Notes on Gender Role Transition
Anne Vitale Ph.D. Editor
August 3, 2000
Why didn't I seek a second opinion or a third? How could I undertake a (gasp!) sex change without consulting legions of therapists? These are the sorts of questions I seem to get on this obviously sensitive subject. Most of them are hurled by non-accepting family members. It is as if there is some desire on their part to have me see shrinks until I find one that says 'Nope, you are not a transsexual, no way, no how.' Why didn't I do this? Why don't I do it now? I would have thought that concerned family members would have done enough research in the medical science and social literature on Gender Identity Disorder (GID) to understand the answers themselves. Apparently they haven't. So, for them, here is my answer...
The first thing someone should know is that gender identity is in the brain, it is not in the testicles, the breasts, the vagina, the ears, the penis, or anywhere else. There is good science to back this up. In fact, there is a growing body of evidence which shows that the brains of transsexuals physically resemble the brains of the sex they identify with. That is to say, the sexually differentiated parts of the brain match the person's gender identity, even in transsexuals. In other words, there may be physical causes of transsexualism, it is not a lifestyle choice. More research needs to be done in this area, since the results are preliminary at this point, but it is sufficient to understand that it is not the penis that makes the man. If you doubt that, ponder the following question of any man you know (including yourself, if you are one). If his/your penis were cut off in an accident, would he/you suddenly feel like a woman? I highly doubt it.
The second thing that is extremely important to understand, is that gender identity is believed to be fixed no later than by age 18 months and it doesn't change &endash; ever. There are case histories that show this very clearly. The most recent one I read came from Johns Hopkins. Even when a child is reared in a particular gender role from birth, if it doesn't match the inborn gender identity, the child , upon growing to the age of consent chooses to go back to his original gender. The best examples of this can be found in cases of infant penile injury or various disorders that cause ambiguous genitalia at birth. In almost all of these cases, doctors used to recommend that the child be raised as a girl. The reason for this was simple &endash; doctors are better at creating vaginas than penises. It was also believed that gender identity was socially created. In effect they believed that if you raised the boy as a girl and gave him estrogen at puberty, he would never know that he was in fact male. But, almost without exception, the child eventually reverts to being a boy, if that's how he was born. There have been some very good studies and books on a particularly clear example of identical twin boys where one lost his penis in a circumcision accident and was raised solidly and unambiguously as a girl from the first months of life. He is now a middle-aged man with a loving wife and two adopted children. This is not transsexual lore, this is real science &endash; research it for yourself if you don't believe me. Gender identity is just as fixed for transsexuals. Transsexualism doesn't go away. I have known enough 50, 60, and 70 year old transsexuals to know this for sure. It just doesn't go away. No amount of therapy or anti-depressants will ever treat the cause &endash; they can only mask the symptoms for a little while.
Since science can't change gender identity (at least at this point), the only accepted treatment for GID is to make the body match the brain. If there were a magic pill to make you feel like a man/woman, I think most transsexuals would take it &endash; I probably would. But, it doesn't exist. Now, having said that, there are some very good things about the accepted, standard treatment regimen. First, it is fairly free of risk. In a person my age (30), with no complicating factors, there is almost no chance of side effects from any of the medications or surgical procedures. Second, it is highly successful. Estimates vary, but the very lowest one I have ever heard is a 90% success rate. That means that at least 90% of all persons with gender identity disorder who undergo sexual reassignment surgery are cured. Cured in this case meaning that feelings of being in the wrong body disappear and the person is free to go on with their life. Most estimates are in the range of 95-98.5%. Third, many if not most transsexuals go on to lead very normal and satisfying lives. Unfortunately, the ones who don't adjust well tend to grab most of the attention. But, the fact is, most of us disappear seamlessly into society at large. We are doctors, lawyers, construction workers, nurses, bankers, mail carriers, engineers, florists, and everything else under the sun. We are also wives, mothers, nieces, sisters, daughters, life-partners, aunts, and everything else a woman can be. As a population, we have a higher than average IQ and income. Some of us have other emotional problems, but most of us find them easier to work through after our GID is cured.
Now, with the scientific background summarized, let us get on to the question at hand. Why didn't I solicit more psychological opinions. In order to put this all in perspective, let me explain a little of my past, the stages of acceptance of my disorder, and what happened when I began my search for treatment.
