy in the Case of a Transsexual

By Meryle Kalra. First published in GEMSNEWS Number 8

This paper was designed to present and evaluate a therapeutic approach to the vocal rehabilitation of a transsexual. It was presented at the International Congress on Sexology, University of Quebec, Montreal, Canada, October 27-31, 1976. The goal was to raise the voice pitch of a 27 year old morphological male who became a female.

The male voice is about one octave lower than that of the female. The average normal range of the male voice lies between 100 Hz and 132 while the habitual pitch levels in normal females reported from study samples range between 142-256 Hz.

No specific data on the incidence of transsexualism have been compiled in Canada or the USA. However, the Erickson Foundation of New York estimates that 2000 people in the US have had sexual conversion up until 1975. Gender alteration male to female is four times more frequent than female to male. Hoenig and Kenna, (1973) found the incidence in England and Wales to be 1.51 transsexuals per 100,000 population. Approximately 1 male per 40,000 population and 1 female per 154,000 population, the male to female ratio being 3.41:1

Materials and methods

The subject, BL was a normally developed physiological male whose sexual identity at age 32 was altered to become that of a female. BL, the second son of 11 children, described herself as being close to her mother, having a strict, controlling father, she remembers feeling sensitive and expressing continuously the wish and desire to become a girl. After successive experiences as a homosexual, a female impersonator and transvestite, BL decided at 29 years to seek sexual identity change and become a female. In 1969 hormone therapy was commenced while several months later sexual reassignment surgery was performed. At the time of her referral for voice therapy BL appeared feminine; however, the distinct male quality to the voice was the most likely characteristic to betray her masculinity. BL complained of being mistaken for a male over the telephone. At the time of her referral her vocal characteristics were judged subjectively to be: 1) male vocal quality; 2) poorly controlled pitch levels; 3) clavicular and shallow breathing patterns; 4) laryngeal tension; 5) absence of vocal resonance; 6) poorly controlled loudness which was associated with irregular pitch use. Without professional guidance the client had obvious difficulty in adjusting the male larynx to the functioning requirements of female larynx. At present no precise histological date describe the effects of oestrogen on the intrinsic muscle mass of the human larynx.

Therapeutic procedures

Voice therapy was administered over a three month period, once a week for approximately 45 minutes each session. Optimum pitch at this time was in the area of D sharp well below middle C at approximately 150Hz. Treatment was directed toward controlling intercostal and diaphragmatic muscle activity to reduce clavicular breathing patterns and lessening pharyngeal tension. Elevation of the optimum pitch to more appropriate and desirable pitch levels was achieved through exercises which reinforced resonance and maintained a balance between the vocal generator and supraglottal resonators. As new pitch levels were acquired, Foeschels’ chewing method was used to increase anterior oral resonance. The first pitch level above optimum pitch was F below middle C at approximately 170Hz. Gradually the fundamental frequency of the voice was moved up the musical scale to G below middle C or approximately 220Hz and the therapeutic procedures were repeated. Analysis of data collected throughout the therapeutic process consisted of both subjective and objective measures.

Results

Subjective data contained a condensed therapy log as well as laryngological examinations during and after therapy to determine whether any structural changes had occurred to the client’s vocal mechanism as a result of therapeutic procedures. Laryngological examination during the course of therapy described the normal configuration of the male larynx in size and appearance and indicated improved function of the crico-thyroid muscle two years post-therapy. No vocal strain or pathology had been induced by raising the client’s original male pitch level to within a low average female pitch range. Optimum pitch had been obtained with maximum comfort for the client’s laryngeal mechanism and integrated into the client’s spontaneous speech patterns. Objective data was demonstrated using a KAY sonograph to determine the fundamental frequency through spectrographic print-outs of voice samples using narrow band widths (45Hz) and wide band widths analysis (300HZ).

Discussion and conclusion

The goal of this study was a) to prescribe a therapeutic model for altering the vocal pitch of a male transsexual, thereby creating a vocal quality more appropriate for a female, and b) to assess the efficacy of this model. Results indicate that in the initial period of therapy the subject exceeded the provided model on imitative speech tasks. At this time excessive laryngeal tension was evident and repeatedly the clinician had to re-establish correct breathing patterns and improve supraglottal resonance through chewing practice.

In the second recording, although laryngeal tension had been reduced, the client ‘was unable to achieve a model of 193Hz introduced on imitative speech tasks. Although an increase in the habitual pitch between the first two recordings could be demonstrated, spontaneous speech deviated from the model by minus 25Hz. Carry over into imitative tasks or transfer to spontaneous speech was not occurring.

For a period of four weeks therapy concentrated on improving carryover from imitative speech work at 193Hz to spontaneous speech. Spectrographic measures for spontaneous speech in the third recording showed the client had increased her habitual pitch to a level close to the stated mode. Her speech had become more functional and stabilized in everyday use. Laryngeal tension was less apparent during spontaneous speech, demonstrating an overall increase in the complementary use of the vocal generator and oral resonator. Improvement in vocal resonance appeared to be directly connected to accentuated anterior oral resonance which best accommodated this higher vocal pitch. The therapeutic success in this case appeared to be an important and significant factor contributing greatly to the improvement of the self-image of the patient. She now perceives herself more completely as a woman, and is perceived by others as a woman, which serves to enhance her self-image and reinforce her new gender identity.

3) Feminine Voice Techniques

A collection of practical suggestions and ideas for self help in the feminisation of the voice, developed by a group of male-to-female transsexuals within the Looking Glass Society. First published in 1997 and reproduced here with thanks to the Looking Glass Society.

Neither hormones nor genital surgery will ‘un-break’ a male voice, and voice-changing surgery is widely regarded as inadvisable, in addition to being at best only a partial solution. Thus, speech training is necessary in order to produce a satisfactory ‘female’’ voice. At first, it may seem hard to concentrate on all the different facets of producing a feminine voice, and lapses will happen. The only solution is to practice and practice again until it gradually becomes second nature.

The Methods

1. Sing! To loosen-up the voice box, extend your pitch range, and help develop good control, it can be very helpful to choose a female vocalist who you like, preferably one with a relatively deep voice, and sing along. The musically-minded may also wish to perform singing exercises, such as singing scales.

2. Raise the position of the laryngeal cartilage. This raises your voice pitch and decreases the characteristic male resonance. (The laryngeal cartilage is the ‘movable’ piece of cartilage that you can feel rising if you place a hand on your throat and sing a rising scale ( doh, re, mi, fa, sol, lah, ti, doh ). The point of this is to try to gain a higher ‘baseline’ pitch than you have previously used, and then increase the pitch further when placing emphasis. For example you might decide that if you pitch the “doh” as your baseline male pitch raising your basic pitch to about “fa” or “so” would be sufficient. But do not overdo the pitch-raising: a squeaky, falsetto voice sounds very inappropriate on an adult woman. The pitch adjustment is a compromise – for the technically-minded you should aim for above 16OHz; if you have access to a musical instrument that’s about the G below middle C. Of course, everyone starts out with a different original voice and some will be able to raise it more than others without sounding squeaky. You might find it slightly tiring on your voice-box at first, as you are unused to speaking in that register, but it should become comfortable with a little practice. If it does not, then you are probably trying to force your pitch up too high.

3. Partially open the glottis when speaking. The position of the glottis controls how much air passes over the vocal cords. When breathing rather than speaking, when whispering , or when producing an ‘unvoiced’ sound where the vocal cords do not vibrate, like ‘hhh’ or ‘sss’ ), the glottis is full open and all the air bypasses the vocal cords. With the glottis firmly closed, all the air is forced over the vocal cords, producing a fully-voiced and typically male voiced sound. You need to try to find a ‘semi-whispering’ position that eliminates the fully-voiced sound with heavy resonance in the chest, and imparts a breathy quality to the voice. You can hear the difference between voiced and unvoiced sounds by comparing S and Z sounds (say ‘sss’ and ‘zzz’ , and feel how your vocal cords vibrate on the Z but not the S). You’re trying to find a midpoint between an unvoiced (whispered) sound, and a fully-voiced ‘male’ sound. Try saying the word ‘hay’, and pay attention to how you change between the unvoiced H sound and the voiced A sound: say it very slowly ( ‘hhhhhaaaay’ and feel the change in the vocal cords as your voice slides from the unvoiced hhh sound to the voiced ‘aaa’ vowel sound. Then try to stop before you reach the full voiced point, and you should be producing a soft, breathy feminine) ‘aaa’ sound. Then try to learn to always use that half-open position for all voiced sounds. This is simply a matter of practice.

