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Notes on Gender Role Transition

By Anne Vitale Ph.D.

Frequently Asked Questions

Contact Dr. Vitale

Last Update, March 17, 2018

This site averages over 1000 readers a day. Even though I don't solicit questions, I get at least two or three request for more information about certain aspects of gender identity each week. Some questions come from other therapist needing advice on working with a gender dysphoric patient, some come from newspaper reporters working on stories but most come from individuals who are either dealing with the issue within themselves or a friend or family member of someone who has recently come out to them and are trying to gain a better understanding of the situation. I try to answer each question as best I can. Given the universal nature of gender issues, I thought I would share some representative questions and my response.
Abbreviations and frequently used terms key:
  • SRS--Sex Reassignment Surgery or GRS--Gender Reassignment Surgery as it is referred to in the SOC version 7
  • HRT--Hormone Replacement Therapy
  • FTM or FtM--Female-to-Male
  • MTF or MtF--Male-to-Female
  • DSM III--Diagnostic and Statistical Manual of Mental Disorders Third Edition
  • DSM IV--Diagnostic and Statistical Manual of Mental Disorders Fourth Edition
  • DSM 5--Diagnostic and Statistical Manual of Mental Disorders Fifth Edition
  • GID Gender Identity Disorder--DSM IV diagnosis for gender issues. No longer used.
  • GD Gender Dysphoria - Current DSM 5 diagnosis for gender issues.
  • WPATH --World Professional Association for Transgendered Health formerly known as HBIGDA, Harry Benjamin International Gender Dysphoria Association/
  • SOCv7--Standards of Care Version 7.
  • CD--Cross-dresser or crossdresser
  • TS-- Transsexual
  • TG--Transgender
  • Trans-- An emerging short hand term used to refer to a class of people who are living with the reality of not being cisgendered.
  • Transman or transwoman-- a natural extension of someone refering to themselves as being trans. Usually used by post transitioned individuals living in their new gender role. It is also meant to differentiate themselves from cis men or cis women,
  • SSRI--Selective Serotonin Reuptake anti-depressant
  • GEDAD--Gender Expression Deprivation Anxiety Disorder

Category 1.--Terms and Definitions

Category 2. Mental illness? Life style choice? Is it genetic? What are we actually dealing with here?

Category 3. Crossdressing vs Transsexualism

Category 4. General questions regarding gender role transition

Category 5. What are the treatment options for transsexuals?

Category 6. Questions regarding hormones.

Category 7. Questions regarding surgery

Category 8. What are the social implications of gender role transition?

Category 9. Questions from friends and family of TG people

Category 10. Questions from other therapist


1a. What is the differences between Sex and Gender?

Historically, the words sex and gender have been used interchangeably in the English language. However, in recent times as the phenomenology of transgenderism reaches beyond a medical issue and gains more traction as a social issue as well, it is becoming increasingly clear that sex and gender are two distinct aspects of being human. Here, I will attempt to expand on the current thinking about sex vs gender. One's sex is a physiological term being used to connate the shape and function of one's genitalia. Typically each of us is assigned as male or female at birth

This is done immediately based on visual examination alone. With the exception of children born with ambiguous genitalia, (intersexuals) it is usually a straight forward determination. One's sex then becomes both a prescription for how the child should be raised as well as a core marker for future identity purposes.

Gender on the other hand is a brain centered identification marker determined by the number of androgen/estrogen receptors in the brain. These receptors and their ability to accept hormones produced by the body, ultimately becomes responsible for influencing behavior that is either masculine, feminine or androgynous. We are now certain that one's sense of gender identity is apparently fixed and unchangeable.

1b. What causes gender roles?

Gender roles are highly influenced by physical limitations and cultural needs. They are also influenced by personal interest. This latter element, personal interest is, in turn, highly influenced by hormones. Although both males and females produce testosterone and estrogen, men whose testes are working properly, have 10 to 20 times more testosterone in their systems than women do. When you combine that with having a correspondingly larger number of androgen receptors in their brain, the individual is going to need to express all of that in what we consider masculine behavior. In addition to the brain responding to all that testosterone, muscle mass, both sexual and physical energy levels are also effected in a more robust way. Keep in mind, however, testosterone can also have a negative effect on a willingness to cooperate with one's peers, a dulling of sensitivity, the blunting of emotional lability and lack of interest in nurturing.

Women on the other hand, have very limited amounts of testosterone. What little they have is produced primarily by their adrenals, which aid them in maintaining muscle tone and sexual desire. What women lack in androgens, they more then make up for in estrogen produced primarily by the ovaries. Estrogen however, makes an entirely different contribution to the female anatomy by rounding it and giving it the typical female shape and soft look. Along with physical changes, estrogen feeds the female receptors in the brain. The receptors in the brain regulate the complex female reproduction system, expands the individual's emotional range, develops tactile and emotional sensitivity, and encourages reproductive desires.

1c, If you believe society causes gender roles then why do you think [so]?

Society may describe and encourage gender roles but it does not cause them. Both I and a host of evolutionary psychologists think that over the centuries both men and women have simply worked out a set of gender roles that tends to work best for both of them. Although that is and has always been in flux, men will always tend to express themselves in a masculine way because they are testosterone-driven, Women will always tend to express themselves in a feminine manner because they are estrogen-driven. Again, however, that behavior will be highly influenced by the ratio of androgen to estrogen receptors in the brain and the bodies ability to provide the correct hormone in sufficient amounts.

1d. If gender roles have a biological explanation, then please explain deviations from the "norm" or "stereotyped" gender roles.

We all start out female at conception. For a male embryo to develop, several other elements beside just having a Y chromosome from the father need to come together at the right time to defeminize the embryo. This is a complicated process that I do not have time to get into here. Roughly, the genitals develop early in the process, then early in the second trimester, if the child is chromosomally male and the testes have developed properly, a surge of androgens is supposed to masculinize the brain. It is entirely possible for that process to get crossed up leaving some genetic males with partial to full feminized brains and some genetic females with partially to fully masculinized brains.

1e. What are the masculine gender roles? What are the feminine gender roles?

We see masculine and feminine gender roles played out around us daily. Gender roles are about male or female expression. One expresses either masculine or feminine behaviors in the way they talk, walk and relate to those around them.

1f. What is the differences between Sexual Identity and Gender Identity?

The primary difference is that sexual identity refers to how an individual relates sexually to others while gender identity refers to how an individual relates to their gendered self. Terms such as asexual, heterosexual, homosexual and bisexual are terms relating to sexual identity. Gender Identity--as it is defined in the Diagnostic and Statistical Manual of Mental Disorder III (DSM III), "is the sense of knowing to which sex one belongs, that is, the awareness that 'I am male' or 'I am female'. Gender identity is the private experience of gender role and gender role is the public expression of gender identity. Gender role can be defined as everything that one says and does, including sexual arousal, to indicate to others or to oneself the degree to which one is male or female."

1g.What does cisgender mean relative to transgender?

Cisgender is a combination of the prefix "Cis" and gender. Cis means "on this side of something" and "trans" means the other side of something. When both Cis and Trans are used in association with gender identity we come up with cisgender or people having a gender identity and body development that are closely in line with each other. Cisgendered people feel comfortable with that alignment. Transgender folks on the other hand experience a mis-alignment with their gender identity and body configuration. Hence the extreme desire to correct the situation

1h. Why do you use the term Gender Role Transition rather than Sex Change?

Gender roles are highly influenced by physical limitations and cultural needs. They are also influenced by personal interest. This latter element, personal interest is, highly influenced by sex hormones. Although both males and females produce testosterone and estrogen, men whose testes are working properly, have 10 to 20 times more testosterone in their systems than women do. When you combine that with having a correspondingly larger number of androgen receptors in their brain, the individual is going to need to express all of that in what we generally recognize as masculine behavior. In addition to the brain responding to all that testosterone, muscle mass, both sexual and physical energy levels are also effected in a more robust way. Keep in mind, however, testosterone can also have a negative effect on a willingness to cooperate with one's peers, a dulling of sensitivity, the blunting of emotional lability and lack of interest in nurturing.

