Unlike it's frivolous name, this book is actually a serious look at
the nature of transsexuality: what it is, why it is, and how sex
reassignment is accomplished, both surgically and socially. You may be
surprised to learn that one out of ten adults in this country believe
themselves to be transgendered to some degree.
What does it mean to be transgendered and how does that relate to
being transsexual? Before we can define transgenderism and
transsexuality, we must first be able to define gender and sexuality
without the "trans".
Surprisingly, although most everyone has a good feel for what these
terms mean, hardly anyone has a good understanding of them. Before we
try to describe the nature and process of sex change then, let us take
a brief moment to examine human sexuality in general.
There are four aspects to Human Sexuality. They are:
1. Anatomical (physical) sex 2. Sexual preference 3. Gender
Identity 4. Mental Sex
Anatomical sex
Anatomical sex is simply what body you are in: male or female. But
it is really not all that simple. There are hairy women and very
slender men. Facial features can range from more "male" to
more "female" regardless of what's between one's legs. In
addition, there is the chromosomal nature of being XX, XY, or even XXY.
On top of that, we have hermaphrodites.
So, all things considered, each and every one of us can not simply
be seen as wholly male or female physically, but truly occupy a range
on a spectrum. And, we can alter our physical sexually characteristics
(short or long hair, nose jobs, sex change surgery) so that the line
blurs even more. True, most people gravitate to one end of the scale
that the other, which creates an inverse "bell curve".
However, the line from one side to the other is truly unbroken, with
more than a few people right in the middle.
This one comes in four flavors: same, opposite, both, or neither.
Regardless of anatomical sex, any individual might be any one of these
four. What's more, most people find their sexual preferences depend on
context and may shift depending on the situation or the person. For
example, a man who sees himself as attracted to the opposite sex might
not be at all attracted to a female body builder. If he were honest
with himself, he would probably find some level of attraction to a
very pretty boy. It is the cultural training we have that leads us
deny and not even experience the capacity to shift our perspectives
here.
In addition, people change over time as well as in different
contexts. Some start out being heterosexual, then shift to bisexual,
then to same sex, then give up altogether, and then jump back in
somewhere else. With the spatial and temporal flexibility in this
area, each of us is fluid. But in the range of people as a whole,
regardless of where you fall on the anatomical sex scale, any
individual might at any time have any one of the four sexual
preferences.
So, since anatomical sex does not determine sexual preference and
sexual preference is independent of anatomical sex, the two factors
are independent and can be multiplied together to determine a great
range of human sexuality on these two points alone. Already we can see
there are a tremendous number of combinations!
Gender Identity describes where on the scale of masculine and
feminine behavior an individual falls. Clearly this is a range. What's
more, each of us changes in context as well. Men who are very macho on
the weekend playing tackle football with friends might be very demure
during the week at their job as a bank teller. And, over time, we all
change. Most men are more masculine at age 35 than they are at age 80.
Gender identity for any one of us does not fall at a single point,
but ranges in a segment of the masculine/feminine line. Which segment
we define depends on our conditioning as a child which "locks
in" somewhere between age 3 and 5. Then, for most of our lives,
we move up and down that segment, feeling uneasy if we get close to
one of the ends of our personal range.
Now, since masculine or feminine is a range and does not depend on
sexual preference or anatomical sex (we all know masculine women and
feminine men) then we can multiply that in as well and create an
ENORMOUS number of combinations of human sexuality.
In the 12th to 14th week of pregnancy, a
developing fetus will get a wash of hormones over its brain. Boy
babies get a flush of testosterone, girl babies get a flush of
estrogen. Testosterone has a direct impact on the level of the
neurotransmitter Seratonin in the brain. As testosterone goes up,
Seratonin production goes up.
Seratonin is an "exciter" which stimulates the firing of
the neurons. When they fire, the neurological activity of the brain
takes center stage, and the biochemical aspect of the brain steps a
bit into the shadows.
In contrast, estrogen increases the relative amount of the
neurotransmitter Dopamine. Unlike Seratonin, Dopamine is an inhibitor,
which means it lowers the tendency for neurons to fire. This does not
mean it diminishes mental processes, but rather that the biochemical
processes of the mind take center stage and the neurons step into the
shadows.
