1. Is Transgenderism a choice?

I am basing my answer to this question on my experience with over 450 gender variant patients who have come to see me over the last 21 years. 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, scientist, dentist, physicians, school teachers, professors, artist, musicians, and other highly educated and otherwise productive people. Being deprived of one's true gender expression kills. 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 deny it and continue suffering an interminably unresolved existence. Fortunately, help is available and the regimen practiced by most gender specialist has returned virtually all of these people back to productive and happy lives.

There is no known cause for gender dysphoria. However, we are sure it is not genetic. That is, a parent can not 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 GID please check out HBIGDA Talk Bologna, Italy 2005

4. 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 GID, and it made me wonder if there is any psychiatric treatment available for GID.

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 let alone changing their sex. Another thing, above and beyond particulars, these individuals usually obsess over a wide range of issues to a greater or lesser extent.

Gender Identity varies from having an unquestionable sense of being male to an equally unquestionable sense of being female. Because gender identity is hormonally set, subject to variability before birth, most people fall appropriately closer to one end of the spectrum then to the other. However, pre-natal hormone availability is subject to extraneous influences, creating a gender identity continuum with some people falling somewhere in between 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 gender dysphoria. The further from the middle, the more intense the dysphoria, and the more likely he or she will only find relief by transitioning.

6. 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 inidividuals?

There is no known "cure" for any of the people I refer to in the paper, no matter what group I have put 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 acknowledgement to complete gender role transition. Fortunately we have the psychological know how, along with the hormonal and medical technology to help these individauls live full and productive lives.

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 20 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.

3. 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 450 gender dysphoric individuals over the last 20 years and only a handful reported being abused as a child. In those cases the gender dysphoria the individuals experienced predated the abuse. Further more I have never read reports of sexual abuse being a determining factor. Recent evidence shows that the most probable cause is a congenital abnormality.

4. 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 Identity Disorder has more to do with gender role preference in life in general then it does with choice of sexual partners or how the individual makes love. GID 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.

5. Is it possible that if I had GID 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.

6. 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 then 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 then the genitalia do in the body. Hormonal surges at the wrong time could very easily disrupt the normal progression of sex/gender identity development.

7. I have viewed your website and I have mixed feeling 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 then that is the way it will always be. There are many men who exhibit feminine mannerism 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.

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

This is an interesting question and there is no way to answer it as stated. 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.

9. 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 then 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.

10. 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 seek 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.

11. 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 also contact HBIGDA (http://www.hbigda.org). Another great source for parents who are concerned about a child that they believe is gender variant isÊ the Children's National Medical Center website or PFLAG Ê

12. 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 transsxualism. 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.

13. Do most transgender individuals dress as the opposite sex?

Yes...at least some of the time. Transsexuals who go on to live in the opposite gender role, eventually do so full time.

14. 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 then 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.

15. 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.

15A. 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 then a few days.

The other, more physical changes take longer and are not easily reversable. 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 feminzation 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 an 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.

16. 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.

17. 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 than 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 then that, if I recall correctly, there is a section in the following essay of mine that deals with mid-life issues. Check it out. http://www.avitale.com/developmentalreview.htm

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.

Millions of people live their lives somewhere other then 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).

20. 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 then you about having a male inner sense of self. As a result they come to see me with more if of an intent to transition then 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.

21. 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.

22. Is transsexualism rampant in this time/generation?

The short answer is NO. I doubt if there are any more gender dysphoric people today then 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.

23. 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.

24. Are genetic or native males more prone to transsexualism then 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 and demeanor 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.

This is a far more complicated issue then 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 then 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.

26. 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 siad 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 reaseach 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 terrifys 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 mean time take care of yourself. I look forward to hearing from you.

CATEGORY 7: SURGERY

1. What surgery is performed?

CATEGORY 9: QUESTIONS FROM FRIENDS AND FAMILY OF PEOPLE WITH GENDER ISSUES.