Women on the other hand, have very limited amounts of testosterone. What little they have is produced primarily by their adrenals, which aid them in maintaining muscle tone and sexual desire. What women lack in androgens, they more then make up for in estrogen produced primarily by the ovaries. Estrogen, makes an entirely different contribution to the female anatomy by rounding it and giving it the typical female shape and soft look. Along with physical changes, estrogen feeds the female receptors in the brain. The receptors in the brain regulates the complex female reproduction cycle, expands the individuals emotional range, develops tactile and emotional sensitivity, and encourages reproductive desires.

1i. What is the difference between Gender Dysphoria and Gender Identity Disorder?

Actually there is no clinical difference. It is the same phenomenon. Gender Identity Disorder was the official diagnosis given to gender dysphoric patients per the DSM IV. With the publication of DSM 5 in 2014, the official diagnosis was softened to Gender Dysphoria. Dysphoria can be defined as a state of unease or generalized dissatisfaction with life. In this case, it has to do with a deep or even morbid dissatisfaction over being assigned a gender role opposite of what the individual experiences internally. The term Gender Identity Disorder (GID) first appeared in the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM, 1994). It replaced the term "Transsexualism" from a previous version. The diagnosis was changed in DSM 5 to more accurately describe the phenomenon.

1j. What is the difference between Intersexuality and GD? Do these individuals identify with both genders, or the opposite gender, or does it vary?

As you probably suspect, there is some overlap between GD and intersexuality. However, the term intersexuality generally is reserved for those individuals who are born with genital malformations caused by XX/XY chromosomal irregularities . It has long been standard practice (a practice now being seriously questioned) to assign these children as either male or female depending on how easily it would be to surgically modify the genitals into looking "normal". It is has only recently been shown to be an unreliable indicator as to how these individuals understand their sense of being male or female when they get old enough to say something about it. (see Intersex Society of North America) So in a way some intersexuals experience GD. The term GD is usually used to refer to individuals whose genitalia appear normal at birth--assigned accordingly--but go on to experience extreme discomfort with their assigned sex as their life progresses.

1k. What is the difference between someone who identifies as "transgender" and someone who identifies as "transsexual"?

The term "transgender" was coined by Dr. Virginia Prince in the mid 1970's to differentiate those individuals who wanted to live in the opposite gender role without surgery from those trans individuals who believed that they needed SRS to feel whole. Those individuals who wish or have had sex reassignment surgery were then and still are referred to as transsexuals. However, over the years the term "Transgender" has been modified through popular usage to be an umbrella term covering individuals who have some propensity to spend at least some time expressing themselves in the gender role opposite of that to which they have been assigned.

1l). Is the term "transsexual" politically correct, why or why not? And when did this change take place?

Although this may not be a universal response, I have noticed that the term "transsexual" is not only found acceptable it is the preferred term to be used in referring to individuals who use hormonal and surgical means to permanently alter their appearance to match their internal sense of gender. Most transsexuals are very binary in their thinking and feel that taking transition to its full hormonal and surgical extreme differentiates them from the more watered down term "transgender".


2a. Is Transgenderism a choice?

I am basing my answer to this question on my experience with over 600 gender variant patients who have come to see me over the last 31 years. All too often, on presentation, many of these people are scared, deeply depressed and at the limits of their ability to face life each day. It is not uncommon for these individuals to be having their marriages and careers falling apart....and being suicidal. All of this coming from lawyers, scientists, dentists, physicians, school teachers, professors, artists, musicians, and other highly educated and otherwise productive people. Being deprived of one's true gender expression can be fatal. If there is any choice involved here, it is between facing the reality of being gender variant and all that is involved in regaining a life, or denying it and suffer an interminably unresolved existence. Fortunately, help is available and the regimen practiced by most gender specialists has returned virtually all of these people back to productive and happy lives.

2b. Is Gender Dysphoria a form of mental illness?

Although gender dysphoria is listed in the DSM 5, most mental health practitioners do not consider crossdressing, being genderqueer, transsexualism or Trans in general to be a mental illness per se. However, due to the discrimination and prejudice these individuals face, many do suffer from mental health issues secondary to their GD. Some of the most common are clinically significant levels of depression, anxiety, depersonalization and substance abuse/dependence.

2c. Is gender dysphoria genetic?

There is no known cause for gender dysphoria. However, we are sure it is not genetic. That is, a parent cannot pass it on to their children through their genes. It may, however, be congenital--a form of birth defect. For a more complete description as to the possible causes of GD please check out HBIGDA Talk Bologna, Italy 2005

2d. I saw a portion of TV show last night about people with a disorder. I think they called it "body image dysmorphic disorder." It looked as if it could be similar in some ways to GD, and it made me wonder if there is any psychiatric treatment available for GD.

I saw a few minutes of that show as well. What they were talking about is Body Dysmorphic Disorder. As you intimated, these individuals obsess over the shape of specific parts of their body. It has nothing to do with gender vs body shape. People with BDD would never feel relief by crossdressing or taking hormones. Another thing, above and beyond particulars, these individuals usually obsess over a wide range of issues to a greater or lesser extent.

2e. Are there many levels of gender variance or is it just something that you have or don't have?

Gender Identity varies from having an unquestionable sense of being male to an equally unquestionable sense of being female. In fact this is the definition of being Cisgendered. Because gender identity is hormonally set by the genetalia of the developing baby, most people emerge at birth with sex and gender identity aligned. However, pre-natal hormone availability is subject to extraneous influences, creating a gender identity continuum with some people falling somewhere between the poles of the male/female binary. It is only when a person's location on the continuum crosses over the line into the other side from which they were assigned at birth, do we have the beginnings of clinical gender dysphoria. The further their feelings are from their birth assigned sex, the more intense the dysphoria, and the more likely he or she will only find relief by taking cross-sex hormones.

2f. Regarding, The Gender Variant Phenomenon, specifically what you refer to as Group 3. Besides the obvious path recommended by your paper, can you please refer me to any other known or suspected cure for the level of anxiety being experienced by these individuals?

There is no known "cure" for any of the people I refer to in the book, no matter what group I have placed them in, because there is no disease involved. The gender variant condition is a permanent state of existence. Individuals born gender variant, die gender variant. The only way to relieve the anxiety that a gender variant individual may be experiencing, is to accept their reality and make an adjustment to it. That can range from a simple acknowledgment to complete gender role transition. Fortunately we have the psychological know how, along with the hormonal and medical technology to help these individuals live full and productive lives.

2g. My 40 year old married son told us yesterday that he is transgender. He has two children ages 4 and 3. He has hidden it all these years. He says he can no longer hide it. He tells me that he is taking estrogen. I don't understand why medicine and therapy cannot help. We take medicine for all kinds of things after all. If he can take estrogen to make him more of a woman, why wouldn't the testosterone make him more of a man?

Thank you for your question. I can't speak directly about your son but I can address your question regarding hormones.

It may seem counter-intuitive but it is testosterone in some genetic males that inflames gender dysphoria. We know for a fact (something we learned over 50 years ago) that giving a gender dysphoric male testosterone makes the GD worse whereas administering estrogen--which lowers the level of testosteron--has a dramatic effect on making the dysphoria go away. The issue one may have with that is that it also feminizes the individual. Most gender dysphoric males are very comfortable with the side effect.

Another fact you should keep in mind is that your son probably had a normal level of fixed testosterone in his body prior to taking estrogen. That would not be unusual. Keep in mind that the average male body can only accommodate so much testosterone (about 1000 ng/dl) before the aromatization process kicks in and turns all excess testosterone into estrogen. That is another reason for not giving your son more testosterone.

Given that hormones are so involved with GD, indicates that the problem is not psychological and not subject to talk therapy. Some gender dysphoric males can keep the problem hidden for decades but it is not much of a life and it seems to get worse as one gets older. There seems to be no natural remission date. We often see men in their 60s and 70s and older who suffered their entire lifes with GD to accommodate others. People who do not treat it, die with it.

There is a medication that helps. For GD males it is estrogen. It might help if you think of it that way.

CATEGORY 3. Crossdressing vs Transsexualism

3a. What is difference between a male cross-dresser and a man wanting to be a woman?

I have never met a genetic male who has gone on to transition to the female gender role that did not have at least one or two experiences crossdressing with many doing it daily. However, it does not mean that every genetic male that cross dresses will go on to transition. Keep in mind that cross dressing is a temporary way for a genetic male to experience what feels llike femaleness. For some genetic males that short period of experiencing the feminine complements their sense of being male. Some crossdressers may make some minor modifications to their body to enhance their feminine appearance when dressed such as beard and body hair removal but they have no difficulty holding on to their core sense of being male.