I knew I had always had the feeling that I was a girl. I have known it since at least the age of 11 or 12, maybe even earlier. After years of suicidal inclinations, I finally had to make one last choice &endash; seek treatment or finish myself off. It just wasn't worth it any more. Even though my life appeared successful, inside I was miserable &endash; all the time. Anyone who knew me as a teenager or young adult knew how miserable I was. I was in over a dozen car accidents (my fault) before I was 22. I did every drug under the sun. I started smoking cigarettes at 17 with the clear intention (not at all subconscious mind you) of shortening my life. I didn't get good at hiding my misery until just the last few years. No one knew why I was miserable, and I can't blame them, but I was miserable just the same.
When I started to think about treatment, I first researched what I felt I had. I read the DSM-IV. I read the accounts of other transsexuals. I took small, tentative steps to express my feelings of being a woman to see how it felt. After months of research, it became pretty clear what I am &endash; a transsexual. Too many stories sounded just like mine. Too many medical texts read like they were written about me. The treatment sounded too good to be true. I didn't think it could really be possible that I could blend seamlessly into the world as a woman. I thought I would be outcast and lose everything. In the last stage before I sought treatment, I finally concluded that I would rather be a homeless, outcast, drag queen, than live the miserable life I was living. So, prepared to lose everything, I decided to come out and seek treatment.
The other thing I found out while I was doing my research was that transsexualism is a real disorder, in real textbooks with a real name. It is called Gender Identity Disorder. I also found out that there is a branch of psychiatry devoted to treating gender disorders. They are known appropriately enough as gender specialists. Since that sounded like the right specialty to me, I started seeking a therapist. I found all levels of professionals: family counselors, religious counselors, psychologists, etc. I wanted the best, so I looked only for licensed clinical psychologists. I read curricula vitae. I checked credentials. I studied philosophies. I talked with patients. When I had it narrowed down to a few, the choice got tough. I finally settled on my therapist for a number of reasons. First, she had the best personal recommendations of anyone in the area. Second, she has been practicing in this field a long time. Third, she is very well respected by her peers and regularly contributes to the advancement of the knowledge base. She is well published and often speaks at professional societies. The last thing that attracted me to her was that she is a transsexual herself. This held appeal for a number of reasons. She must know something of what it feels like to be transsexual, so she should be able to empathize. She knows very well the different treatment options, likely outcomes, and pitfalls to watch out for. And, she sets for me a very good example of a well-adjusted, professional, successful transsexual woman. So, it was settled. I would send her a brief biography and have a preliminary interview with her to see if we liked each other.
After the intake interview, we did feel we were compatible, so I began therapy with her. Throughout the sessions, she never encouraged me to move forward. In fact, she was (and continues to be) very conservative about letting me move forward in my transition. She follows the very conservative HBIGDA Standards of Care. She has been consistently negative when describing the outcome of surgery or any of the other options available to me. She has gone to great lengths to make sure that I understand my treatment options in a realistic way and that I don't attach any romantic notions to my transition. She never told me I was a transsexual. I told her. This is one of a very few disorders that are primarily self diagnosed. After all, how can anyone else know if I feel like a woman or not. All my therapist does is help me work out my feelings, and approve treatments that I request when we both agree that I am ready for them. In general, she is much more the gatekeeper and guide than the cheerleader. And that is just what I wanted &endash; someone to tell me if my common sense was not working properly or let me know if some other problem was masquerading as GID. Since our therapeutic relationship seems to be working well, I continue to see her.
So why didn't I see anyone else? I have the best, so why should I? I am happier than I could have even dreamed possible, so why should I? My therapist is effectively and judiciously implementing the most widely accepted course of treatment, so why should I? I haven't a doubt in the world about what I am doing. That is why I don't need any more opinions. Reality is a tough judge, and reality tells me every day that I am doing the right thing. When I leave for work at my highly paid engineering job… when I come home to the house I own and pay all of my bills… when I see one of my numerous friends (transsexual and non, straight and gay, men and women, I have them all)… when I smile just because I am alive, I know beyond any shadow of a doubt that I am doing the right thing. You want a second opinion? Fine, I'll give you one - besides being a happy transsexual, I'm a pretty one, too.