If the effect of this flush of testosterone or estrogen only lasted
for the two weeks the chemicals are present, it would have no lasting
effect on the mind. But, for reasons we shall see later in this book,
the brain "locks in" to a bias toward the neurology or the
biochemistry. It is this bias that makes a mind more focused on logic
or more concerned with feelings.
In truth, this hormone wash can vary in intensity from individual
to individual, so that any given person may range from very heavily
favoring the neurology or the biology to being more evenly balanced in
which kind of processing takes control.
As nature would have it, again for reasons we shall later explore,
most people are born very heavily biased to one side or the other.
Still, this just indicates our preferred method of thinking - the kind
of thought process we fall into first or most skillfully. Each of us,
however, often employs the other manner of thinking when the first one
is at a loss or when we need an internal second opinion.
The neural networks of the brain function in a binary fashion so
those with a testosterone wash tend to see the world in more logical
terms, more spatial terms. The biochemistry of the brain functions in
a more wave-like fashion, so those with an estrogen wash tend to see
the world in more experiential terms, more temporal terms. Spatial
thinkers look outward and first see things in terms of their
arrangement and where it leads. Temporal things first look inward and
see things in terms of what they mean and how they are going.
Because men tend to fall toward the spatial end of the scale and
women to the temporal, society has built up rewards to motivate the
population based on the expectation of this bias according to
anatomical sex. And, most nearly often, this is an accurate system.
But when something causes an individual to get the opposite pre-birth
bias than anatomical sex would suggest, he or she is technically a
transsexual.
Why do I say "technically"? Because the practical
definition of a transsexual would be someone who actual has surgery to
change his or her anatomical sex, or at least someone who truly wants
to. In truth, most of those born with the opposite bias are never
aware of it, and would be appalled to even consider changing their
sex.
In a like manner, there are many who have had sex change surgery
(called SRS for Sex Reassignment Surgery) who are not mentally
transsexual at all. Why? Because gender identity determines how
masculine or feminine we wish to be, and society determines the range
of behavior which is acceptable along that scale, based on anatomical
sex.
So, a man with very feminine tendencies might wish to change their
anatomical sex through surgery, whereas a man with a masculine gender
identity might be quite comfortable as a male, even though he is true
transsexual in the mental sense.
Finally, it must be considered that each of us has an inherent body
map in our brains. This blueprint gives us a feeling for the shape in
which we expect to find our physical selves. Even if we are typically
matched between Mental Sex and Anatomical Sex, our body map may be for
the opposite physical sex.
In psychology, stress caused by feeling one is in the wrong body is
called genital dysphoria, and stress caused by feeling on is living in
the wrong role is called gender dysphoria, which lumps gender identity
and Mental Sex into one overall symptom.
Those who have enough pressures upon them from all four of the
aspects of human sexuality may choose to remedy their uneasiness
through surgical means. Other combinations of these tendencies will
lead an individual to choose to cross-dress and experience femininity
or masculinity occasionally, yet continue to live in the role which
pleases him or her most of the time. The term
"transgendered" describes both of these kinds of people.
Those who elect surgery are transsexuals, and those who do not are
cross-dressers (the term transvestite means the same as
"cross-dresser", but is not considered politically correct.)
It should be noted that cross-dressers almost always know they
don't want surgery, even though they may fantasize about it for erotic
or adventurous purposes. In contrast, most transsexuals start out
believing they are cross-dressers, and spend many years suffering an
internal conflict wondering if it is something more, even while they
try to deny it to themselves.
Having briefly explored the meaning and causes of transgenderism
and transsexuality, it is time to outline the nature and methodology
of the transition from one sex to another.
The Nuts and Bolts
In truth, there is much more to sex reassignment surgery than the
surgery itself. Still, the nuts and bolts of the actual procedure
seems to be a topic which most piques the interest. In deference to
this interest, I'm putting a description of the specific of the
surgery right up front. With that out of the way, we can continue or
exploration into the whole phenomenon, including it's personal,
social, financial, and legal ramifications.
Technically, you cannot truly change one's sex. That's why the
procedure is not really called "sex change surgery" but
"sex reassignment surgery". The idea is to alter the
physical appearance of a person's anatomy to approximate as nearly as
possible the anatomic arrangement of the other sex.