Genetic males who eventually go on to transition permanently to the female gender role (transsexuals) on the other hand, cross dress to ease gender expression deprivation. Dressing is serious business for these individuals. It is only during these cross dressing periods that they can find a sense of wholeness. Unlike the cross dresser described above, transsexuals have little or no love for their alienated sense of masculinity and they are more than willing to give up its influence on their lives via taking cross-sex hormones and major surgery.

3b. I am 37, married for 4 years. My wife is a great person, very loving, supportive and very open minded. Our relationship has gone to heck, mainly because I want to tell her I enjoy a more feminine lifestyle. However, I have no desire to transition, I simply enjoy the attributes of being more feminine. I have been this way for years, since I was about 12 and will not change. I feel far more comfortable in a female, mental state than trying to be masculine.

I have been quiet about my situation. However, it's either tell her and take a chance or not and probably end my marriage? Any advice you offer is greatly appreciated.

As you noted, you have been crossdressing since the age of 12. That in all likelihood means that it will continue indefinitely into your married life...stringing both of you out further and further in the lie by omission. Sooner or later this sort of thing comes out anyway so the sooner you tell her the better. I suggest that, despite the risk, that you pick a good time and let her know in as gentle a way as possible. That is far better then being caught in a crossdressing misadventure that would be very difficult to explain. That might indeed end your marriage. See suggestions on How to Tell Your Spouse by Julie Freeman, the wife of a crossdresser.

3c. I am in the most beautiful relationship I have ever been in. I feel cared for, happy and excited to see my man at the end of the day. Our physical relationship started out slow and heated up fast. I love him, so it makes it that much more exciting. We have been together for over a year now. We are both in our 50's. He told me about his desire to wear women's clothing about four months into the relationship. We never discussed it again, but whenever he is "missing", or late, I suspect he is off doing his crossdressing thing. I am afraid to bring up the subject, but know I really should. He is my best friend and lover and I don't want to lose him. I guess I am asking your advice on how to approach him, because I need to be honest in this relationship. Can a man have a happy "marriage" and a secret life?

I am glad to hear that you are experiencing a wonderful relationship. Ultimately that is what is important here. You are right about your partner not being able to stop dressing. Almost everyone who has ever tried to stop, has found themselves back at it again in one way or another. Having said that, it does appear that he has found an outlet for his needs and since it is only cross dressing (there are far worse clandestine activities men can get into) that can only be healthy.

If your partner is as wonderful as you say he is, my guess is that his "secret life" is far less strange and weird as you might imagine it to be. There are cross dressing organizations all over the world. Most of the folks are just like your partner, responsible, caring and compassionate. They too have partners, wives and families. Getting together for these men is often no more then dinner out at a safe place or a quiet time to spend with friends who are just being "girls" together at someone's home or a cross-dressing boutique.

I suggest that you broach the subject in as non-accusatorial manner as possible with him....more or less just expressing your curiosity. He probably has some idea that you are uncomfortable with his cross dressing and that may be the reason he doesn't share more than he needs to about it and where he goes.


4a). I just turned 50. I have been gender dysphoric all my life. Is it too late for me to consider transitioning?

No, it is not too late to seek treatment. In my practice, clients who are 50+ are very common. In fact because of their maturity, they tend to be very good candidates for transition. I would not let your age be a limiting factor if indeed you are interested in transitioning.

4b). What do you recommend to an individual who believes they have gender dysphoria?

It all depends on where I am asked that question. If it is via e-mail over the internet I ask them where they live and then try to find someone to refer them to that is qualified to help. If the person is in my office I take the individual seriously and start my standard therapeutic procedure.

4c). How often are individuals who believe they are gender dysphoric incorrect in what they feel?

In my practice that has rarely happened. In fact I can only recall twice in the last 24 years where someone has come in and said they were gender dysphoric only to realize after several therapy sessions that they were not. Gender dysphoric feelings are very clear and unless the person has some other psychological or characterlogical problems they usually know what they are talking about.

4d). What are the best support systems for individuals with gender dysphoria?

Other gender dysphoric people. The most common support structures these days is the internet. It is almost always where gender dysphoric people find that they are not alone in their feelings. In my practice I have the advantage of being able to provide in-person therapy and support groups. Groups are very helpful in establishing long standing friendships that can be very helpful for all parties.

4e). Of those men who fully transition via SRS, what are their success-rate statistics? I enjoy the writings of those who suddenly feel fulfilled, knowing deep in their core that they did the right thing for themselves. And yet, there must be "false positives," those who thought they knew what they were doing, but then found disappointment on the other side and remained generally unhappy about themselves. It would be informative, I think, to hear their thoughts on themselves.

Yes...there are some "false positive" post-op individuals out there in the world. Fortunately they are rare. Actually extremely rare. There have been many outcome studies done over the last 30 years. Here is a paragraph from a paper I wrote that was published in Gender and Psychoanalysis entitled Implications of Being Gender Dysphoric: A Developmental Review.

Treatment: Although there is still some disagreement as to how gender dysphoria begins and who should qualify for hormonal and surgical intervention, there is a remarkable amount of agreement in several important areas. Most psychologists now agree that gender dysphoria qualifies as a subject of clinical attention separate from other disorders. Further, most clinicians agree that the gender identity beliefs these people hold are profound, deep seated, and non-delusional. Even more significantly, outcome studies now clearly indicate that when three conditions are met: a proper differential diagnosis, a significantly long trial period of living in the gender of choice, and a satisfactory surgical result, there is only a small incidence of postoperative regret. Indeed, in a review of the outcome literature Pfafflin (1992) reports that less than 1% of the female-to-male transsexuals who had undergone sex reassignment had any regrets. For male-to-female transsexuals the number was slightly higher at less than 2%. Later studies supporting Pfafflin's report include Bodlund O. et al., (1996); Cohen-Kettenis P.T (1997); Exner, K. et al., (1995); Rakic, Z. et al., (1996), and Smith Y. L. et al., (2001). It should be noted that satisfaction is measured by self report of improvement in the individual's psychosocial well being.

4f). Can you tell me if there is a link between sexual abuse in a male between the ages of 8 and 10 and gender identity disorder? Could sexual abuse cause this disorder and if so can you direct me to some articles that deal with just that sort of circumstance?

Although we are uncertain as to what may cause gender dysphoria, I can say for certain that there is no reason to believe that sexual abuse at any age is responsible. I have worked with over 600 gender dysphoric individuals over the last 31 years and only a handful reported being abused as a child. In those cases the gender dysphoria the individuals experienced predated the abuse. Furthermore I have never read reports of sexual abuse being a determining factor. Recent evidence shows that the most probable cause is a congenital abnormality.

4g) I recently met a man who told me that he was a male lesbian. What does that mean? Is this a case of gender identity disorder? Are there any references to male lesbianism in the literature?

When a man uses this phrase, it generally means that he is attracted to women but not in a male way. For him the accent would be more on what other men would refer to as foreplay. Penetration of his partner may not be his main objective when having sex with a woman.

Gender Dysphoria has more to do with gender role preference in life in general than it does with choice of sexual partners or how the individual makes love. GD may be present but such a diagnosis would require much more information than what you have presented me with.

I'm sorry but I don't know of any references to male lesbianism in the professional literature.

4h). Is it possible that if I had GD from early childhood (6-8 years) could it, in your opinion, with the help of psychological counseling (instigated by anxious parents) have gone into remission and resurfaced at a later date say early or late puberty?

I can't say with any certainty if gender issues can go into "remission" in early childhood and re-emerge in puberty, but it is well known that social pressures to conform to expected gender presentation can be very effective at submerging the issue, especially in children. I have worked with a lot of people who report similar circumstances. Every case is different and you will have to work that out for yourself with the help of a therapist before you can go on with transition. Given your psychological bent, I'm sure you already know this.

4i). Is transsexuality possible for a person whose sexual organs appear to be 'normal' from the biological point of view? If yes, how and why?

It is very common for transsexuals to have normal appearing genitalia. The problem for transsexuals is that despite their normal appearing genitalia, they have a strong internal sense of being a different gender than their genitalia show them to be. How that can happen is still being looked into. It probably has something to do with the fact that gender identity forms in the brain at a different time than the genitalia do in the body. Hormonal surges at the wrong time could very easily disrupt the normal progression of sex/gender identity development.

