An Introduction to Gender Dysphoria for Female to Male Transsexuals

Most of us are perfectly comfortable with the fact that we are male or female. In fact we normally never give it a thought.
But there are a very few people who feel they were born with the wrong body and often they remember feeling this way even in childhood. When the feeling becomes strong enough, the person may seek medical treatment which may include powerful hormone therapy and surgery. These extreme measures are accompanied by discomfort and risk, so no one would entertain them on a whim. Rather, transsexuals take such drastic measures because they feel so strongly and consistently that they should have been born with the body of the opposite gender

The rate of occurrence of transsexuality is not accurately known. Because of the social stigma attached to being transsexual, arising from a widespread lack of awareness of the true nature of the condition, it is something that is often kept hidden. Therefore it is only possible to collect statistics on the numbers of declared transsexuals and such figures undoubtedly represent only a proportion of those affected. Rates of occurrence of known female-to-male transsexuals are significantly lower than those of known male to female, typically around 1/3 to 1/4. This would put the current estimated figure at least 1 in 30,000 of the female population, however as this rate has varied somewhat with time and between different parts of the world, it suggests that varying cultural factors might play a role in the decision to be open about the condition.

The historical records of human behavior clearly indicate that transsexualism existed long before it found a name. But until modern medicine recognised, defined, and developed therapies for this condition, transsexuals were left to cope with their difficulties by more or less unsatisfactory, and often tragic, means of their own devising. The term transsexual, originally coined by Dr. D.C. Caudwell in 1949, is not a very good one as the condition has little to do with sexual orientation, so the term causes much confusion in the mind of the general public. The reasons for crossing the gender divide are about just that - gender, not sex. The main issue is to produce a change in attributed gender to that which matches the persons own gender identity.

We live in a world where, due to stereotyping, dress codes are different for women and men. There have always been women and men who felt themselves to be other than their bodies ordained and who expressed this in the way they lived their lives, In the so called primitive societies such people became shamans. In another time they would have been persecuted as witches. There is a certain magic to having a foot in both camps and at various times and places in history this has been both revered and feared. There are many historical references to transgendered behaviour, St. Joan of Arc was burned at the stake as a witch for dressing as a man.

The dysphoria that some experience is so strong that they feel they have no alternative but to change the way they live.
Once this is done, their energy can be channeled into living that life to the full. Until then they live with a handicap. The gender dysphoric person has degrees of dysphoria, just as they will have degrees of coping skills and of success and failure. The transgenderist may live entirely in the desired gender role without the need for surgery, a transsexual on the other hand, will want surgery to complete the process.

Problems are encountered by transsexuals in the U K. as a result of not being able to have their birth certificates amended to show their changed gender status. The U K. has no alternative to the birth certificate as an identity document so when applying for life or medical insurance, obtaining a mortgage, joining a pension scheme or obtaining employment, a passport or driving license, a transsexual can be asked to produce their birth certificate. Their original gender is also recorded on national computer networks such as the DSS where it is accessible to anyone of sufficient rank. It makes it difficult and embarrassing for transsexuals to obtain employment, higher education and benefits.

Transsexuals in the U K. cannot marry a member of the opposite gender, Unless they are the citizen of another country, if they take part in a marriage ceremony overseas, it is automatically void when they return to the U K. When they die, a transsexual's next of kin have the added trauma and indignity of having to cop e with a death certificate which states their official gender .

The currently accepted and effective model of treatment for the condition of transsexuality utilises hormone therapy and surgical reconstruction and may include counseling and other psychotherapeutic approaches. In all cases, the length and kind of treatment provided will depend on the individual needs of the patient and will be subject to negotiation between the Consultants involved, the patient's General Practitioner and the patient.

John Money established seven criteria important for correct sexual development in the foetus after conception. These are:
1 . Chromosomal Sex (normally 46XX for a female and 46XY for a male ). 2. Gonadal Sex (the structure of the ovary and testis). 3. Hormonal Function. 4. Internal genital morphology 5. External genital morphology. 6. Assigned sex (at birth).
7. Gender differentiation. In transsexualism there is no abnormality known in the first six of these variables though it is believed that the prenatal hormone environment may affect areas of the lower brain, such as the hypothalamus, and, more controversially, the organisation of the cortex.