4. Place emphasis with pitch not volume : Upward intonation places emphasis. Men place emphasis in their speech by varying the loudness, but keep their pitch within a very narrow range; on the other hand women tend to keep their loudness much more constant but vary their pitch a great deal to express emphasis.

5. Speak slowly, enunciate clearly especially consonants at the beginning and end of words. Don’t mumble; clear voice requires fat big lip movements. On the whole, women enunciate much more clearly and precisely than men.

6. Pace your speech carefully. Start and end sentences slowly and gently; do not sound clipped. Do not swallow pronouns, articles or other little words at the beginning or end of sentences. Male speech tends to be characterised by what speech therapists call ‘hard attack’ – the first syllable is pronounced very hard, and quickly. Women usually start a sentence more softly.

7. Use appropriate content. Men and women tend to talk about the same things in different ways; what you say contains gender cues, just as much as how you say it. Women tend to concentrate more on thoughts and feelings, while men concentrate on objects and actions. Men generally use more ‘short cuts’, colloquialisms and bad language, too. A simple illustration is to imagine someone asking a friend if they are going to go for a drink after work. A male might say something like ‘Coming down the pub?’ rather abrupt, using the minimum of words and concentrating on the desired action in a rather impersonal way. A woman might say ‘Do you feel like going for a drink tonight?’ : concentrating on her friend’s feelings and desires, personal, and not abbreviated.

8. Pay attention to tongue position. The tongue is higher and flatter for female than for male. This gives ‘dental’ sounds (ones that involve the teeth, like T and D) a softer, breathier, almost sibilant quality in the female. Say ‘tttt’ in male mode then ‘ssss’; find the halfway position, that is the female position for the letters T and D; likewise for a TH sound, etc. Use plenty of air to get a breathy sound.

9. Hold your mouth in the right shape. A slight smile helps, and is the ‘resting’ facial expression for a woman anyway. Rounder lips (a slight pout), and good lip movement, help produce a clearly enunciated voice.

10. Develop head resonance . One of the biggest problems facing TS women is, after learning to produce a soft, feminine voice, to then learn how to speak loudly when necessary without the voice returning to a masculine sound. Women gain loudness by using the cavities inside the head as a ‘sounding box’ whereas men use the chest. To gain a louder feminine voice, develop head resonance rather than chest resonance – open your mouth a little more, use more air, and ‘push’ your voice up into your head.

11. Use Feedback. Record samples of your voice and listen to yourself. Read a passage of text, listen to yourself and keep practising. It can be helpful to actually read these notes aloud, practising each point as you read it. Then listen to yourself and successfully refine your voice.This information sheet is distributed by the Gender Trust and is intended as a basis for information only. The Gender Trust does not accept responsibility for the accuracy of any information contained in this sheet.

Gender Trust – 2003, This information sheet is distributed by the Gender Trust and is intended as a basis for information only. The Gender Trust does not accept responsibility for the accuracy of any information contained in this sheet.

Transgender Theory

To understand the history of transgender people, one must also understand how both transgendered people themselves, and non-transgendered people explained the presence of such apparent misfits in the otherwise neat binary sex/gender social fabric. One can understand how law, medicine, and society in general treated transgendered people only within the context in which the transgendered person fit into a theoretic framework. If transsexuals were a medical entity, one still needs to know if it is a psychiatrically pathological entity, or a developmentally intersexed entity. If the former, one would expect that “cures” would be attempted, if the latter, then compassionate, though not always welcome, medical treatments might be applied. The law could see the transgendered person as a civil indentity question, a criminal pervert, or as a medical entity. The law’s treatment very much depends on the explanitory world view surrounding the transgendered in society.

Judeo-Christian-Moslem culture, drawing on a single verse in one old testament book, Deuteronomy 22-5, held that cross-dressing was an “abomination in the sight of the Lord”. Some biblical scholars hold that this line refers to a prohibition of the Hebrew people from participating in religious practices of the neighboring cultures, which included the followers of Cybele whose priestesses were post-operative male to female transsexuals. This single edict, surrounded by edicts that are seldom if ever followed today, save for the Ultra-Orthodox Jews, is sometimes quoted as sanctioning the worst transphobic treatment of transgendered people. Other old testament laws detail the status of “eunuchs”, males whose genitals have been surgically removed. Primarily these laws prescribe a second class status to the eunuch, since they are no longer “men”, they do not have male privileges, including the right to “testify” in court… since they no longer have the required equipment, testicles. (This is not a pun, but literally the origin of the words… one needed testicles to testify… and the old testament really does refer to the story, or testimony, of patriarchy.) Thus, built into Judeo-Christian-Moslem is the assumption that MTF transgendered people are untrustworthy abominations. This explains why Judeo-Christian-Moslem cultures have mistreated transgendered people while other cultures have either tolerated, or sometimes, venerated transgendered people, why Joan d’Arc was burned at the stake for wearing men’s vestments as well as armor, while the hijra of India have houses that have been in existence for hundreds of years.

Early in this century, as the United States population moved to the cities, transgender people, though extremely rare, started finding each other, just as they had in other city cultures in more populated countries as China and India. These gatherings of transgendered people were noted by their neighbors. These good people, educated in Christian values, complained to the civil authorities, who duly passed ordinances outlawing transgender expression, society, and existence. It was the cities who passed the laws against transgendered people. It must be noted that these laws were passed in the same climate and time that produced laws prohibiting citizens of African descent from owning property in the city limits, or of Catholics to operate schools. It should be noted that while the cities passed ordinances against transgendered people, the States were concerned with criminalizing homosexual conduct. City police, when they wanted to harrass homosexuals, used the ordinances against the transgendered as more visible targets. Thus, the Stonewall riots of 1969, naturally began with the standard sweeping arrests of transgendered people. The ordinances began to be repealed in the 1970s. It is perhaps fitting that the first governmental bodies to atone for past discrimination by passing anti-discrimination measures in the 1990s should be the very cities that once had laws designed to expose them to criminal sanction.

Laws criminalizing homosexuality were also used to incarcerate or force medical treatment on the transgendered. In the name of eugenics, homosexual and transgendered people were sterilized against their wills. Later, when hormones became available, various medical treatments were devised. Some sought to reduce the libido by suppressing natural hormones, others sought to replace putatively low hormones. These actions were done under the theory of enlightened criminologists that many lawbreakers were rehabilitable using modern medicine. It was rarely questioned in law enforcement that the law itself was in need of rehabilitation. But there were movements to do just that, lead by social reforming physicians such as Magnus Hirschfeld in Germany.

There were times, when the transgendered person came to the attention of the courts through the medical establishment, rather than the police, when compassionate justice prevailed. Until the mid to late century, the prevailing mechanism for transgendered people to gain protective legal status was to seek a change of sex status through correction of birth certificates or registry in the same manner as was done in cases of intersex, where physicians provide for a ‘second opinion’ as to a person’s sex later in life. The law literally saw transsexuals as a form of intersex and helpfully corrected sex designations when asked. It was not until the popular press created the myth of “sex change” that the law began to see transsexuals as separate from intersexed people. Only after this change in perception was it neccessary for specific statutes needed to secure a mechanism for transsexuls to change birth certificates and indentification cards. Even then it was done as an extension of the intersex theory, a reaffirmation, to counter the “sex change” paradigm.

At the turn of the century, the concepts of sexual orientation and gender identity were conflated. One was either a normal man or woman, or one was an abnormal psychosexual invert. In some respects this concept is closer to the modern concept of the classic transsexual in that it was conceptualized as a person who both identified with and shared the same sexual object as a normal member of the opposite sex. Only through education by the homophile community and open minded sexologists such as Evelyn Hooker and Alfred Kinsey was the homosexual person viewed as having a congruent gender identity, merely finding one’s own sex to be the chief object of amorous affections. This left the concept of gender identity separable from sexual attraction, opening the door to conceptualizing the catagories of the lesbian identified male to female and the gay male identified female to male transsexual. Still, it took the work of FTM transman Lou Sullivan in the late ‘70s, early ‘80s, to get the medical establishment to recognize the distinction.