4j). I have viewed your website and I have mixed feelings about what I should believe. I read your essay in which it talked about the mother's tumors causing this disease, my mother suffered from cancer during pregnancy. I'm 16 and I'm not sure about my sex. I have always been happy being male during childhood and I want to sincerely remain male but I am just very worried that my sex is messed up due to the fact that I constantly have scary thoughts that I might become female.

First of all I never said that gender identity issues are a result of a mother having a tumor while she is pregnant. I did say that it is beginning to look like gender issues begin in utero and one possible cause may be stress to the mother at a critical time of the child's gestation. Your fears are unfounded. If you are happy being male than that is the way it will always be. There are many men who exhibit feminine mannerisms and behaviors but have no interest in being female. It is just the way some men are. Males who transition to the female gender role do so only after great consideration and great difficulty. It will not happen to you if you do not actively take part in the process. However, if you continue to obsess over this issue, I suggest that you get your parents to take you to a gender specialist. If you give me the name of your city and the names of several others you are willing to travel to, I will try to find a therapist near by.

4k). Is Male-To-Female gender identity mostly about appearance (if the person already identifies as female)?

This is an interesting question and the ansewer is, No. The administration of cross-sex hormones has a profound effect on the indifidual's brain. As you must be aware, there is more to being female than appearance and identifying as one. There is also gender expression. Gender expression includes important areas such as how one feels inside (Is it a feminine feeling or a masculine one?). Gender expression dictates how one dresses, moves and talks. And probably most importantly, gender expression has a big influence on how we are perceived in the world and how we relate to others in turn.

4L). What factors do you think are responsible for more young Americans coming out as transgender? Is it due to the availability of more resources?

First of all there is more information regarding gender issues out there. The internet has made it possible for young people to not only do research on their condition, they can contact others like themselves and compare notes. Twenty years ago a young person would have found it almost impossible to get any information. It would have required a trip to a medical school library to get far less information than they can now get in their own bedroom. The internet has also made it possible to easily ask someone like me for a referral for medical care in their community. I give out at least three referrals a week to people all over the country. The names come from the Harry Benjamin International Gender Dysphoria Association's (HBIGDA) directory.

4m). Is there a median age when certain individuals realize they identify with the opposite or both genders?

Most people who go on to transition become aware there is a problem somewhere between the ages of 4 and 7. When they decide to ask for help with their problem is another issue entirely. In the past there has been a strong tendency for people with gender issues, especially males, to chose to hold off to the last minute to seek help. By holding off, these individuals go to great lengths to try and override their gender dysphoria by investing more and more energy and time into activities that they hope will make their need to be female 'go away.' This often includes dangerous military duty, getting married and having children and macho jobs. When none of that works, and there is no clinical evidence that it ever will, they are commonly now in their forties or early fifties. More recently, with the advent of the internet, more and more gender dysphoric individuals are aware of the fact that gender identity issues are not socially based and nothing they will ever do short of treatment will resolve the issue.

Gender dysphoric females are much more direct on how they face their issues. They often voluntarily start living their lives in the male gender role in childhood. The advent of the internet has also affected their age of presentation. They are coming in younger and younger now. The current median age of my FTM clients is about 35.

4n). Which are the best resources for transgender individuals?

For now the Internet will work. However, readers need to be careful that they select qualified sites to read. I suggest that they start by going to the WPATH ( site to use their directory service to find a gender specialist near you. Another great source for parents who are concerned about a child that they believe is gender variant is "The Transgender Child" by Stephanie Brill and Rachel Pepper. It is available at The Transgender Child website.

4o) Do most transgender individuals have reassignment sex surgery?

I can't answer this question directly. Keep in mind that the term transgender is an umbrella term that covers a large range of gender issues including transsexualism. Only transsexuals ever go on to have surgery. My guess is that most transgendered individuals never seek professional help so that would automatically preclude them having surgery.

4p). Do most transgender individuals dress as the opposite sex? least some of the time. Transsexuals who go on to live in the opposite gender role, eventually do so full time.

4q). What is your experience with college-level transgender individuals? Are most comfortable in their own skin?

Today's college age, gender dysphoric youth are much more aware of what they are dealing with. Some of them find ways to express their gender identity issues openly and seem much more healthy than their counter parts who are trying to live what they think is a "normal" life. If, however, the dysphoria is deep seated, there is only so much they can do to feel comfortable. Medical intervention is usually the only answer for them.

4r). Is there a diagnostic test, for example, genetic testing, that will let one know if they are gay, lesbian, transsexual or heterosexual?

No. there is no genetic test that can be administered to tell anyone what their sexuality is. That can only be done by honest self examination. Transsexualism, which has nothing to do with sexual preference, is different. We can't do a genetic test, but we can administer cross-sex hormones and see if the individual responds positively or negatively to them. That procedure is routinely done after the individual has had an extensive period of psychotherapy and is fully aware of the consequences. A negative reaction would result in extreme anxiety and discomfort. A positive reaction is one where the individual reports a calming affect. Often described as a feeling of well-being.

4s). How long does it take, if at all, to determine a reaction from hormones?

There is ALWAYS a reaction to taking cross sex exogenous hormones. If the individual has a history of gender dysphoria or as I would prefer to call it, Gender Expression Deprivation Anxiety, the primary reaction is a relaxing one. That is the individual experiences feelings of well-being as the anxiety is relieved. If a non gender dysphoric person is exposed to cross sex, exogenous hormones, the opposite occurs; a state of anxiety is induced that goes away once the hormones are no longer being taken. The time period for all of this to occur is very short, ranging from hours to no more than a few days.

The other, more physical changes take longer and are not easily reversible. If a genetic male takes estrogens, he will start to notice tenderness in his nipples in a matter of weeks as the first signs of breast development. The rest of the feminization will gradually happen over the rest of the period he continues to take the hormones. Depending on the person's age and level of male development at the start of the process, it usually takes six to twelve months before the changes are so advanced that friends and acquaintances would notice and may start to inquiry about your appearance. Of course, a spouse or lover would notice much sooner.

In genetic females that take androgens, the physical changes are far more profound and happen very quickly. Menses stop within the first or second scheduled periods and there will be a strong and profound increase in libido. Within the first few months beard growth, body hair and voice changes begin to be obvious to the casual observer. FTMs often speak of experiencing general body pain as male pattern muscles start to develop.

4t). I am a TV/CD with feelings of being TS. I recently learned that I have minor Obsessive Compulsive Disorder (OCD) tendencies. Is there a connection with being OCD and being TS? If so will medicines to help being OCD at least reduce my TS feelings?

Although in the past I have worked with one or two individuals who had clinically severe OCD along with TS feelings, the conditions are not generally associated with each other. I know that it may seem that your need to crossdress is a bit compulsive and perhaps you obsesses over wanting to be the opposite sex, but that is not really the same as obsessing over everyday factors such as germs on your hands or if you shut off the stove 20 times a day. Whatever the level of OCD, medication (usually an SSRI antidepressant) has not been shown to have any appreciable effect on reducing TS feelings.

4u). I am 53 years old an am struggling to come to terms with being a transsexual. I was reading a web site that said you had written an article about confronting one's gender issues "before it is too late". I looked for it on your web site but couldn't find it. Could you direct me to it, please?

I am not at all certain as to what essay the author of the web site was referring to. Although I think I know what the author means, I would never advise anyone to transition "before it is too late". First of all I have never advised anyone to transition. That is a decision only the individual can make. If a client of mine decides to transition then I am there to help him or her through it. I can, however, tell you that the median age of my current client load of MTFs is about 48. As you might expect, the problems a 48 year old MTF has far exceeds those of someone younger who has not had the time to become so heavily invested (family and career obligations) in being male.

Other than that, if I recall correctly, there is a section in the following essay of mine that deals with mid-life issues. Check it out.

4v). One question for my wife. She would like to know --after we read your entire site - if antidepressants could help make a TS happy enough to not care whether they are TS, or need to transition. Basically it's become a life or death issue for me. I know I can't continue living like I am. Its taking it's toll on my mental well-being. I know we are grasping at straws, and I'm sure we are not the first to ask this, but is getting on zoloft, welbutrin, or any other antidepressant a viable option? Has it been tried? Does it work?

