An Outline of Treatment for Transsexualism

The process of treatment for gender dysphoric individuals seeking gender reassignment is set out in the publication Standards of Care for Gender Identity Disorders produced by the Harry Benjamin International Gender Dysphoria Association and now in its fifth version.

The five elements of clinical work involved are diagnostic assessment, psychotherapy, real life experience, hormonal therapy and surgical therapy

Treatment generally begins with the patient's general practitioner who may refer to a gender identity clinic or to a psychiatrist, although in some cases the patient may refer themselves direct to a private psychiatrist. The purpose of this step is to obtain a written psychological evaluation by a licensed clinical behavioural scientist with proven competence in general psychotherapy, sex therapy and gender counseling/therapy

The person will be expected to enter into the Real Life Experience, a period of time in which they fully adopt their new gender role in every day life. They have to show themselves to be self-supporting and socially active during this time, so this includes full or part time employment, or working in community based voluntary activities or as a student. The person is expected to acquire a new legal name reflecting the chosen gender and demonstrate that people are aware that they are living in their new role. The real life experience tests the person's resolve and capacity to function in their chosen gender.

Hormone therapy is initiated in consultation With the individual's medical advisers, but the Standards of Care state there should be evidence of either at least three months of real life experience or a period of psychotherapy (usually a minimum of three months) before hormones are prescribed. The hormones administered are oestrogens, progesterone and/or testosterone-blocking agents to biological males and androgens to biological females.

The male to female taking oestrogen may experience the following reactions:

Initially, there is likely to be some breast development or increased sensitivity in the breasts. Nails and hair grow faster and there may be mood swings and crying for no apparent reason. There may be a temporary increase in libido for the first 2-3 months, but by six months the sex drive is greatly decreased and erections are rare and occasionally painful. Skin texture is likely to be noticeably softer by this time, lips are fuller, breast development continues and fat redistribution has caused major feminisation of the face. The hips have started to expand and rotate slightly forward due to changes in the tendons so hip discomfort is not uncommon. Some re-growth of hair is possible while facial hair growth may have slowed.
Minor water retention is probable and testicular atrophy has occurred. By one year the sex drive is virtually non-existent.
Continued fat redistribution has caused the waistline to shift and added curvature to the rear. Breast development continues, testicles have atrophied significantly and erection is extremely difficult. Maximum breast development is reached at around 2 years, by which time the individual appears female aside from the genitalia.

The female to male taking androgens may experience the following reactions :

Initially there may be mood swings with increased aggressiveness. The skin texture takes on a rougher appearance and acne is likely to occur. Muscle mass increases, as does the libido, and the menstrual cycle may be interrupted. By six months the skin texture has changed and muscle mass is still increasing. the voice is noticeably lower and facial and body hair growth has begun. Clitoral elongation is noticeable. By one year the voice is lower, facial hair is present, even beard growth and male pattern hair loss may occur. The individual may grow in height and shoe size and the clitoris continues to grow and may be 2-3 inches long at this point. Menstruation has probably ceased and there may be weight gain.
Missing hormones for a few days will have little effect, possibly mood swings, but stopping for a significant period of time will result in general reversal. Certain effects of hormones cannot be reversed, these include breast growth and sterility after oestrogen in male to female, and facial hair growth, male pattern baldness and changes in voice after androgen in female to male.

For those individuals who wish to continue to full gender reassignment the next stage is surgery. The Standards of Care state minimum criteria for eligibility for surgery which include a 12 month period of continuous hormonal therapy and successful continuous full time real life experience. The surgeon should be a urologist, gynecologist, plastic surgeon or general surgeon and certified as such by a nationally known and reputable association.
Sex reassignment surgery in male to female most commonly involves removing the testicles, creating a vagina-like opening and using the scrotum to line the new vagina and create labia. The penis is inverted and some of the penile tissue is used to create a clitoris. The nerve endings in the penis are still intact so hopefully orgasm will be possible. Other surgery may also be undertaken, including breast implants, Adams apple and facial reconstruction and tracheal shave to alter the voice.

In the female to male the first step is a mastectomy and repositioning of the nipples followed by hysterectomy, removal of the uterus, ovaries and fallopian tubes. At present there is no effective way to create a fully functioning penis, some techniques used include penile implants and forearm and intestinal grafts.

The cost of gender reassignment is considerable, and surgery is likely to be more expensive for female to male because of the different processes involved. Male to female will generally require electrolysis for permanent removal of facial and other body hair and this is a lengthy and expensive process.

This information sheet is a very brief introduction to the subject. Those considering gender reassignment should make sure they have a full understanding of the processes and the likely outcome and should consult a qualified and experienced medical practitioner. No treatment, including any form of hormones, should be undertaken except under appropriate medical supervision.