Transsexualism describes the condition in which an individual identifies with a gender inconsistent or not culturally associated with their assigned sex, i.e. in which a person’s assigned sex at birth conflicts with their psychological gender. A medical diagnosis can be made if a person experiences discomfort as a result of a desire to be a member of the opposite sex, or if a person experiences impaired functioning or distress as a result of that gender identification.

Transsexualism is stigmatized in many parts of the world but has become more widely known in Western culture in the mid to late 20th century, concurrently with the sexual revolution and the development of sex reassignment surgery (SRS). Discrimination or negative attitudes towards transsexualism often accompany certain religious beliefs or cultural values. However, some cultures have less difficulty integrating people who change gender roles, often holding them with high regard, such as the traditional role for ‘two-spirit’ people found among certain native American tribes.

The current diagnosis for transsexual people who present themselves for psychological treatment is ‘gender identity disorder’ (leaving out those who have sexual identity disorders without gender concerns). The DSM changed its terminology in 1994 away from the diagnosis of ‘transsexualism.’ However, this diagnostic label is often necessary to obtain sex reassignment therapy with health insurance coverage. Some people diagnosed with gender identity disorder have no desire for sex reassignment therapy at all, particularly not genital reassignment surgery, and/or are not appropriate candidates for such treatment. While some feel that formal diagnosis helps to destigmatize transsexualism, others feel that it only adds stigma, essentially feeling that such a diagnosis is equivalent to saying something really is wrong with transsexual people. The diagnosis of ‘gender identity disorder’ is seen as insulting and irrelevant to some transsexual people, and may be considered a causal factor in instances of harm occurring to, or death of, transsexual people as the result of prejudice and discrimination when deprived of their civil rights.

Transsexual men and women (sometimes referred to as trans men or trans women respectively) typically desire to establish a permanent gender role as a member of the gender with which they identify, often pursuing medical interventions as part of the process. These physical alterations are collectively referred to as sex reassignment therapy and may include female-to-male or male-to-female hormone replacement therapy, or various surgeries such as orchiectomy (castration), facial feminization surgery, sex reassignment surgery, trachea shave, and mastectomy (removal of breasts). Transition usually takes several years. Not all transsexual people undergo a complete physical transition due to, for example, the expense of surgery, risk of medical complications, or because they found balance at a mid-point during the process. While many transsexual people adopt heterosexual lifestyles and gender roles, some identify as gay or lesbian. Gender identity takes precedence over morphological sex.

Gender was originally a linguistic term. In many languages, words can be considered masculine, feminine, or neutral, completely independently from the attributes of the things to which the word applies. Different languages manifest gender in various ways, recognizing two genders (female, male), three genders (female, male, neuter), or in some cases none at all. In some (e.g. the Romance languages), variation by gender is indicated by relatively simple changes in nouns and adjectives, while others require more complex grammatical changes. In English, a transsexual person’s first step in transition often includes the request to be referred to using pronouns for their target gender (‘she’ rather than ‘he,’ ‘her’ rather than ‘him,’ and ‘hers rather than his,’ or vice versa). Some English speakers who feel that they are best described as something in between or other than masculine or feminine prefer to use ‘they’ and ‘them,’ as well as ‘ze’ and ‘hir’ (examples of gender neutral pronouns in English) or other invented neutral pronouns.

Austrailian sexologist Norman Haire reported that in 1921, that Dora-R of Germany under the care of Magnus Hirschfeld, began surgical transition from 1921, ending in 1930 with a successful genital reassignment surgery. The word transsexual was used popularized by German-American endocrinologist Harry Benjamin in his seminal 1966 book ‘The Transsexual Phenomenon’ to describe transsexual people on a scale (later called the ‘Benjamin scale’) that recognizes three levels of intensity of transsexualism: ‘Transsexual (nonsurgical),’ ‘Transsexual (moderate intensity),’ and ‘Transsexual (high intensity).’ According to Benjamin: ‘True transsexuals feel that they belong to the other sex, they want to be and function as members of the opposite sex, not only to appear as such. For them, their sex organs, the primary (testes) as well as the secondary (penis and others) are disgusting deformities that must be changed by the surgeon’s knife.’ Benjamin suggested that moderate intensity male to female transsexual people may benefit from estrogen medication as a ‘substitute for or preliminary to operation.’ Dr. Benjamin’s terminology fell out use by the 1970s.