There are three main currents of thought on the origin of gender identity in humans, Essentialism, Social Constructionism, and PsychoSocialism. In academic circles these differing theories are hotly debated. But in the lives of ordinary people, especially transgendered people, the model that is applied by the medical, educational, legal, and even parental authorities that transgendered people interact, as individuals and as a class, deeply influence the interaction and the outcomes.

PsychoSocial Theories

Though Sigmond Freud was from Austria originally, his work influenced North American thought to a greater degree than European. His thoughts on the developing sexual identity and sexuality of infants and children profoundly influenced how transgendered people would be viewed in North America. Freud felt that gender identity was mediated by the existance or absence of a penis, directly. In the case of the owner of a penis the discovery that not all humans have one occasions deep anxiety lest that delightful organ of pleasure might be removed. This “Castration Anxiety” led to a distancing of the owner of the penis from the caretaker who did not own one… presumably because that person might want to steal it. While simultaneously, the owner of the penis wishes to emulate the other caretaker who by good fortune still owns a penis. Thus the owner of a penis learns to be a boy. Meanwhile, the infant who does not own a penis discovers that there are individuals who do own one. This occasions extreme jealousy. This “Penis Envy” leads one to court, and compete for, the affections of the caretaker who owns this marvelous appendage, while simultaneously emulating the caretaker who does not own a penis, who demonstrates ways of successfully courting the affections of the owner of a penis. Thus the one who lacks a penis learns to be a girl.

The existance of transgendered people brought the theory a serious challenge. How to explain people who end up having the exact opposite reaction to the presence or absence of a penis? The first answer of any theorist to such a challenge is denial, “transgendered people are psychotic”, likening the transsexual to a delusional man who believes himself to be Napolean. This glib answer sufficed for those who had never actually spoken at length with transgendered people. But the diagnosis of psychosis failed to hold up apon examination. The challenge remained.

For FTM transgendered people the failure to resolve “Penis Envy” was enough explaination. But MTF trangendered people were still a mystery. The psychoanalytic theorists response was to posit a family constellation involving an overly close mother, who kept her son wrapped up in her emotional world, and a distant or absent father. The son could not make the emotional and subsequent identity break with his mother. Perhaps we can call this theory “Castration Envy”? This seemed at first glance to hold up well, since such family histories were indeed present in MTF transgendered people. Except it didn’t explain all of the cases since many profoundly transsexual MTF individuals had extremely good relationships with their fathers. The theory further broke down when comparing the statistics with non transgendered people. The were many families with an absent or emotionally distant father, the vast majority of single mothers, whose sons did not show signs of being transgendered. Though it remained popular to blame mothers, especially single mothers for all sorts of society’s woes, transgenderism was not able to hold up as being caused by family dynamics when tested statistically.

Still the psychoanalytic model held for most of the 20th Century, inspite of repeated failures of psychoanalytic therapy to dissuade transgendered people to abandon their gender identity. It is probably responsible for the prevailing attitude that Gender Identity Disorder is a psychiatric illness as defined by the American Psychiatric Association’s Diagnostic and Statistic Manual.

Toward the middle of the 20th Century, as the psychoanalytic model for all mental illness began to be cast into doubt, a new model of gender identity came into vogue, “Imprinting”. One the chief proponents of the theory was John Money, Ph.D. Observing that intersex infants with the same physical features at birth who had been assigned to different sexes both seemed to adjust equally well, Money theorized that there was a critical period in the infant’s early life when the parents’ sexually dimorphic treatment imprinted apon the child a congruent gender identity. The notion of imprinting comes from observation that some animals imprint the image of a caretaker in infancy. The popular image is that of gosslings first sight of a farmer’s child, who subsequently is followed around as “mother”. This lead to the standard procedure of early genital surgery for intersexed infants to unambiguously assign a sex, any sex, to child so that an unambiguous gender identity will be imprinted by parents and family who “know” the childs sex. It lead to a medical ethic of misinforming even the parents as to the intersexed nature of the child. It also resulted in sterilization of thousands of male children, who born with a phallus too small to be comfortably described as a penis were reassigned as female.

Transgender people were explained by the imprinting theory simularly to the psychoanalytic model, blaming the mother. Again, an overly emotionally close mother, and sometimes the father as well, coset and pamper a male child in a manner that the hapless male child gets the message that it is female. Sometimes it was noted that the feminine male child was “physically beautiful”, that is, like a pretty girl child, illiciting a response from adults in a manner that reinforces the mistaken identity as a female child. Similarly, a physically adventurous female child might illicit masculinizing responces.

Money’s hypothesis and recommendations lead directly to the tragedy and “experiment of opportunity” of John Theissen, a man who’s penis was accidentally destroyed during circumcision. Mr. Thessien was later surgically reassigned as female. His parents then proceeded to raise him as their daughter, while his identical twin brother served as “control”. When the children we several years old the clinics declared that the reassigned child was accepting “her” gender as a girl. The case became known as that of John/Joan. Money published this case as proof of his hypothesis. Unfortunately, John Theissen as a teen refused to continue the program, insisting that he was a boy… he grew to be a man, obtained phalloplasty, married, and is raising three children from his wife’s prior relationships. It can be said that his is a case of surgically created transsexuality, as his personal gender identity was at odds with his sex assignment as an infant. Mr. Theissen’s story was published in Rolling Stone magazine in the mid ‘90s after a scientic paper was published by Milton Diamond, a proponent of pre- and neonatal hormonal brain sex differentiation.

Social Constructionism:

As the Second Wave of Feminism grew in strength, critism of discrimination against women led to a reaction to prescribed restrictive societal roles for the sexes. “Biology is not destiny” became a rallying cry. What started out as a critism of socially constructed roles developed into a theory of gender which denied Essentialism in every form, stating instead that society took the biological differences of procreation, and instilled in them an artificial behavioral difference. The theory, thus expanded, denies that there is any natural basis for gender identity. Thus it denies to transgender people any rational cause… while at the same time, presenting no reason why not.

To some authors this meant that transgender people were free to express themselves in any manner they chose since all gender expression is as valid as any other. Only societal convention stands in the way of such freedom. Such conventions can be modified by the society as is deemed desirable. To some, all such restrictions are to be avoided, in a live and let live ethos.

Other authors, Janice Ramond and Germain Greer being notable examples, saw MTF transgender people as exploitive of women, aping the forms of femininity, supporting the artificial sexist forms that oppress women. It is interesting that in this regard they exhibit a hidden Essentialism, one that focusses on the genitalia as defining classes of human beings. They decried the restrictions on one class, while dispising those of the other class when they break those very restrictions.

Still the existence of transgender people poses a challenge to the social constructionist theory. One must explain both why gender identity exists, how it is perpetuated, enforced, and why some rare individuals “chose” to express a gender identity at odds with societally prescibed gender expression norms.

Performance Theory has it that we are taught to Perform Gender, to act it out, in the same way that we learn to act out social roles like teacher, student, friendly store clerk, police officer, etc. One is said to “do gender” rather than “have a gender”. This is very similar in basics to the psychosocial theory of imprinting, save that there is no instinctual basis for having the ability to absorb a particular gender identity. We are taught a set of gender behaviors that become so ingrained as habit that we forget that we are merely acting them out.

Transgender people are explained by this as having been improperly instructed. Even among those inclined toward psychosocial models as one would expect physicians to be, one finds this theory in currency. It is the model used in justifying Behavioral Modification Therapy to treat Gender Identity Disorder in children. Under the assumption that even though gender identity is arbitrarily socially constucted and taught to children, one should not allow children to express gender behavior different than the norm. Some rationize it on the basis of wanting the children to fit in, experience less rejection and bullying, a ‘blame the victim’ mentality. Others are simply moralists that insist that God has ordained that we should all behave in a certain prescribed manner.

One Post-Modern philosophical theory, one that has a striking resemblance to the psychosocial theory that transgendered people are simply crazy, has it that transgendered people are suffering under a “false consiousness”. That they are not really experiencing a gender at all… but an alienation from their social and biological reality. This theory is perhap the most transphobic of all theories in that it denies what is called in Post-Modern cant, “agency”, the characteristic of experiencing and expressing their existence and very real psychic pain.