Your question regarding antidepressants (SSRIs) is very common. Antidepressants-- usually prescribed by a primary care physician these days-- is usually the first thing most males try before they come into see me or any other gender specialist. No doubt SSRIs have some mitigating effect on mood but they are, at best, a Band-Aid. Since depression in gender dysphoric males is secondary to their gender issue, the underlying problem continues to persist. We know that to be true because estrogen (which is something of an antidepressant itself), even in moderate doses, routinely resolves both the dysphoria and the depression while SSRIs alone do not. I know this answer leads to further concerns but that is an issue that needs to be addressed in person between you and a therapist. I hope this has led to some clarification.

4w). I have read your web site and the FAQ. There is much to consider and understand. I think that I have some form of GID. Sometimes I want to be a woman, and sometimes I really love being a man. I often tell people that if I had a choice between male and female I would choose neutral, the qualities of both sexes. Why can't I be both? Or maybe, how can I be both? Is this like trying to have your cake and eat it too?

Millions of people live their lives somewhere other than at the extremes of the male/female binary. This includes people you pass on the street each day. Legally you have to choose one or the other-- male or female-- but privately, where it really counts, just do what comes naturally. It is a little discussed fact but because cross sex hormones effect the brain so drastically, it is exactly the state everyone who transitions will come to find themselves in. They may look like the gender they had aspired to--and that is very satisfying-- but in reality they have become a being who is now both male and female, free to express as much of each side as they like. In effect they do indeed have their cake and eat it to (at least as far as gender expression goes).

4x). Could you enlighten me as to what would be an acceptable solution to my lifelong dilemma. I am a female and definitely heterosexual, I tried the lesbian thing and although I think women are beautiful, I have no interest in them sexually. I have been all my life distinctively male in my interests and behavior. I have no interest in female clothing or activities and feel very uncomfortable when I force myself. It just doesn't feel like me. I am not aggressive like many males, although I am somewhat dominating. At best when I am engaged in a male-like activity, such as doing construction work, the guys forget I'm a female and treat me as one of them. I have never had a successful long-term relationship (I'm 48). I am uncomfortable every day and have no idea how to resolve my dysphoria or to have a successful relationship.

Most of my gender dysphoric female clients seem to be a bit more certain than you about having a male inner sense of self. As a result they come to see me with more of an intent to transition than to sort things out. Your situation seems more like the gender dysphoric males I see in that they do want to try and sort things out first. Transition seems to be way in the back of their minds even for those that do go on to transition. A good gender specialist should be able to help you fit all the pieces together and find your place in the gender spectrum. With that knowledge you can decide what to do next. If you tell me where you live and the names of a couple of other cities you are willing to travel to, I will try to find someone to refer you to.

4y) How can I safely transition around my parents when I know they disapprove of transsexual or transgendered persons. I am moving out of state soon to live my life far from home so I want to hide this as much as possible. Do you have other advice for me on this topic?

The only way to transition around parents is by telling them what you are up to up front. If you decide to move away from them, unless you do not want to see them again, you still have to tell them. Hopefully you can get them to understand that transsexualism happens and being disapproving of it, in my opinion, constitutes irresponsible parenting. If you are working with a therapist--and that is always a good idea-- she or he can help provide educational material for them and perhaps personally intercede for you.

4Z). Is transsexualism rampant in this time/generation?

The short answer is NO. I doubt if there are any more gender dysphoric people today than there ever were. Especially if we assume that the cause of the disorder is congenital. The big difference now is that it can be successfully treated and more and more people world wide have access to the helpful information over the internet.

4aa). Is there a particular age when someone realizes that he/she is a transsexual?

There are two important times in a transsexual's life. The first is when he or she realizes that he or she is gender dysphoric and admits to him or herself that he or she wishes they were the born the other sex. That can happen anytime in childhood but usually around the age of 6 or 7. The second is when the individual realizes that the dysphoria is not going to go away and that the anxiety over the issue has become problematic for them in their daily life. About then, the individual should be familiar with the phenomenon and know of it as transsexualism. The second situation can happen anywhere from their early teen years to mid adulthood.

4bb). Are genetic or native males more prone to transsexualism than genetic females?

We don't have any specific data on whether gender dysphoria occurs more often in genetic male or genetic females. Western society allows females to express masculine behavior in dress to a degree that is not allowed for men relative to their need to express an innate sense of femininity. That difference may account for the fact that more males present not only more often but in greater distress than genetic females. However, I would venture a guess based on those gender dysphoric females I have worked with and how they reflect upon their lives and relationships that gender dysphoria occurs at about the same rate for both men and women.

4cc. Do most people with Gender Identity Disorder have a deep-seated feeling of being inferior to the sex that they long to be? (i.e. not just being the wrong gender, but also feeling rejected by them?)

This is a far more complicated issue than I have time to address right now. However, I will say this. I don't think so. In fact I know for certain that most people who transition come to understand their situation better than the either/or comparisons you are suggesting. It doesn't take long for a post-op person to understand that although they now look and act very much like the gender they aspired to all their life, to realize that in fact that is as close to being absolutely male or female they will ever get. That does not, however, mean that they are inferior in any way. It is simply a different state of existence and has it's own virtues. People who transition are notorious for fitting back into society quite comfortably without notice. Rejection, unless one makes a special point of declaring one's transsexual status is rarely if ever an issue.

4dd). I don't want to sound lengthy, but I have a few questions. I am sixteen, but I have already come to the conclusion after about three-four years of feeling that way. A few problems I have is that I keep second guessing myself and that my mother found out once and said that I was making it all up. Also I really don't act like a girl though I feel that I am one. I have heard of people creating masks for their male exterior in this type of situation and that may be it. Do many people have these questions and doubts and if I have them then does that mean that I am not a girl and that I have evaluated my person incorrectly? I am just distressed and want help. I have been driven to the point of almost suicide in regards to this question though i have been talked out of it repeatedly with such success that I realize that it is an ignorant thing to do. I do a lot of research on this and I have come to the conclusion that as soon as I get to college I am going to seriously consider transitioning (even though I will be broke and it is highly costly). I am at the point to which I will pay any price to become who I am, but I am terrified. Not of the changes themselves I even want to go as far as SRS seeing that looking at my penis is something that weighs down my soul, I even gone as far as to already pick out my name when it came to me and I realized that my name was Katrina (this was before hurricane Katrina so I am not basing it off of that), but of how others will react. I don't want to lose my family or friends and that terrifies me. I guess I am rambling on purely for the sake of trying to get someone to listen (though I have talked to my school psychologist many times), but not to be rude, but he is not as well versed in transsexuality as you are and it gets hard talking to him about it. I just want simple advice on what I should do and if you recommend getting over my fears and going through transition as soon as possible or if I should wait on the issue. Things get confusing and I would like advice.

With the exception of your age, your situation is very common among gender dysphoric males when they first come into see me. No matter how badly they need to be female, everyone is frightened of loosing family and friends if they were to transition. Resolving all of that is a major part of what working with a good gender therapist is all about. If you tell me what part of the country you live in, I will try to find a therapist to recommend to you. Perhaps you can get your family to take you to see him or her. In the meantime take care of yourself. I look forward to hearing from you.


5a). What treatment is there for transsexuals?

The currently accepted and effective model of treatment for gender issues is based on the Standards of Care (SOC) written and enforced by the World Professional Association for Transgender Health. The tripartite treatment plan outlined in the SOC, involves an extended period (usually about 3 months) of psychotherapy prior to making a referral for hormone replacement therapy. This period is followed by an extended time (at least one year) in which the individual is required to live successfully full time in the new gender role prior to getting a referral for sex reassignment surgery. Although the SOC are minimum guidelines to be used to set eligibility criteria for patients, in actuality the course of treatment can be tailored to the individual's needs, and is usually negotiated among the patient's therapist, administrating endocrinologist and surgeon.

5b) What other treatments are there?

Male-to--female Transsexuals often undergo electrolysis or laser treatments to remove their beard and body hair. Transsexuals might also seek speech therapy to help attune their voices to their acquired gender.

5c). Are there any rules governing this treatment?