Medical treatment to enable transition is carried out according to the Standards of Care set out by the Harry Benjamin International Gender Dysphoria Association and regularly reviewed by them. The Standards of Care state that transsexualism has three criteria:

(1) The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment

(2) The transsexual identity has been present persistently for at least two years

(3)The disorder is not a symptom of another mental disorder or a chromosomal abnormality.

The availability of treatment can vary widely according to the support available from your doctor and filnding available from your local health authority. Private treatment usually enables a much more rapid passage through treatment, but is extremely expensive. Anyone considering the private route should ensure that all medical personnel are fully experienced and qualified and that treatment follows the guidelines set out in the Standards of Care, which includes specification of credentials for professionals and for the Real Life Experience.

To obtain treatment under the National Health Service, the first step is to visit your GP, who should then refer you to a specialist gender identity clinic. The main GID clinic in the UK is based at Charing Cross Hospital in London, but there are other clinics around the country These clinics are usually very busy and it may take some months to get an appointment. The initial appointment is likely to be with a psychiatrist specialising in gender dysphoria who will be looking to make a diagnosis of gender identity disorder and discover whether any mental disorders are present in the patient.

Timetable for the medical decision to begin prescription of hormones varies according to the individual readiness of the patient and the perception of the medical team. The patient will need to be at least 18 years old and be able to demonstrate a good knowledge and understanding of the effects of hormone therapy. In addition the medical team will expect the patient to show that they have experience of living in their chosen gender role or have undertaken a period of psychotherapy after the initial evaluation.

The Real Life Test must be undertaken for a minimum of 12 months before a patient can be referred for surgery. This is a time during which you are expected to live fully in the chosen gender role, including either full or part time employment, community based voluntary work, or enrolment as a student. The Real Life Test is an opportunity to experience life in the new gender and encounter and deal with problems and emotional challenges that arise. You will be expected to acquire a new name reflecting the gender change, to have this legally registered and to alter personal documentation such as driving licence and passport to show this change. Although the birth certificate cannot be changed, all other documents can be altered, including most professional and examination certificates. 

Hormone therapy plays an important role in the anatomical and psychological gender transition process. Biological females who are prescribed androgens can expect

1\ a permanent deepening of the voice, this usually occurs within four months and is irreversible
2\ permanent clitoral enlargement. Some breast atrophy may occur but at this stage it is usual to bind the breasts
3\ cessation of menstruation within three to six months
4\ increased strength and weight gain particularly around the waist and upper body with decreased hip fat. With exercise this can take the form of muscular development. Testosterone will not alter height or bone structure
5\ growth official and body hair is likely to follow the pattern of hair growth inherent in the family, for example if other male members of the patient's family have a tendency to baldness or if they do not have a great deal of body hair this is what can be expected with hormone treatment
6\ increased social and sexual interest and arousability, there may also be heightened feelings of aggression.

The degree of change and the speed at which change occurs varies between individuals but maximum physical effects are generally achieved after two years of continuous treatment. Side effects of androgen treatment may include infertility and acne, and there may be an increased potential for depression. There may be increased risk of heart disease, in line with general statistics which show heart disease affects more males than females, and patients should be assessed regularly for liver function and blood count, glucose intolerance and gall bladder disease. Patients with existing medical problems may be put at further risk, and therefore it may not always be in the patient's best interests to enter into hormone therapy. In such cases the ratio of risk and benefit should be fully considered by both the patient and the prescribing physician.

Surgery is not normally available until there has been a minimum of 12 months' continuous hormone therapy and 12 months of successful continuous real life experience. The patient would be expected to show that they are dealing successfully with work, family and social issues before they are referred to a surgeon. There may well be a lengthy waiting list for surgery once this referral has been made.

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

Following gender reassignment it is important to continue to monitor health by regular check ups. If there is a family history of breast cancer it is advised to continue monitoring even after mastectomy Following oophorectomy, reduction in testosterone dose should be considered.