Oppression Theory starts from the assumption that transgendered people are very much in command of their faculties and have made a rational decision to avoid societal restrictions on desires they experience. The usual script is that an ambitious woman noting that she is unable to succeed “in a man’s world”, dons mens clothes, assumes a fictious identity as a man, in order to achieve career success. These “passing women” are the darlings of the feminist historian because they are reveared as daring pioneers for women’s liberation, or they are held as examples, proof, of how horrible conditions were in some past epoch. To the feminist historian, modern FTM transsexuals are an embarrassing disproof of the theory. Similarly, Oppression theory is used to explain modern MTF transgendered people as being examples of internalized homophobia in gay men, too ashamed to live openly, and so have to “pretend” to be women in order to express their desire for same sex relations. To such gay male chauvenists, the fact that half of transgendered people identify as lesbian or gay male after transition, are an equally ebarrassing disproof of the theory.

Social Constructionist theories fail to note that ethnobiological studies of sexually dimorphic behavior in animals is not socially constructed for non-humans. Nor does it explain the cross cultural similarity and temporal stability of core gender identity throughout history around the world.

Essentialism:

Essentialism posits that men and woman are “made that way”. It is a deceptively self-evident fact that most everyone accepts since for over 99% of the population there is a clear cut correlation between genital morphology and gender identity. It is easy to for the average person to ignore the disquieting cases of intersex that cast doubt on the simplistic assumption of binary sex assignment. The question of which sex an intersex person “really is” demonstrates the esentiallist bias through much of Western Society for the past two centuries. Historically, Essentialism divided on which of two somatic characteristics was indicative of the “real sex” of an individual, genitalia or gonads. For most people the genitalia, the presence or absence of a penis was the overriding feature. As medical science grew more sophisticated in the 19th century, the gonads came to be the indicative feature. But early in the 20th Century the newly discovered chromosomes, specifically the presence or absence of the “Y” chromosome, became the newly crowned final arbiter of “real” sex. The faith in microscopic examination to “scientifically” determine one’s sex was unquestioned.

In 1968 the International Olympic Committee instituted chromosomal karyotyping for all female athletes. Any that did not have the required 46,XX chromosome karyotype were disqualified from competition, informed that, scientifically speaking, they were not women. The demonstrable fact that they had female genitalia, had lived as female all of their lives not knowing that they did not have the officially approved karyotype for women, did not enter into the unfeeling officials minds. Reductionist Essentialism had no room for intersexed people. They were counselled to fake an injury, slink away into silence to keep their shame of being “not female” from becoming known.

In 1970, the Corbet vs Corbet decision to nullify the marriage of a MTF transsexual to a non-transsexual man used karyotyping as the “scientific” marker for sex and gender that the law was henseforth to follow in the United Kingdom, throwing the legal status of transsexual and many intersexed people into limbo, neither male nor female.

Although essentialism has often been used as a philosophy to ‘prove’ that transsexuals and transgendered people do not have a valid claim to their identity, Essentialism still has explanitory power. If the locus of gender is found, not in the genitals or chromosomes, but elsewhere, transsexuals could be rationally described as “men trapped in women’s’ bodies” or “women trapped in mens’ bodies”. There are several loci that are, or have been proposed as the Essential Seat of Gender, but they come down to two main catagories, “Brain Sex”, and “The Soul”.

Many religions have a concept of an essential self, separable from the body. In Judeo-Christian-Moslem belief systems one’s soul separates from the body after death. This soul retains the sense of self, including gender indentity. Some religious thought includes the concept of the soul entering the body at some point in becoming a living being… and therefor must become, or always have been a gendered self. For religions that included the concept of reincarnation, the notion that a being always returns to the same sex body suggested an explanation for transgendered identity. Once in a while, a soul finds itself in the wrong sexed body. This idea was openly discussed in newsletters published in the ‘60s and ‘70s by the Erickson Education Foundation, as this was the personal belief of Reed Erickson, the Foundations benefactor. The Church of Latterday Saints (Mormon) debated the issue of pre-born souls finding themselves in the wrong body with Kristi Independence Kelly in 1980 at her excommunication. The Church held that, though the pre-born souls did have a gender before birth, God did not make mistakes: “There is no such thing as a man in a woman’s body or a woman in a man’s body” was declared, ex-cathedra by the leader fo the Mormon faith. Apparently, intersexed people must have also intersexed souls?

Some non-Judeo-Christian-Moslem cultures held that transgendered people were indeed gendered souls in the wrong body. Some believed that this juxtaposition have the transgendered person a special status with the spirits of nature or the powers. In ancient times in the mediteranean culture, MTF transsexual women became priestesses, Galla, of the goddess, Cebele. The Hopi Nation held that a transgendered spirit, or katchina, sent visions to transgendered people. In India, the hijra, transgendered and intersexed people are both reviled and revered, given varying circumstances. Mystical Essentialism has played an important role in various cultures, including our own.

The early 20th Century european researchers and medical practitioners believed that gender and sexual behavior in general are the result of a sexually dimorphic brain. That is to say that the brain itself has a sex. This sex usually conforms with the chromosomal and the genital sex. However, just as there can be chromosomal and genital >intersex conditions, the brain might also exhibit intersex morphology leading to behavior and that elusive personal experience, gender identity, at odds with either somatic or chromosomal sex. Magnus Hirschfeld, a leading early researcher described the entire spectrum of what today we would call Queer expression, gay, lesbian, bisexual, transgender, transsexual, as forms of “Sexual Intermediates”, or intersex. This was not a metaphor or a rationalization. Instead it was an earnest theory, based on careful observation and scientific generalization, understanding the then current lack of neurological science. Hirschfeld and his colleague, Harry Benjamin believed that as our understanding of the brain grew we would discover just where and how the brain was organized to produce sexual orientation and gender identity. For Hirschfeld, there was no major divide between non-conforming sexual orientation and gender identity, they were simply different forms that intersex could take. Thus for Hirschfeld, the late 20th century division between the concepts of gender identity and sexual orientation, the great political divide between the gay & lesbians and the transgender community would be meaningless. To Hirschfeld, we are all transgendered, gay and transsexual alike.

In the first decades of the century, experiments with cross sex gonadal implants in animals suggested that there was a connection between hormones and gender specific behavior. This lead to horrific experiments in humans during the NAZI era and beyond as hormones became available as a common pharmaceutical. Testosterone was administered to gay men and MTF transgendered people in an attempt to ‘cure’ them. The hormone treatments had no effect on the sexuality or gender identity of the experiments. No lasting harm was done to the gay men. But the supermasculinizing effects on the transgendered victims was severely traumatizing.

In the later decades of the century, neuroscientists found significant sexual dimorphism in microstructures in the brains of animals and humans. Experiments on rats indicated that hormone levels during a period in late gestation and early post-natal development to be critical to the development of these structures and subsequent behavior. Gorby was able to create what he described as a laboratory model of transsexuality in rats. He demonstrated this in both MTF and FTM cases. When he introduced them to each other, the FTM rats mounted the receptive MTF rats.

Using human children to explore gender identity and sexual orientation would be extremely unethical in the laboratory, but science often uses “experiments of opportunity”. Simon La Vey used autopsy material from straight and gay men who had died from aids to find that a small microstructure of the brain differed in the two populations, suggestive of a sexual orientation controlling microstructure. The same technique of using autopsy was performed by Swaab to discover a different structure associated with gender identity. Shaffer, in an as yet unpublished study, used MRI data from a large pool of controls, MTF and FTM transsexuals to demonstrate that the corpus collosum showed sexually dimorphic structures that, on a statistical basis, correlated with gender identity. Both Swaab’s and Shaffer’s work ruled out effects of hormones in adulthood.

The early data is tantalizing, and agrees with laboritory findings using animals. However, it is also known that experience can shape the brain. Lack of sensory stimulus and a chance to work out problems leads to dramaticly less brain development in infantile rats. In humans there is a suggestion that early musical training affects the shape of the corpus collosum, building greater connectivity between the two hemispheres of the brain. These early experiences suggest that early gender experiences could also lead to sexual dimorphism in the human brain by a similar mechanism. This would agree with Dr. Money’s imprinting hypothesis… But would be at odds with Gorby’s work with rats, and the results of the case of “John/Joan”.