Although there are no legally binding rules, standards of care have been drawn up by the World Professional Association for Transgender Health (WPATH). The association has established standards of care for the treatment of GD, which is generally accepted by medical providers across the world these standards are revised from time to time to take into account new scientific information, and were last updated in 2014 with version 7. They provide directions for the treatment of transsexuals, which may be modified in line with a patient's particular needs and circumstances. They include minimum eligibility requirements for some procedures, such as referrals for hormones and for genital surgery.

5d). Do you think the standards of care as proposed by the World Professional Association for Trangender Health are reasonable?

Yes, in fact the SOC may be the most important development in the history of treating gender dysphoria. Prior to the SOC being written in the late 1970s by HBIGDA (now known as WPATH), surgeries were being performed on demand on kitchen tables by doctors who didn't have the slightest idea what they were doing. No hospital would allow the surgery. Hormone regimens were random and the surgery was about to be declared illegal. The SOC not only legitimized the surgery it provided a clear and workable path for thousands and thousands of others to follow. So are they reasonable? Sure, people handle the SOC with little or no difficulty.

5e). What do the guidelines state?

With regards to hormonal therapy, the WPATH guidelines set three criteria. Firstly, patients should be of legal age of medical maturity. This can range from 16 in most European counties to 18 here in the USA. Secondly, they should be aware of the effects and risks of taking the drugs. And thirdly, they should have documented proof that they were living in their desired gender role for at least three months or have undergone a period of psychotherapy sufficiently long enough for the gender specialist and the client to determine the time is right to make the referral. With regards to surgery, there are six eligibility criteria, the most important of which are that the patient should be a legal adult; have had 12 months of continuous hormone therapy; and have lived in their desired gender role for a year - a period known as the real life experience (RLE). There are also two readiness criteria. Patients should demonstrate that they are consolidating their gender identity, and enjoy better mental health as a result of dealing effectively with work, their family and relationships. Letters of Referral from two licensed mental health providers to the surgeon are required to check that patients meet these criteria.

5f). Why are the guidelines important?

Some of the procedures are irreversible, so patients need to fully understand and be prepared for treatment. Some of the side-effects of hormone therapy, such as an increased risk of blood clotting, can be life threatening to patients in poor health, for example those with heart disease. Some people with psychotic illnesses, such as schizophrenia and manic depression, may mistakenly believe they are transsexual, but a thorough psychological assessment should prevent misdiagnosis. Transgender psychiatrists also admit that the boundaries between transsexualism, transvestitism and homosexuality are not entirely clear to them. The guidelines help them to determine which patients would benifit from surgery.

5g). What do transsexuals make of the guidelines?

There is no consensus of opinion. Some transsexuals believe that some therapist stick too strictly to the eligibility criteria, without taking into account the circumstances and history of the individual patient; others believe they are sensible precautionary measures. Most of my clients seem to appreciate the fact that there is a well-established, medically proven system in place to aid them in this difficult task.

7. What are the repercussions of sexual reassignment surgery? Are they generally positive or negative?

SRS has been performed on tens of thousands of individuals over the last 50 years. If the result was less than positive, the surgery would have been considered malpractice decades ago. To the contrary, there is plenty of empirical evidence to show that the surgery has led to positive outcomes in the lives of thousands of people who have had the surgery.


6a). I have heard that one of the uses of hormone replacement therapy is to see if the individual accepts or rejects the treatment. In your experience (or in other documented sources) where there was a rejection, what are the responses?

First of all, keep in mind that a referral for hormone replacement therapy is made with great caution. Individuals are not only evaluated for severity of gender variance but they are educated to the effect the hormones will have on them. Most of the people I see come in very aware of the effect HRT will have on their secondary sex characteristics but few are aware of the general health risks and the psychological effects they will experience. For example, I explain to all my clients MTF clients that paradoxically taking estrogen will diminish not only their libido, it will diminish their need to crossdress. I know that is counterintuitive but it is a fact.

I also warn them that getting on estrogen can result in a sense of well being that leads to a strong desire to continue taking it. They had better be prepared for that consequence. A similar feeling of well being is reported by FTMs on testosterone.

I am not aware of any documented study of people rejecting HRT but an informal review of four of my colleagues show that out of the 1500 plus people we have collectively seen over the last 20 plus years, there have only been a handful of people who have stopped HRT once they have started. Two of us had patients who stopped because they complained that it reduced their libido and it decreased their desire to crossdress. Two of us report where a client has been frightened off after their breasts began to develop. One of my clients eventually had an orchiectomy and had his small breast development removed surgically and continues to live in the male gender role. One of my colleagues reports a similar experience with his client also having a double mastectomy.

6b). What does hormone therapy involve?

Male-to-female patients treated with estrogens can expect to experience: breast growth, some female-like redistribution of body fat, softening of the skin; a decrease in body hair, decreased upper body strength, decreased fertility and testicular size, less firm and harder to achieve erections. More importantly, most individuals report a relief from their gender dysphoria and a feeling of well-being.

Female-to-male patients treated with testosterone also report a relief from their gender dysphoria and a feeling of well-being. They can expect the following permanent changes: a deepening of the voice, clitoral enlargement, appearance of facial and body hair, and depending on their age the possibility of male pattern baldness. Reversible changes include: stopping of menses, weight gain, increased upper body strength, increased libido, decreased hip fat, courser, oily textured skin and mild acne at least at first.

6c), I am considering trying female hormones and would like to know if the shrinking of the male genitalia is permanent or not. If I choose not to continue towards changing sex from male to female, are there any permanent effects using female hormones?

First of all, this is a question you should be asking your therapist and/or endocrinologist. Do not take hormones unsupervised! However, I will say this, when a genetic male takes estrogen he will experience permanent breast growth almost immediately. He will also experience minor shrinking of the penis and the testes if he takes it for an extended period. All other hormonal changes are reversible.

6d). How will hormones affect the emotional state of someone undergoing transition?

Hopefully in a positive way. That is the whole idea. When estrogen is given to a gender dysphoric genetic male and testosterone to a gender dysphoric genetic female the usual result is an overwhelming feeling of well-being and an often dramatic increase in ability to function.

6e). I heard that most surgeons require that their MTF patients go off all HRT a few weeks prior to surgery. Is that true? If so why?

Yes it is true. In the one to two years (and in some cases longer) period leading up to surgery, genetic males require very large doses of feminizing estrogens in order to overcome the androgenic effects of their testicles. Estrogens even in the low doses commonly given to menopausal women are widely known to be a possible cause of blood clots. By having the individual go off HRT for a short period prior to surgery reduces the risk of the formation of clot's that might form during the surgery. If blood clot's form, there is the danger that one or more will get into the blood stream where they can migrate to other areas of the body causing serious ancillary damage such as a stroke.

6f). How long do most individuals stay on hormones?

All their lives. MTFs start by taking large doses of estrogens to counter act the continued attempt by the testicles to produce androgens. Once SRS or an orchiectomy is performed the dosage can be reduced drastically. Essentially post-op genetic males have the equivalent endocrinological system of a post-menopause genetic female. Staying on a low dose of estrogens has the same benefits for post-op MTFs as it does for post-menopausal genetic women.

6g). Is it true that those that take hormone therapy also find that their hands and feet shrink in size and if so by how much?

Hormones have no appreciable effect on the size of feet or hands. Both the hands and feet may eventually look a bit more feminine but the size will not change.

6h). From a 50 year old married man who asked if going on Estrogen for 30 days would help.

We know that to be true because estrogen (which is something of an antidepressant itself), even in moderate doses, routinely resolves both the dysphoria and the depression while SSRIs alone do not. I know this answer leads to further concerns but that is an issue that needs to be addressed in person between you and a therapist.

Given your life long gender dysphoria, there is good reason to believe that estrogen would probably relieve your depression and anxiety by relieving your gender dysphoria. That brings us to the "further concerns" I mentioned. As you know, estrogen is a feminizing agent. Once people with issues such as yours start to take estrogen, typically they find that it is very hard to stop taking it. Not only does it give them a feeling of well being, they soon learn that if they stop taking it, even for a few days, the depression and anxiety return. A 30 day trial, even on a low dose, would probably yield the same result. Permanent relief will only come with the constant intake of estrogen. That, of course, would lead to more and more feminization of your mind and body. You and your family would have to learn to live with that.


7a). What surgery is performed?