Part of this procedure involves extended hormone therapy, which
alters secondary sexual characteristics. In male to female
transsexuals, it leads to the growth of breasts and the build up of
body fat in particular areas. In female to male transsexuals it lowers
the voice and causes body hair and beard to grow. (It should be noted
that the male to female transsexual's voice is not changed by taking
estrogen.) We shall fully explore the purpose and effects of hormone
therapy later in this book, but for now we shall ignore this aspect in
favor of a blow by blow description of the surgery.
Contrary to popular belief, the penis is not amputated during SRS.
Rather, the internal penile tissue is mostly removed, but the outer
skin is left attached, inverted and inserted into the body inside out
as the new vagina. The testicles are removed, but the scrotal tissue
is also left attached and used to fashion the vaginal lips or labia
through standard plastic surgery procedures.
Here is how it happens. Once the patient has been prepped, sedated,
wheeled into the operating room and anesthetized, the doctor slits the
skin of the penis lengthwise from the head or glans down to the base
on the underside. The skin is then peeled away from around the penis,
but since the slit only opened the penis, the base of the skin is
still attached.
The penile skin is then turned inside out, much like one might turn
a sock inside out. When this is done, the slit is stitched back
together, creating an inverted penis, which will ultimately form the
new vagina.
Before this occurs, a rather miraculous, yet simple procedure is
performed. Earlier, when the internal penile tissue was removed, a
small stub of tissue was left behind, still attached. This is erectile
tissue, which becomes stiff when stimulated, and also carries sexual
sensation.
A tiny slit, perhaps a half-inch in length, is made in the new,
inverted penis near the base where it is still attached. The stub of
erectile tissue is pushed through the slit, forming the equivalent of
a clitoris, and providing the opportunity for complete orgasm and
sexual satisfaction after surgery. In addition, a second tiny slit is
made below the one for the clitoris. The urinary tube is rerouted to
this second slit to create a typical female urinary opening.
Once this procedure has been accomplished, the skin and muscles of
the lower abdomen are lifted up with surgical instruments, providing a
gap near the pelvic bone. The inverted penis is pushed into the gap,
still attached at the base, so that it hinges down and into the proper
location for a vagina.
To allow for proper vaginal contractions later, some of the
abdominal muscles are repositions around to new vagina so that they
can squeeze in on it, both by conscious control and also automatically
during orgasm.
The new vagina is filled with surgical gauze to maintain shape, and
then anchored in place with a thin surgical wire which enters the
abdomen from the outside, runs under the pelvic bone, through the new
vagina, back up around the pelvic bone and out the abdomen again. Once
the vagina has healed in place, which takes approximately seven days,
the wire is removed by the surgeon, who simply slips it out.
The post op patient will remain in bed for seven to eight days. The
pain of surgery is not at all as bad as one might expect. The only
real pain comes if one sneezes, coughs, or laughs. The procedure does
take a lot out of one's reserves, so that the patient drifts in and
out of sleep and is too weak to roll over unassisted for the first day
or so.
For the first three or four days, the patient is on a catheter for
urinary purposes, which allows urine to drain through a tube to a bag
on the side of the hospital bed. This is standard medical procedure
for all urinary surgeries. In addition, any use of general anesthetic
usually causes a shut down of bowel function for three or four days.
Many post op patients require an enema to get the system flushed out
and working again.
Urination after the catheter is removed is painful and difficult at
first, but not to the point one cannot bear it. Over the course of the
first few post op weeks, urination becomes increasingly easier, and
the bladder is able to hold more and more until pre-surgical bladder
capacity is usually recovered.
Most patients are back at work two to three weeks after surgery.
The area of surgery will be sore for more than a month. Sexual
sensation may return in as little as two weeks. Sexual intercourse can
be allowed six weeks after surgery.
Most everyone is familiar with the two principal categories of sex
hormones: Estrogen and Testosterone. In fact there is a whole range of
different specific hormones which are lumped into these two broad
categories.
Hormones are very powerful, natural drugs. They strongly affect
both mind and body. In concentrations too low, they can allow diseases
to flourish, such as osteopleurosis. In concentrations too high, they
can open the door to other maladies, such as blood clots and cancer.