Science could very well demonstrate that the seat of sexual orientation and gender identity is located in the brain. How that arises developmentally is still open for further research.

transhistory.org/history/TH_Theory.html – 2003

The Rights of Man, Woman and Transsexual

The authors are in the employment department at Bates Wells & Braithwaite. Copyright 2001 Times Newspapers Ltd. 30th January 2001

Employers are disturbingly ignorant of sex change issues, say . With 5,000 transsexuals in Britain, issues about gender reassignment are arising within the workplace with increasing regularity. Several employers have sought advice from us in the past year about the treatment of employees undergoing gender reassignment. Although few cases about transsexuals have been reported, it is clear from the output of the Equal Opportunities Commission that many cases are being brought, and often settled. But there appears to be a disturbing ignorance among employers about the legal protection of transsexuals and good equal opportunities practice.

In 1996 the European Court of Justice held, in the case of P v S and Cornwall County Council, that the dismissal of an employee because she was starting gender reassignment was unfair and contrary to the European Equal Treatment Directive. As a result, the Sex Discrimination (Gender Reassignment) Regulations 1999 were brought into force. They amended the Sex Discrimination Act 1975 to extend protection in employment and vocational training to anyone who ‘intends to undergo, is undergoing or has undergone gender reassignment’.

Gender reassignment is defined as ‘a process undertaken under medical supervision for the purpose of reassigning a person_s sex by changing physiological or other characteristics of sex and includes any part of such a process’. There is no definition of ‘intends’ within the regulations but clearly more than cross-dressing is envisaged (although individual freedom of expression by way of dress is now to some extent protected by the Human Rights Act 1998). The category of individuals protected is wide, with no differentiation between pre and post-operative transsexuals.

Less favourable treatment of a transsexual is permissible in limited circumstances: where the job requires performance of intimate physical searches or doing work or living in a private home where objection may reasonably be taken by the individual to this degree of intimacy and contact. These genuine occupational qualifications are applicable at all stages of the gender reassignment process.

There are two further exceptional circumstances: where it is necessary for the employee to live in shared accommodation, or where personal services are being provided to vulnerable individuals ‘and in the reasonable view of the employer those services cannot be effectively provided by a person whilst that person is undergoing gender reassignment’. However, these two genuine occupational qualifications do not apply to individuals who have undergone gender reassignment.

There is thus, evidently, potential for difficulty with, for example, a care worker who has completed the process of changing but by whom an elderly client does not wish to be cared because the client is aware of the transsexuality. A refusal to provide work would amount to discrimination. Employers and prospective employers should bear in mind that tribunals are able to draw the inference of discrimination from the very fact of less favourable treatment.

It is often practical issues that cause difficulties at work. In particular, there is the question of which lavatory a transsexual should use. The answer is straightforward: whichever he or she prefers to use. If this preference causes embarrassment among staff, the employer must attempt to inculcate a more enlightened attitude. A last resort may be to agree with the transsexual that a lavatory be designated as unisex (this should preferably not be the same as the disabled facility).

This course of action was approved by an employment tribunal in the 1999 case of Bourne v Roberts & the Post Office. Equally, employers are often concerned about when other employees should be informed about a change of gender. All that is required is agreement on a timescale and to be flexible. Again, it should be borne in mind that the legislation encompasses the whole process from the stage of intention onwards. Personnel records should be updated at an appropriate point, and any references to previous gender removed (save if required for specific and legitimate purposes, such as insurance or pension records). It is an anomaly at present that transsexuals are unable to alter their birth certificates to reflect a change in sex.

The regulations do not address the question of discrimination in areas other than employment, such as education and access to goods, facilities and services. However, it is recognised that domestic legislation is inadequate and is likely to be expanded. Last May a case brought by a transsexual, Lisa Jones, against a landlord who asked her to stay away from his pub in Honley, near Huddersfield, settled for £1,000 compensation plus a £600 contribution towards costs. We can expect more such cases in future.

By Lucy McLynn and William Garnett

Gender Trust – 2003, This information sheet is distributed by the Gender Trust and is intended as a basis for information only. The Gender Trust does not accept responsibility for the accuracy of any information contained in this sheet.

Frequently Asked Questions about Transsexuality

Most of us are perfectly comfortable with the fact that we are male or female. In fact we normally never give it a thought. But there are a very few people who feel they were born with the wrong body – men who feel they should have been born women and vice versa. These people suffer from a recognised medical condition known as gender dysphoria and are generally referred to as transsexual.

Because transsexual people are born with bodies that seem perfectly normal to other people, we may suspect that the source of these deep seated feelings about the body arises from the brain. A report from the Netherlands Institute for Brain Research confirms this theory. In examining the brains of many individuals, including homosexual men, heterosexual men and women and six male-to-female transsexuals, they found that a tiny region known as the central region of the bed nucleus of the stria terininalis (BSTc), which is believed to be responsible for gender identity, was larger in men than in women. The BSTc of the six transsexuals was as small as that of women, thus the brains of the transsexuals seem to coincide with their conviction that they are women.

The rate of occurrence of transsexuality is not accurately known. Because of the social stigma attached to being transsexual, arising from a widespread lack of awareness of the true nature of the condition, it is something that is often kept hidden. Therefore it is only possible to collect statistics on the numbers of declared transsexuals and such figures undoubtedly represent only a proportion of those affected. Not very long ago estimates of the rate of occurrence of male-to-female transsexuality might have been around 1 in 100,000 of the male population. Today, with the greater awareness and openness that exists, some estimates now put the figure at greater than 1 in 10,000. It is known that other chromosomal or intersexed conditions can have rates of occurrence of, or approaching, 1 in 1,000 of the population and it may well be that this is the true order of magnitude of transsexuality.

Rates of occurrence of known female-to-male transsexuals are significantly lower, typically being around 1/3 to 1/4 of the rate for male-to-female transsexuals. However, this rate has varied somewhat with time and between different parts of the world. This suggests that varying cultural factors might play a role in the decision to be open about the condition.

The currently accepted and effective model of treatment for the condition of transsexuality utilises hormone therapy and surgical reconstruction and may include counselling and other psychotherapeutic approaches. Speech therapy and facial surgery may be appropriate for some male to females, and most will need electrolysis to remove beard growth and other body hair. In all cases, the length and kind of treatment provided will depend on the individual needs of the patient. The male to female will take a course of female hormones (oestrogen) similar to those used in the contraceptive pill and HRT, the female to male will take the male hormone testosterone.

At this time they will also be required to carry out the Real Life Test, during which they will be required to legally change their name and all documents to show their new gender identity. All documents including passport, driving licence, medical card, etc can be changed, but at present it is not possible for UK citizens to change their birth certificate. During the Real Life Test they will also be expected to live, work and socialise full time in the new gender role, to deal with any problems which may arise for example at work or within the family, and generally become familiar with the reality of living this way. After a minimum of a year (two years if being treated via the NHS) if the Real Life Test has been successful and the psychiatrist is satisfied with the person’s progress, they can be referred for surgery. After surgery the person will continue to take hormones for the rest of their life, but probably at a reduced dosage.

Because the BSTc is so small none of the non-invasive imaging techniques currently available can measure it, it cannot be detected through scans, X-rays of blood tests. Diagnosis is carried out through lengthy and in-depth assessment by a specialist consultant psychiatrist, however it is important to understand that gender dysphoria is not a psychiatric condition, nor is it a mental disorder.

In a male to female transsexual person, the effects of feminising hormones vary greatly from patient to patient but most patients experience noticeable changes within 2-3 months, with irreversible effects after as little as 6 months.

The main effects of feminising hormones are as follows:

1) Fertility and ‘male’ sex drive drop rapidly, erections become infrequent or unobtainable and this may become permanent after a few months.

2) Breasts develop, the nipples expand and the areolae darken to some extent, but typical final breast size is usually somewhat smaller than that of close female relatives.

3) Body and facial fat is redistributed. The face becomes more typically feminine, with fuller cheeks and less angularity. In the longer term, fat tends to migrate away from the waist and be re-deposited at the hips and buttocks, giving a more feminine figure.