Depending on the appearance and health of the patient, surgery for male-to-female transsexuals may include: Facial feminization Surgery, removal of the penis (penectomy); construction of a vagina (vaginoplasty); removal of the testicles (orchiectomy); construction of a clitoris (clitoroplasty); and possible breast augmentation; nose reshaping (rhinoplasty); cosmetic surgery such as hair transplants or facial remodeling; shaving of the Adam's apple (thyroid chrondroplasty) and raising the pitch of the voice (crico-thyroid. For female-to-male (FTM) transsexuals, surgery may include removal of the womb and ovaries (hysterectomy and oophorectomy); removal of the breasts and male chest contouring (bilateral mastectomy); matoidioplasty( freeing of the hormonally enlarged clitoris) and possibly construction of a penis (phaloplasty). Only a small number of FTM transsexuals undergo phaloplasty because of the expense and what most of them consider less than adequate surgical results.

7b). I'm one of those males that would like to live as a woman, but I'm not sure about Sex Reassignment Surgery. I don't even like going to the dentist. Is this normal?

Sex Reassignment Surgery is very common choice amongst the people I see day to day, but it isn't necessary. Many people choose to live as non-ops. One reason they choose to do so is because they are afraid of undergoing surgery. That is why I start speaking about surgery relatively early in my work with people who have made it clear that they are going to transition. I try to make it sound as ordinary and safe as it really has become. I also encourage them to discuss their fears with several different surgeons. They should also talk with friends who are now post-op and see what that experience was like for them.

7c). I have heard that in some cases, the prostate gland is removed as part of sex reassignment surgery. Is that true?

To the best of my knowledge, surgeons have never removed the prostate gland here in the USA. Estrogen replacement therapy tends to reduce the size of the prostate gland, leaving it quiescent.

7d). I'm in college writing an essay on SRS. I was wondering if you had anything to share regarding the aftermath of surgery. I understand there are many psychological issues before the irreversible surgery (depression, suicidal ideas) but what about after? Is it completely wrong to think that some patients are putting in all of the time to get the surgery and then cutting off the psychological help? Or is the surgery enough to solve these problems?

That is a good question. Actually a certain percentage of post-ops do stay in therapy for a while after surgery. However, that is mainly to ease out of the years of pre-op work that has been going on. Keep in mind that a letter of referral is given only to those individuals who have come to terms with their transsexual status and have shown that they are living comfortably in their new gender role. To clarify, it is not the surgery per se that solves the problem. It is the hormones and all the years of preparation that solves the problem.


8a). When breasts grow, how do genetic males handle the look?

One of two ways, either you let them show or you hide them with loose clothes. That is not a glib answer. It is what people do. It depends on your state of mind. Incidentally, it is not unlike what many self conscious 12 year old girls go through as their breast begin to develop.

8b) I am 50 and disabled. I've read were TS people have been injured by people that see us as less than human. So I have some concerns.

Many hate crimes against the transgendered are reported but in fact they are relatively rare. Of the 650 + clients I have worked with since 1978, I have never had anyone report being mistreated by a stranger. Although there are some notable exceptions, most of the incidence where people have been seriously hurt or even killed have had some thing to do with sexual encounters. Simply follow the same rules of safe conduct that most genetic women follow and you should be all right. (see

8c). Besides some of the social problems that come with transitioning, what are some of the moral or spiritual issues that come up.

Rarely do I see anyone with religious concerns who has not already worked out their spiritual issues regarding transition with their spiritual leader. However, if the individual has strong religious ties and is associated with a particular church, mosque or synagogue then there could be a problem. That is where a good therapist can help all parties to come to a workable solution.

Familial concerns are much more common. Most people who come to see me are in mid-life with familial obligations. The idea of altering the family structure or even destroying it to save their life can lead to overwhelming feelings of guilt and shame and are much more common and problematical than spiritual issues.

In such a circumstance the therapist should go to great lengths to educate family members about the gender variant condition and make an effort to keep the family together. I am happy to report that success in keeping the family together has increased dramatically in the last several years.

8d) What happens to those intensely dysphoric people who do not transition? How do they cope? I contemplate never transitioning and thus enabling me to make that commitment to my wife and family. How on earth can I do that and have a happy life without this persistent voice going around and around in my head?

When people wait until they are in mid life and have established a career and family before attending to their gender dysphoria the situation becomes almost impossible to resolve without disrupting the lives of loved ones. The sooner people with gender dysphoria understand that their condition is chronic, the easier the solution becomes. Gender variant people can no more change their gender variant identity then those who fit the more common male/female gender binary. I know all of that doesn't answer the question directly but there are certain truths in life that can not be denied. Being gender variant is one of them.

Of course, it is perfectly possible to be gender dysphoric and NOT transition. Gender dysphoria is not new. There is evidence of it dating all the way back to the beginning of recorded history. Since there was no treatment for it then, gender dysphoric people did the best they could to make their lives work and many societies accommodated them. (see

The only real solution is to make every effort possible to get family members to understand the seriousness of the problem. Seeing a good family therapist that is knowledgeable in these matters is a good place to start. I have also found that by referring couples to groups of other couples where there is a gender variant partner also helps.

8e) Statistics on the percentage of men who are dealing with gender issues range from 1% to 10%. No one knows for sure, of course. How about women? Reading between the lines it appears that a much smaller number have similar issues. Why is this? I suspect it's because they don't carry the same amounts of shame and guilt that men do about expressing themselves and being themselves however they please. Society seems to give a wide latitude to girls and women. Maybe that's enough?

I have worked with about 50 genetic females (vs 400 genetic males) who were dealing with gender issues over the last 21 years. In many ways the pressures they face by their families to remain female despite a strong desire to transition are similar to those of genetic males who are considering transition. The big difference, and your suspicions are correct, is that many gender dysphoric women can and usually do live primarily as men anyhow. That is, they avoid female dress styles and couple with straight female partners who in turn pretty much relate to them as if they were male. That goes a long way to ease their gender expression deprivation anxiety. The problem, as you have surmised, is that it is often not enough. Knowing that there is a way to permanently masculinize their bodies and function more fully in the male gender role is more then many can resist. That is when they search out for help.

8f) Do you think society is becoming more accepting of transgender?

Yes. That is apparent in several different ways. For example, only twenty years ago, in most cities in America, it was illegal for a man to crossdress in public. Now even the California DMV has a form that allows an individual to change, with a doctor's approval, not only their name but their gender identity on their driver's license. From there it is only a simple step to change all other forms of ID and go on with life.

8g) What should the society know and understand of the transgender community? What is something most people do not know about them?

First of all society must come to understand that gender identity is not simply binary. Because one's gender identity and sex form at different times while the child is still in the womb and that process is subject to potential problems, there is a very real chance that the process could be upset, leaving the child gender variant. This happens often enough for there to be, in reality, a gender spectrum. Transgendered people are born gender variant and as such are simply trying to find a space in life to exist comfortably. Also it is important not to confuse gender issues with homosexuality. Even though we hear the term LGBT used, it is a marriage of political convenience, not a biological one.


9a) Is there a way of dealing with Gender Identity Disorder without gender reassignment? My daughter has told me repeatedly that she prays each night that she wakes up in a man's body. Because she is a Christian, she faces a moral dilemma each day regarding the depth of our relationship.

Gender dysphoria is a very persistent disorder. It can't be cured in the normal sense of the word. When I treat someone, my only objective is to help them live with their gender variant condition. That can range from encouraging them to introduce some minimal form of cross gender behavior in their daily life to giving serious thought to complete gender role transition. There are no other known alternatives other then to suffer the anguish of inaction. There should be no more a moral dilemma involved with gender identity issues than with any other medical condition.

9b) I am looking for information on the effect of a child whose father is suddenly becoming a woman, including crossdressing, hormones, name change, etc.

I suggest that you check out a new study by Richard Green recently published in the International Journal of Transgenderism. The URL is:

Here is the abstract:

Continuing contact between transsexual parents and their children has met with significant opposition. Two areas of concern are effects on the gender identity of the children and reaction by the children's peer group. Eighteen children, 10 boys, 8 girls of 9 transsexual parents, have been evaluated. Their ages range from 5 -16 years. All live with or have regular contact with their transsexual parent. No child has gender identity disorder. No child has had extensive conflict with the peer group. All continue positive relationships with their transsexual parent.