At normal levels, hormones determine our secondary sexual
characteristics, such as breasts and beards as well as fat
distribution and muscle mass.
Mentally, hormones affect our intellect by making us more capable
in the external or internal worlds. They also adjust out feelings,
causing us to be more aggressive or submissive, more reasonable or
emotional.
Certainly, any drug capable of all this is not to be taken lightly.
That is why it is extremely important to use hormones only under the
care and direction of a qualified specialist. Unfortunately, hormonal
issues have historically been considered part of Women's Medicine,
which has been traditionally ignored. So, although more and more
studies are being done in this area today, there is not the wealth of
information available for male medical issues of the same caliber.
For example, very little is known about the affects of different
kinds of estrogens such as Estrone or Estinyl, on the mind. From
personal experience, I have found that using only one of these
hormones alone is not sufficient. Both are present in the female body.
Estinyl is originally created, and then breaks down into a number of
other hormones in the blood stream, including Estrone.
Estrone tends to make one feel more gentle, more graceful and
feminine (regardless of how one may actually appear to others!)
Estinyl causes one to look more toward external issue than internal
ones. So, with Estrone alone, one becomes passive and internalized,
often leading to depression or a lack of ability to accomplish real
world tasks. But Estinyl alone makes one less feminine in thinking and
at a male level of external assertiveness and rational thinking.
For me, after trying many levels and balances between these two, I
found that an even balance between the hormones made me feel feminine
as a person, yet motivated to accomplish. In addition, this balance
allows me to have access to strong emotions, spontaneously when events
warrant, but also to be reasonable in business or practical
situations. This balance will not necessarily be true for anyone else,
as the effects of hormones vary greatly from individual to individual.
Physically, I have found that Estrone alone slows body hair growth,
softens skin, and adds a thin layer of fat all over the body. But it
also makes one more sensitive to cold, lowers the metabolic rate, and
robs one of energy. In contrast, Estinyl alone creates a higher level
of musculature, hardens body lines, removes fat, and raises the
metabolism, often making one feel hot when others are comfortable.
Once again, by balancing the two, a good physical compromise is
reached, where there is enough muscle to feel well toned, but enough
fat to soften the lines. One has a resistance to both cold and heat.
Metabolic rate centers at a good, athletic level.
Of course, most people interested in hormones want to know:
Yes, but hardly ever as large as a normal woman. Usually the
results end up at about an "A" cup, though if you are fat,
you will get more apparent growth because the fat is redistributed to
the breasts.
Yes and no. For female to male transsexuals, the voice will lower
to normal male levels as the voice box or Adam's Apple increases in
size. For male to female transsexuals, the voice must be altered,
either by surgery or by a special technique in which one learns a new
pattern of vocal chord muscle control, which is covered elsewhere in
this book.
No. A penis or vagina will remain even with hormone therapy,
although the penis may diminish somewhat in size, and the clitoris may
enlarge significantly. The physical effects of hormones are primarily
in the secondary sexual characteristics. Some of these effects are
almost immediate, occurring a week to ten days after starting
hormones. Other effects, such as muscle redistribution, continue for
years.
There is a third kind or hormone with very special effects:
Progesterone. Progesterone is the hormone associated with menstruation
and pregnancy. In pre-menopausal women, it ranges from being almost
absent from the system during the middle of a cycle to being the
predominant hormone just before ovulation. Progesterone is what
principally causes premenstrual syndrome (PMS). It also has many
physical effects.
For a number of years, women undergoing hormone replacement therapy
(HRT) have taken a combination of Estrogen and Progesterone to mimic
the natural cycles of menstruation. In addition, it is thought that
Progesterone helps reduce the elevated risk of uterine cancer often
associated with HRT involving Estrogen.
The most commonly prescribed Progesterone is a synthetic hormone
which is similar, though not identical, that which naturally occurs in
a woman's body. For years, women on this therapy suffered leg cramps,
shortness of breath, difficulty in sleeping, and many other serious
and minor maladies before anyone thought to attribute these effects to
the synthetic Progesterone.