4) Body hair growth often reduces and body hair may lighten in both texture and colour. There is seldom any major effect on facial hair, although if the patient is undergoing electrolysis, hormone treatment does noticeably reduce the strength and amount of re-growth. Scalp hair often improves in texture and thickness, and male pattern baldness generally stops progressing.

5) Many people report sensory and emotional changes: heightened senses of touch and smell are common, along with generally feeling more ’emotional’. Mood swings are common for a while following commencement of hormone therapy or any change in the regime.

In the female to male transsexual, where biological females are prescribed androgens, changes include:

1) A permanent deepening of the voice, this usually occurs within four months and is irreversible.

2) Permanent clitoral enlargement occurs.

3) Some breast atrophy, but at this stage it is usual to bind the breasts.

4) There is cessation of menstruation within three to six months

5) Increased strength and weight gain particularly around the waist and upper body with decreased hip fat. With exercise this can take the form of muscular development. Testosterone will not alter height or bone structure.

6) Growth of facial and body hair is likely to follow the pattern of hair growth inherent in the family, for example if other male members of the patient’s family have a tendency to baldness or if they do not have a great deal of body hair this is what can be expected with hormone treatment.

7) Increased social and sexual interest and arousability may occur and there may also be heightened feelings of aggression.

The most frequent form of surgery for male to female patients is known as penile inversion. When carried out by a skilled and experienced gender surgeon the results look almost indistinguishable from the external genitals of a natal woman. The transsexual women, however, does not have ovaries and a womb, is not able to conceive and does not have monthly periods. During the operation tissue and skin from the penis and scrotum is relocated to form a vagina and clitoris. Following surgery the patient will need to keep the newly formed vagina from closing up by performing regular dilation.

In the female to male, surgery is often carried out in stages, and the first stage is usually removal of the breasts with a bilateral mastectomy during which the nipples are preserved but may need to be reduced in size. The next stage is usually hysterectomy and oophorectomy to remove uterus and ovaries. Both these stages are commonly performed operations and can be carried out by any competent surgeon who does not necessarily need experience of gender reassignment surgery. Further stages are more specialised and involve metaidoioplasty for construction of a microphallus by surgically releasing the enlarged clitoris, or possibly phalloplasty which is construction of a penis. There are various techniques in use for phalloplasty, but as yet there is no method which can produce a totally realistic and fully functioning penis. Scrotoplasty may be carried out at the same time, or separately, to create a scrotum from the labia and silicone implants.

There is no evidence of any genetic link to the condition of gender dysphoria and therefore it is not something that is known to be passed down through generations of the same family. Nobody knows exactly what causes the condition, although there are various theories that consider a possible link between hormone disturbance in the mother during the first weeks of pregnancy or other interruptions to the normal course of pregnancy while the foetus is at a critical point of development.Is this Person a Man or a Woman?

In this example let us look at the male to female transsexual person. Gender dysphoria occurs when the person believes themselves to be a woman, their brain knows them to be a woman, even though their physical body may be that of a man. The only ‘cure’ for gender dysphoria is to change the body to match the brain. Therefore after surgery both brain and body are those of a woman. This person is in all respects a woman, even her passport will show this. It is therefore extremely painful for such a person to be addressed as ‘him’ or ‘Mr’. Having gone through so much to find a sense of inner peace in their true gender role, they should rightly expect to be treated as the woman they know themselves to be.

Even after hormone treatment and surgery, a transsexual male to female, may still retain certain male physical characteristics. These may include a voice that is unusually deep for a woman, or they may be very tall, or have large, hands and feet and heavy bones, particularly in the jaw and brow area of the face. They may have a receding hairline and need to wear a wig. When you meet this person for the first time you may feel shocked, uncomfortable or uncertain how to treat them. Hopefully you will understand that this is a medical condition for which the person is receiving treatment from highly qualified doctors and consultants, that they have been carefully assessed and diagnosed, and in many cases their treatment has been carried out under the National Health Service. If you think of it in this way you will find it easier to accept that this is a genuine and serious situation. If you are willing to accept this person for who they are, you will be helping them to adjust to a very difficult life challenge, and you may find you are making a very good and loyal friend.

What is the Difference Between Transvestite and Transsexual?

The differences are very distinct between a person who cross dresses and someone whose brain is telling them they belong to the opposite gender role. The transvestite may just cross dress occasionally, or may enjoy dressing regularly either in the privacy of their own home or to socialise. Some live full time in female clothes, but they always retain their core identity of themselves as male and will not want to consider gender surgery. Generally TVs who are “out” are sociable and may attract a lot of attention, they may enjoy wearing outrageous or fetish outfits and spend a lot of time involved with their clothes and appearance. It has often been observed that TVs tend to be heterosexual males while drag queens and female impersonators are often gay men. Although transsexual people are often very concerned about their dress and appearance, this is not the driving force behind their cross dressing. For the transsexual person clothes are an expression of their core female identity and many strive to blend in by studying how women of their age and background dress and learning how to tailor their appearance and mannerisms to attract as little attention as possible.

The above is a general guideline, but this is far from being a black and white issue and most cross dressers would place themselves somewhere on a gradient between the outrageous female impersonator at one extreme and the totally integrated post operative transsexual at the other. Many people who later go on to complete full gender reassignment begin the search for their true identity within the transvestite community, perhaps this is the only obvious and safe place where they feel they can cross dress. Also there are very few social groups where transsexual people meet, so those who enjoy socialising may be attracted to transvestite clubs. Many individuals feel very confused about their true gender identity, so how can an outsider be expected to judge whether a person is TV or TS when that person themselves does not know – or cannot accept – where their true identity lies and is therefore not giving out any clear signals about themself.

Long before they begin medical treatment, in fact often long before they even realise what is happening within them, most transsexual people will already show signs of thinking and behaving in ways more usual to the sex opposite to that of their physical appearance. They will frequently recall knowing from childhood that they were in some way “different” and it is usual for a transsexual woman to remember dressing in the clothes of a mother or sister, having a dislike for traditional boys’ toys and games, and feeling more comfortable in the company of girls.

Because of social pressures, particularly on young men, many transsexual people enter a period of denial in their late teens, in which they try to suppress any thoughts or feelings to do with their gender identity. For example it is common for a male to female to take up a typically male profession such as the armed forces, police, engineering, lorry driving, and also to marry and have children. They tell themselves that this proves they cannot possibly be a woman. At this time of their life they may also absorb themselves totally in a career – often becoming very successful – or in some form of sport or hobby which occupies all their spare time. Some may continue to cross dress.

But in time the stress begins to build until the person no longer feels able to keep this thing hidden and they need to seek help and medical treatment. When the gender dysphoria has been suppressed in this way for many years, the person may have developed other problems such as severe depression or a dependence on alcohol or drugs, and this will also need to be dealt with, along with any commitments to family responsibilities. There may be a break with wife, children and siblings, a change of career, loss of home, money and security, so the road to gender transition is an extremely difficult and often painful one.

Transsexual people often reveal themselves to be extremely isolated individuals, some people never make it through transition. Those who do have to find a lot of inner strength and determination to keep going. During transition these people need the support and understanding of friends and family as well as work colleagues and society in general. After surgery it is common for many people to melt away into society, living a normal life and often nobody guesses what they have been through. However the scars created by the pain of living with gender dysphoria for many years may remain and make it difficult for them to settle into an ordinary lifestyle.

Transsexual people are just ordinary people who experience all the challenges and problems that everyone has to deal with. Some are optimistic and cheerful, some slip easily into depression, some are determined, some are fragile, some make friends easily, some find socialising difficult. They are people like everyone else – they also suffer from a condition called gender dysphoria.

Understand what is happening, and accept the person for who they truly are – this is often all a transsexual person wants from you. Try to offer encouragement and support. Imagine how you would feel if it was you – take a moment to try and imagine how you would feel if you woke up tomorrow morning to find your body had become the opposite gender.

After all it could easily have been you who was born with this medical condition, nobody knows exactly what causes it but the dysphoria is believed to occur in an unborn baby during the first three months of the mother’s pregnancy. Someone who has already been through so much does not need to be victimised and taunted, humorous remarks, clever comments and other subtle ways of intimidation can cause intense pain. Also remember it is now against the law to discriminate against someone because they are transsexual.