9c). My 24-year-old daughter has just announced to us that her voice sounds deeper because she is "in transition." We had no idea what she was talking about and we are intelligent, educated and sophisticated people. She also has a learning disorder and I wonder if there might be a relationship here. It is hard not to feel guilty and we dread when the news is made public. How can a parent of one of these tortured individuals not feel as if they made a mistake in raising their child?

First of all, I think it is important that you understand that Gender Identity Disorder rarely, if ever has anything to do with how the individual was raised or whether or not an individual has a learning disorder. We are all but certain now that the gender variant condition is due to a congenital anomaly. In gender variant genetic females as your daughter appears to be, it could be due to a surge of androgens (probably from the mother through the placenta) to your unborn daughter's brain during a critical period of her embryonic development. You, as her mother would not have even known that it happened. Having a gender variant child is nothing to be ashamed of. Gender variance happens.

Secondly it often comes as a surprise to parents to find that their child has a gender issue. Especially if the child is "extremely creative and talented and a high achiever". It is not something most children feel comfortable talking about. Often they are ashamed of these strong feelings and hide them from those they love the most. More then likely your daughter has been protecting you and your husband from all of this. Your comment, "It is hard not to feel guilty and we dread when the news is made public." is telling in that regard. That is something the three of you need to discuss at length.

You didn't mention whether or not your daughter was seeing a gender specialist or not but since her voice is changing and she says that she is in transition, she probably is. As you know, she doesn't have to have you meet her therapist but I think it would be helpful if all of you had as many family sessions as needed to place this all in perspective. I know if I were seeing your daughter, I would have encouraged her from the onset to have you join us in our sessions before anything as important as a referral for androgen replacement therapy commenced.

9d) A week ago my husband and I received a letter from our daughter stating that she was going to begin hormone therapy for the purpose of transitioning. We have known for many years that our daughter is a lesbian and that she prefers to wear male clothing, but this came as a distressing shock to us. She said that she did not want to undergo therapy and that she was going to proceed with this process on her own. Do you think that she should undergo therapy before embarking on this path?

Gender role transition is a very important matter. NO ONE should even consider doing it without the aid of a therapist that knows what they are doing. You might inform your daughter of the World Professional Association for Trangender Health's Standards of Care, (WPATH SOC 7). A pdf copy of the SOC is available elsewhere on this site. I suggest that if you have not already done so that you read them yourself. Hopefully she will follow through and see someone.

9e) My fiance recently told me that he had a gender identity issue but that he has it under control. Shall I take him at his word or is this more then I can expect him to handle?

You and your fiance need to be very, very careful about going any further in your relationship without looking at this issue closer. Gender dysphoric feelings DO NOT CHANGE simply because someone has fallen in love. There are no "miracle drugs" and the only hormone that helps gender dysphoria in males is estrogen. I suggest that you read: Trans Forming Families: Real Stories About Transgendered Loved Ones, 2nd Edition by Ari Ishtar Lev (Editor), Mary Boenke (Editor), Jessica Xavier (Introduction) The book is available on and should give you a good insight on how other couples have handled the problem. It is a positive book and you may be surprised as to your options.

9f) I am still in shock. My 19 year old son came home unexpectedly and found my fiance running around the house in panties and a bra. Help me understand.

First of all, if you have not already done so, let your fiance know that you are concerned and would like an explanation. There may be nothing to it or there may be a lot. Either way you need to find out. I am assuming that since you have a 19 year old son that your fiance is probably in his mid-forties. If he is a cross dresser now then he probably has been his entire life. The need to cross dress in some men is very strong and does not go away. I suggest that you read the entries on my web site The articles are written by the long time wife of a cross dresser. The couple is doing just fine and have been doing so for many years.

9g) I have concerns about my 5 year old son. He has for the last year or so been found wearing girls underwear that he has taken from the bathrooms at school and also has taken from family cousins on outings such as camping and so forth. Once or twice he was caught putting on his cousins (girl) one piece swimsuit. I have thought nothing about it simply because he has also brought home boys underwear from school and if he wasn't such a boy (playing with insects and cars etc.) I would be more concerned, just thought maybe you could give me more insight as to whether or not children can get confused without having GID?

First of all, I would be far more concerned that your 5 year old is stealing and far less concerned about what he is taking. If you have not addressed his stealing with him yet, I sure would start soon. Secondly there is nothing about this situation for you to think that your child has GID. Especially since he shows no other signs. His play habits are male so he probably thinks of himself as a boy. Of course, you could ask him directly about it. He may or may not tell you the truth, depending on how you phrase the question so try to make it sound as if you will be willing to accept his answer no matter what it may be.

9h) My ex-husband is ready to tell our 13 year-old daughter about his preferences regarding women's clothing and gender identity. He is on estrogen and dresses as a female when away from her. However, since he only lives a mile away from us, he is concerned she will find out from one of her schoolmates in a harsher way than him telling her now.

I can read lots on your site about the significant other, but I can't find anything to see if a 13 year old is ready. If I remember being 13 correctly, it took a lot, lot less than this to be mortified, so it doesn't seem right to me.

Your husband is right about being the one to tell your daughter. If she does hear it from others, even if it is done nicely, she may feel that she was betrayed by him and that she was not considered important enough to have been told directly. It could be critical to their future relationship. Although 13 year olds are very sensitive to what goes on in their parent's life and what their friends know about it, there seems to be little choice to be had here. She will have to know sooner or later. It is more a matter of how the disclosure is made not how to avoid it.

I don't know how close your daughter is to your ex-husband. How she takes the news will depend on that relationship. Keep in mind that children are much more concerned about being loved by a parent and their own security then what the parent looks like. Hopefully your ex-husband is seeing a therapist and an endocrinologist for his hormones. If so I suggest that the disclosure come on a joint visit to the therapist's office.

9. I will like to know more about this gender identity disorder because just 2 years ago, my younger sister revealed to me that she is a lesbian and that pretty much she had struggled with her sexuality ever since she was 5 years old. She is very confused and since many of our family members are not aware of this situation because she's been hiding it very well. Please I need some of your insights.

You seem to be confusing some of your terms here. Let me see if I can clear some things up. First of all being a Lesbian has to do with sexual intimacy--preferring to have a female-female relationship. That would be called an individual's sexual identity. When a genetic female feels that she is really a man she is talking about having a male gender identity. If your sister has been dealing with her gender issues since she was 5 that certainly has nothing to do with her sexuality.

I'm not sure how old you sister is but she should try to read all she can about gender issues. She might also consider seeing a gender specialist.

9i)My ex-husband has recently started taking estrogen on his way to transitioning to being a woman. We have four children. When is an appropriate time to talk to children about the changes?

That depends on the age of the children. It will be some time, perhaps as long as 6 months to a year before there are any visible signs of the transition. I would not say anything until the children begin to ask for answers. Then I would tell them an age appropriate amount of information. Keep in mind that children under 5 take the news almost without comment while older children will ask some questions that should be answered honestly and in a matter of fact way.

9j) In your experience, have parents been mostly supportive of their transgender offspring? Any advice for parents?

I have no way of actually knowing the answer to this question. I am almost certain that if a young gender dysphoric person believes that their parents would be adverse to knowing that they are gender variant, they would keep that information to themselves and go underground with their problem. If on the other hand they feel comfortable disclosing than there is a good chance they will get the professional help they need.

9k) I am the mother of a 28 year old transgendered FTM. Since he 'came out' 8 years ago, changing his name and his way of dress. He has, also, been slowly and steadily breaking his emotional ties with the family. The family has engaged in reading and discussion leading us to accept him and address him by his new name. I recently asked him if he felt accepted by the family, and he answered yes. However, he said that he would never be the same way with the family as he was before because he said the family did not give him what he 'deserved or was entitled to' as he was growing up. My family and I are heartbroken and at a loss as to know how to proceed.

The feeling of having been gypped of their boyhood and being angry at their parents over it is something of a pattern with female-to-male transsexuals. (Incidentally, I have not noticed a similar pattern in genetic males who transition to the female gender role).

Eight years is a long time for this standoff to be going on. Someone in the dialogue is being overly resistant and unrealistic. I would hope that your child is transitioning under psychological/medical supervision. In my practice I make a point--especially if I know there is a problem-- to bring the family into our work together to iron out just such a discord.