Lately, several studies have revealed that the synthetic variety is
indeed the culprit of these problems. The solution is to use natural
Progesterone instead, which occurs in such organic sources as Mexican
wild yams. One can get these supplements from most health food stores,
but the quality and concentration of the Progesterone content varies
widely. I have chosen, for the time being, to avoid using them
altogether, and so far have suffered no noticeable ill effects.
Recently in the news is some disturbing information about Premarin.
While Estinyl is also synthetic (though apparently without serious
side effects), Premarin is a natural hormone. It is purified from the
urine of pregnant mares, hence it's name: PREgnantMAReuRINe.
The problem is, that to get the urine, the mare are kept constantly
pregnant, then locked into small stalls an attached to machines much
like dairy cows. For most of each year, they remain confined, often in
the dark, acting as living factories without any kind of normal life.
For a few brief weeks a year, they are let out to pasture so they can
become pregnant again.
Some women have boycotted Premarin until more humane methods are
implemented. But, since a Premarin/Estinyl mix is essential to a well
balanced life, one must weigh the moral implications against ones
personal needs and arrive at a decision for oneself.
In other areas, the whole notion of HRT is being questioned as a
plot against women. Recognizing the tendency of post-menopausal women
to be more assertive, and considering the fact that menopause is a
natural occurrence, some women's groups are speaking out against the
whole concept, branding it as an attempt to keep women docile and rob
us of our elder wise women. Again, one must make this assessment at a
personal level, rather than simply going with a crowd in either camp
or trying to impose either point of view on everyone.
There are several reputable sex reassignment surgeons in the world
today, and none of them will perform the procedure without sufficient
proof that an individual has met the requirements. These requirements
are not law, but are based on a set of Guidelines originally proposed
by a Dr. Harry Benjamin.
As applied today, these guidelines require that a person seeking
SRS must meet the following specifications:
Live for at least one year full-time in the new gender role
(called Real Life Training or RLT)
Engage in hormone therapy for at least one year (which can be
simultaneous with the full-time experience)
Gain the recommendation of a psychologist or therapist after an
appropriate series of sessions.
Gain a recommendation of a psychiatrist that surgery is not
contrary to the mental health of the patient.
When all these qualifications have been met, each surgeon also
requires an HIV test to read negative (which they have performed at
their facilities) and a personal interview so that they may verify
your mental and physical condition personally.
These guidelines are not arbitrary, yet often seem so to those who
are so motivated and sure of their feelings. But the surgery is not
the big issue in the long run. The real issue is the kind of life you
will have to lead afterward. If you were to have surgery before RLT
only to discover that you really hated the new role, well that would
be a life disaster.
On the other hand, it should be kept in mind that even if one were
to have surgery, the option always remains to continue to live in the
original role, since exposing one's genitals publicly can usually be
avoided, therefore no one would have to know. In fact, I have met one
such person who felt a deep personal need to change his physical sex,
while continuing to live in the old role. For him, it works just fine.
Having briefly outlined the basics, it is time to look deeper into
our subject. What follows is a series of essays regarding all aspects
of sex change and gender identity. Some will cover the material
already presented in greater detail. Others will explore whole new
topics ranging from the conceptual to the practical. Still others will
provide personal commentaries written by those who have taken this
journey themselves.
There are those of you reading this book who are simply interested
in the subject of sex change, but have no desire to follow that path
yourself. There are others who are seriously contemplating this
course, or have perhaps already started down it. As we begin to dig
deeper into the subject, the material presented will hold a different
meaning for each of you.
For those who are simply interested, you will find a much wider
variety of concerns than you have likely imagined. For those who are
faced with this path, you will find these essays both a road map and a
recipe book.
To help guide you to the specific areas in which you are
interested, the remainder of this book has been divided into three
principal sections, followed a series of questions and answers.
Section One deals with practical issues regarding transition,
surgery, and post op living. It includes essays on developing a female
voice, hormone use, information provided by the most noted surgeons,
discussions of legal rights and concerns in the workplace.
Section Two explores personal issues through the stories of those
who have taken this journey themselves, related in their own words.
Section Three examines social ramifications of sex change, as well
as providing useful information for dealing with situations such as
harassment or how to tell one's parents.
The Questions and Answers come both from those in the transgender
community and those who have stumbled across it.
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