Gender Trust – 2003

Female to Male Breast Reconstruction

The great challenge in reconstructing a male- appearing chest from a female breast is the management of the overlying breast skin. There is always a “skin excess” when the underlying glandular and fatty breast tissue is surgically removed. One goal in gender reassignment surgery is to manage this skin excess with a minimal amount of scarring. Excess skin can easily be cut away but every incision in surgery leaves a scar — the challenge for the surgeon is to remove this excees skin and to “hide” the incisions in natural folds, previous scars, or in the pigmented skin of the nipple-areolar complex.

The most critical factor in determining the appropriate procedure for each patient is the breast size. A very large breast (C-cup or larger) always requires a more extensive incision or series of incisions. Obviously, the larger the breast size, the more overlying skin there will be left to manage after the underlying breast tissue is removed. My preference for the large breast is to place an incision in a horizontal direction with a gentle curve that follows the curve and lower border of the pectoralis muscle. This scar, although it is long, can heal very nicely and can be “hidden” in the fold that is created by the well-developed pectoralis muscle. With a long incision, there is no problem removing the skin that is in excess after the breast tissue is removed and this procedure can be performed in one stage with only a small percentage of patients requiring any surgical revisions. Chest hair growth is also very beneficial in helping to conceal the scarring. With this procedure, I often will completely remove the nipple areolar complex, decrease it to the appropriate size, and replace the nipples in their new elevated and more lateral position as skin grafts. Liposuction also is an integral part of any breast reconstruction surgery to help create a smooth contour and transition from the breast to the surrounding chest wall.

The B-cup breast size has always created controversy for the plastic surgeon. A patient could be evaluated by 10 different surgeons and receive 10 different opinions on how the procedure should be performed and where the incisions should be placed. Common incisions used are: 1) the inverted “T”, 2) a horizontal incision on either side of the nipple, 3) a vertical incision under the nipple which curves outward near the fold of the pre-existing breast, and 4) the peri-areolar incision.

My preferred incision for the B-cup breast and smaller is the periareolar incision. The average male nipple-areolar complex (NAC) size is about the size of a dime or slightly larger. The average female NAC size is about the size of a half dollar, but it will be much larger in larger breasts. An incision is always made around the entire border of the NAC to reduce the size. This incision is called a periareolar incision. Because this incision is placed at the junction where the normal skin joins the pigmented or colored skin of the NAC, this incision can “hide” nicely and can appear to be the border of the pigmented skin. The excess skin is removed in a circular fashion around the NAC. The challenge is then to close the large skin circle to the dime-sized new NAC. The discrepancy in size of the outer skin circle to the inner circle (NAC) creates a very pleated skin closure — much like a drawstring purse. With normal healing, all skin will contract and tighten. We are relying on the skin contraction properties (which are different in each patient) to tighten the skin and to reduce the appearance of the pleating. Almost every patient will require a minor surgical revision to manage persistent pleating after the first stage procedure. If bothersome pleating exists after the revision, then the patient and surgeon must decide on creating another scar and in which direction. Often this additional scar or scars will be short and well-accepted by the patient because residual pleating rarely extends for more than an inch from the border of the NAC. Obviously, if the scar can be limited to the periareolar incision, this is the most desirable situation as there would be no obvious scarring that the patient might have to “explain” to someone when the chest was exposed.

In summary, the goals of female to male breast reconstruction surgery are to remove the glandular and fatty breast tissue with a smooth transition to the surrounding chest wall, to decrease the NAC size, and to perform the surgery with acceptable and minimal scarring.

Originally published in 1998 True Spirit Conference book.

Gender Reassignment Surgery: Female to Male Breast Reconstruction

By Beverly A. Fischer, M.D, 2002, amboyz.org

Female to Male: Sex Reassignment Surgery

This is one of the more controversial aspects of the transgender (TG) experience. There are many transgender folk who choose not to have any surgery, some who pick and choose which surgeries they want, and some who feel they have no choice but to go through all of them. There are also the moral pressures to consider from internal and external sources. Average cost ranges are as follows:

Chest…………………..$2100 – $7500

Hysterectomy………….$10,500 – $18,000

Metoidioplasty…………$8,000v- $15,000

Phalloplasty……………$15,000 – 150,000

Please keep in mind that these costs vary from doctor-to-doctor as well as from country-to country.

Most of the surgeries listed above can only be acquired by paying the surgeon cash up front. The cost is one of the weightiest factors as to whether a person decides to have the surgery or not. Many FTMs are under-employed, if not unemployed. Those who do seek surgical alteration often work 2 and 3 jobs to save the money needed. Some of the younger FTMs work the streets just for survival money, although a few have used this as a means to supplement other earnings for surgeries. A few FTMs have been able to acquire some or all of their surgeries through insurance. This is very rare since most insurance companies explicitly exclude transsexual treatments from their covered procedures.

When to have any of the surgeries is also an issue for many FTMs. The Harry Benjamin Standards of Care (SOC) clearly delineates when a transsexual can do certain things pertinent to their transition. Many transsexuals who only choose to do one or two of the surgeries circumvent the SOC. However, this can mean seeking doctors through the black market. The other concern for many FTMs is the condition of the body before and after taking hormones. There have been several FTMs who have sought and received different surgeries before taking hormones. Reasons for this will be disclosed in the following paragraphs.

The double mastectomy and/or mastopexy is the procedure most commonly sought by FTMs. The biggest reasons for this are image/presentation and comfort. Transsexuals are asked to dress and live in the world as a person of the gender they are trying to achieve for a set amount of time&emdash;usually six months to one year before they are allowed to pursue hormone therapy or any of the surgeries. The biggest obstacle for an female to male is usually hiding the breasts. However, this is absolutely necessary. Far too many FTMs have been humiliated, harassed, and even beaten up for walking into the men’s room because their chests gave them away. This harassment is not exclusive to the bathroom situation. Mainstream society is notorious for its violence toward anyone presenting a conflicting image, period. Many FTMs choose to have this surgery before they pursue hormones for several reasons. With testosterone comes body hair. The chest hair that grows in around the sutures and incisions can, at the very least, be incredibly annoying, and in the extreme can become ingrown and even cause infection. Many FTMs also look to the advantage of estrogen keeping the skin more pliant as a bonus. Several individuals have gone through the mastopexy, waited 6 to 9 months to heal, and then begun testosterone therapy. It seems that most of these individuals have less visible scarring or less extensive scarring. The muscle growth into the chest with the testosterone seems to them more natural as well.

A couple of advantages to testosterone are that the healing rate (from surgery) appears to be quicker, and with the advanced muscle development, there is less chance of severed or damaged muscle.

Some of the older FTMs have had the advantage of having an hysterectomy before they’ve sought hormone therapy. Many FTMs feel there is an advantage to this as there will be less of a strain on the liver once testosterone therapy is initiated. Some symptoms of chemical/hormonal imbalance (such as migraines) often disappear after the FTM has his hysterectomy. One advantage of hysterectomy is the possibility of either reducing the dosage of testosterone or extending the time period between injections, thus possibly reducing the strain on the liver. Those who do undergo this surgery are sometimes advised to then take small doses of estrogen. Many refuse because of the implications of femaleness. Many people do not understand that estrogen is present in the male body as well. Testosterone is also used to alleviate osteoporosis, though, and estrogen may not be necessary. People should also be aware that excess testosterone in the system is naturally converted into estrogen.

There are many who choose not to undergo an hysterectomy and suffer no ill-effects, although there does seem to be a greater degree of difficulty dealing with the last few days before the next injection, known as the trough. In the 3 to 4 days before the next injection, many FTMs (with female reproductive organs still functioning) report irritability, shortness of attention span, headaches, fatigue, lack of sex drive, and sometimes cramping similar to menstrual cramping. Some FTMs who experience extremes of these symptoms then pursue hysterectomy, or opt for an oophorectomy.