You might also check the Children's National Medical Center or PFLAG. Ê

Your in luck on this one. I am not familiar with the licensing requirements in your state but I have never heard of anyone being denied a license any where in the USA, Canada or the UK because they have transitioned. I have at least 30 post-op colleagues who I am on a first name basis with who are either licensed psychologist or MDs. Some transitioned while already licensed while others after transition.

4. I am an LMFT practicing in Kansas. I have recently begun working with a 50 year old adult male who is presenting with symptoms of Gender Identity Disorder. In assessing this person for the first time yesterday, it became clear that this individual is also struggling with some significant cognitive deficits.

My question for you is: have you encountered such a situation where an individual has presented to you with GID, looking to have the sex reassignment surgery, but is compromised by such intellectual and cognitive deficits? If so, what has been your outcome with this and the outcome for the patient?

Yes I do have some experience in working with gender dysphoric males who have cognitive disabilities. Three of them. Their ages are some what younger then 50 but that may not matter much. All three are currently subsisting on SSI. Two of the three are currently living together as a couple, the third is living alone. All three are without family and get by from day to day. All three are on estrogen replacement therapy via my recommendation and are living as women. Their situation has remained constant for over the last 10 years. I see them very occasionally when they need me to help renew their SSI status or the endocrinologist that monitors their hormones requires them to check in with me. All three talk about eventually having SRS but in reality, since they would have to pay for it and have very little to just get by on, that is not a likely outcome. They are, however, very patient and just go about their daily lives as women with hope that they will eventually save enough to get the surgery. Essentially in treating someone with a cognitive disorder, I suggest that you take their complaint of being gender dysphoric as seriously as you would with anyone else. If the individual is in the mild range they probably will be able to handle a partial transition with special guidance and with the cooperation of the endocrinologist prescribing the HRT. I have no doubt that the three individuals I continue to see have profited greatly from the treatment.

5. I am a student studying beauty therapy. This includes a unit on epilation. We have been give an assignment wherein we are to explain how medical treatment would affect the treatment of hair removal . If you could help it would be much appreciated.

Male to female gender dysphoric individuals who transition to the female gender role take two types of medication: estrogens and anti-androgens. Both effect hair growth. Estrogen alone, given over an extended period of time reduces body hair and prevents male pattern baldness. It does nothing to reduce beard growth. Beard hair can only be eliminated by electrolysis or laser treatments.

Anti-androgens such as Spironolactone, work to eliminate much of the male body hair by blocking the androgen receptor sites in the hair follicals. Interestingly enough, spironolactone does not kill the hair follicals around the genitals. Instead it leaves a female typical triangular patch.

6. A psychologist in Italy, obviously upset by my public position stating that I think gender Issues need to be included in the up coming edition of the Diagnostic and Statistical Manual, Edition V (DSM-V), sent me this statement:

"Transsexual people are not sick. Transsexualism is not dysphoria! We are sane and the diagnosis should not be in the DSM-V."

My Reply:

Dear Doctor

Thank you for your comment. I have never said that transsexual people are sick and being in the DSM does not necessarily imply that. However, having said that, it is very common for people who have been suffering with gender expression issue all their lives, to get caught between their need to live a normal life (i.e. have a wife/husband and kids) and their need to be the opposite sex. In fact the intensity, or dysphoria, can build to such a degree that it is not uncommon for some people to become deeply depressed, withdrawn, unable to function and prone to suicide.

That is a condition that deserves psychological attention and coverage by insurance. Indeed where else would professional help come from if not from a therapist? I believe gender issues should be described in the DSM so that it can be treated properly. Let's hope that changes such as I have suggested ( I have suggested that it be called Gender Expression Deprivation Anxiety Disorder) and those of others, get incorporated in the DSM V.

Although I could probably write a book on doing group work with gender variant people, I'll just list those aspects that I found the most important here.