In recent years, more and more FTMs are choosing the metaoidioplasty (also inaccurately referred to as genitoplasty, and often contracted to metoidioplasty). One reason is money. It is less expensive, and therefore easier to set one’s sights on as an attainable goal. Metaoidioplasty is the freeing of the enlarged clitoris (micro penis) and construction of a scrotal sack with testicular implants. The patient can opt for several choices. A urethral extension can be constructed so that the FTM can pee from his freed penis. This choice carries the risk of infections, fistulas, and corrective surgeries for complications. A hysterectomy and / or vaginectomy can be performed simultaneously. If the vaginal canal is left intact, this gives the FTM better options if he chooses to pursue a phalloplasty in the future.

The phalloplasty is usually a series of surgeries, not just one. The surgeries are still brutal and leave extensive scars on several places of the body&emdash;usually the inside of one forearm, the lower side of the torso, and the side of one thigh. Although these surgeries have been improved upon in the past ten years, there are still major drawbacks that deter many FTMs. The amount of time spent in recovery from the surgeries is extensive. Some FTMs have spent nearly one year in recovery stages from the surgeries, dealing with infections, getting corrective surgeries, and sometimes having to deal with their body’s out-and-out rejection of the graft. The emotional toll of this surgery can be incredibly high. The surgically constructed penis is also non-functional sexually. It does not get erect or flaccid on its own. Most constructions utilize Teflon inserts to achieve erections. A few surgeons use pumps similar to those used for penile reconstruction in genetic males suffering from cancer or erectile dysfunction. There is a chance of rejection with this option. The constructed penis frequently does not look like a penis. In recent years, some doctors have been fine-tuning their surgical techniques and have also teamed up with tattoo artists for better aesthetic results.

Notes on Gender Transition

Revised September, 1997

FTM 101 — The Invisible Transsexuals

By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor

Female to Male Transgender: General Health Care

There are many reasons why FTMs will be reluctant to seek out medical attention or even preventative health care. Many older FTMs have assimilated even without hormones or surgery. Their greatest fear is discovery. Sometimes even their own partners and families don’t have a clue about their situation, and if they do, they are just as frightened of discovery. Mainstream society has not been very kind to anyone who is perceived as different. An even greater deterrent for many FTMs is the very treatment they receive once in a doctor’s office or in hospital. Far too many of us have stories of being treated like the latest circus attraction, or of being outed to the entire waiting room. Perhaps the greatest fear for many of us is being involved in an accident and being “discovered” on the scene or in the emergency room. The person fears being unconscious or so severely injured that he cannot defend himself while outrageous remarks are tossed about, jokes are cracked, epithets are shouted, treatment is interrupted or stopped. All of these things have happened and continue to happen to transsexuals every day. If it hasn’t already happened to us, it has happened to a friend, and we know that it could happen to us.

Since most insurance companies have explicitly written us out of their policies, most of us find it difficult to seek health care through those avenues, even if they are available to us. There have been many transsexuals who have been denied even simple health care because doctors and insurers can claim that the condition would not exist if we were not pursuing transition. Unless we can find sympathetic health care workers, we are often at the mercy of the big money machine insurance companies.

For the FTM specifically, dealing with the female reproductive organs can be a nightmare. Most of us do not have regular pap smears. The procedure is invasive. And again, finding a gynecologist who is sympathetic is difficult. Most FTMs will not seek out a gynecologist unless they are already experiencing symptoms of a problem. Most gynecologists, when it comes to female reproductive organs, have one goal–that of the continuation of the human race. When a male person with female reproductive organs comes into the office, most gynecologists see the organs and their possibilities, not the person. There are FTMs who have been dealing with severe symptoms of endometriosis or other health problems, and their gynecologists will not remove the organs at the patients request because the gynecologist sees the possibility of saving the organs. The FTM could be in severe, constant pain, not want the organs in the first place, have no intention of ever having children, even be past childbearing years, and the physician will override the patient’s wishes just to save the reproductive organs. Never mind the physical, mental, and psychological strain this puts on the patient. Never mind that it is the patient’s body.

Although many FTMs perform their own breast exams, most do not. They will rarely go to a physician if they find anything unless they already have a doctor who is aware of their situation. If surgery is recommended, many will not follow through because of probable exposure in the operating room. This is often true of hysterectomies as well. FTMs who choose to have one of the lower surgeries can get the hysterectomy at that time. If the FTM has opted to not undergo alteration surgery, chances are he is not getting any kind of medical attention for any health concerns.

Diet is an on-going concern. Many of the FTMs who are seeking some or all of the surgeries are working several jobs just to earn the needed money. There is little time for proper eating and sleeping. Those on the streets have an even greater difficulty meeting even the minimum dietary needs. Usually their main focus is on taking the steps they deem necessary for their transition. It is very important to point out to them that their health is one of the steps of their transition. If they do not have their basic health, they will not be able to maintain the work schedule they’ve set for themselves, they will not heal well from surgery or may even compromise their health to the point that they won’t be able to have surgery, and that they may achieve the goals they’ve set for themselves and then not have the health to enjoy their new life to the fullest.

Notes on Gender Transition

Revised September, 1997

FTM 101 — The Invisible Transsexuals

By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor

Female to Male Transgender: Mental Health

Mental health is tightly intertwined with general health. Most FTMs tend to isolate. Not only do they deny themselves contact with society at large, they tend to isolate from each other. Even though this has slowly been changing in urban areas within the past five years, it tends to be the rule of thumb. Many FTMs who meet at meetings are happy to share the physical changes they experience. They are very private about emotional and psychological changes. The struggle against gender stereotypes is more pronounced for FTMs; or the majority of FTMs are simply more aware of gender stereotypes. This often creates a barrier between FTMs and MTFs, creating an even greater sense of isolation&emdash;an isolation from those who might be best equipped to understand or help us.

It is quite often difficult for any transsexual to feel confident about themselves or even feel good about who they are when so many people in their lives (and society as a whole) have regarded them as deceivers, evil, worthless, liars, mentally ill, psychologically unfit, ad nauseum. We are required to seek psychological treatment just for verification of our circumstances. We are told how we are to act, whom we are allowed to love what our sexuality may or may not be, what clothes to wear. Many of us have been taught to lie about who we truly are by the very people who are supposed to be helping us learn to accept who we are. It has only been within the last ten years that some therapists and psychologists have become guides to our process and let us come up with the answers to who we are. Needless to say, the trust level transsexuals have for therapy and mental health professionals is very low. Most sympathetic counselors understand that they will have to do a great deal of coaxing and laying down of a foundation for trust with most transgender folk just to draw them out.

The constant threat of being “outed,” harassed, beaten/ and most profoundly, the threat of being killed is an everyday concern that wears on transgender people. People in the mainstream feel that Brandon Teena “got what he deserved, because he deceived” the people in the town where he was murdered. Sean O’Neil received the same general response from his neighbors: people felt he deserved to face the charges brought against him for deceiving those around him. Some of those charges were valid. However, the majority of them were not. (Ask us for more information about these people’s cases, if you are interested.)

If the person is “out” about their transition, or has even transitioned on the job or in a small town, the risks are even greater. The emotional and psychological toll of these threats is tremendous. There is the added threat in many areas of being locked up and committed to any number of treatments, including shock treatment. These kind of mental pressures make every transgender person susceptible to mental illness of one form or another at any given point in their lives. This does not mean that we are mentally ill or incapable all of our lives. Because this is usually the perception that we encounter, our frustration level is only compounded. The suicide rate for transgender folk is very high. Substance abuse, eating and sleeping disorders, abuse as children, and domestic violence have only recently been being viewed as symptoms of the social pressures that transgender people are under as opposed to being a part of our so-called illness. Not only do we need more help around these issues, we need more education and compassion.

As more and more transgendered people come together and share their experiences with each other as well as the rest of the world, the primary emotion that arises is anger. It is usually the first barrier that must be dealt with by mental health professionals. Because of that anger, transsexuals can be marked as socially unfit. Western medicine’s approach to classifying the symptom and not dealing with the root problem(s) is constantly used as a weapon against transgender folk. Until transgendered people are given space to feel safe, that will continue to be true. It is not just the transgendered folk who need help or have a problem; it is society as a whole.

Notes on Gender Transition

Revised September, 1997

FTM 101 — The Invisible Transsexuals

By: Shadow Morton, Yosenio Lewis, Aaron Hans–James Green, Editor