Today, transsexualism is often included within the broader category of ‘transgenderism,’ which is generally used as an umbrella term for people who do not conform to typical accepted gender roles, for example cross-dressers, transvestites, and people who identify as genderqueer. Transsexualism refers to a specific condition in the transgender realm. Thus, even though a crossdresser and transsexual are both transgender people, their conditions differ radically. Though some people use transgenderism and transsexualism interchangeably, they are not synonymous terms.

Some transsexual people object to being included in the transgender spectrum; anthropologist David Valentine contextualizes the objection to including transsexual people in his book ‘Transgender, an Ethnography of a Category.’ He writes that transgender is a term coined and used by activists to include many people who do not necessarily identify with the term. He observes that many current health clinics and services set up to serve gender variant communities employ the term, but that most of the service-seekers do not identify with the term. The rejection of this political category, first coined by self-identified activist Leslie Feinberg, illustrates the difference between a self-identifier and categories imposed by observers to understand other people. Historically the reason that transsexual people rejected associations with the transgender or broader LGBT community is largely that the medical community in the 1950s through the late 1980s encouraged this rejection of such a grouping in order to qualify as a ‘true transsexual’ who would thus be allowed to access medical and surgical care.

Though the beliefs of some modern day transsexual people that they are not ‘transgender’ reflects this historical division, other transsexual people state that those who do not seek SRS are very different from those who need to be of ‘the other sex,’ and that these groups have different issues and concerns and are not doing the same things. The latter view is rather contested, with opponents pointing out that merely having or not having some medical procedures hardly can have such far-reaching consequences as to put those who have them and those who have not into such distinctive categories. Notably Harry Benjamin’s original definition of transsexualism does not require that they need to have had SRS.

The word ‘transsexual’ is most often used as an adjective rather than a noun – a ‘transsexual person’ rather than simply ‘a transsexual.’ Transsexual people prefer to be referred to by the gender pronouns and terms associated with their target gender. For example, a transsexual man is a person who was assigned the female sex at birth on the basis of his genitals, but despite that assignment identifies as a man and is transitioning or has transitioned to a male gender role and has or will have a masculine body. Transsexual people are sometimes referred to with ‘assigned-to-target’ sex terms such as ‘female-to-male’ for a transsexual man or ‘male-to-female’ for a transsexual woman.

Psychological and biological causes for transsexualism have been proposed, with evidence leaning toward prenatal and genetic causes. There is considerable evidence that prenatal exposure to endocrine-disrupting anti-miscarriage drugs such as diethylstilbestrol (DES) may be positively associated with transsexualism, though research in this area has yet to establish a firm causal link. Some people consider research into the ’causes’ of transsexualism to be based on the assumption that it is a pathology, an assumption that is rejected by many transsexual people. Others think of the condition as a form of intersexuality (sexual characteristics midway between male and female), and support research into possible causes, believing that it will verify the theory of a biological origin and thereby reduce social stigma by demonstrating that it is not a delusion, a political statement, or a paraphilia (sexual fetish).

Harry Benjamin wrote, ‘Summarizing my impression, I would like to repeat here what I said in my first lecture on the subject more than 10 years ago: Our genetic and endocrine equipment constitutes either an unresponsive, sterile, or a more or less responsive, that is to say, fertile soil on which the wrong conditioning and a psychic trauma can grow and develop into such a basic conflict that subsequently a deviation like transsexualism can result.’

To obtain sex reassignment therapy, transsexual people are generally required to undergo a psychological evaluation and receive a diagnosis of gender identity disorder in accordance with the Standards of Care (SOC) as published by the World Professional Association for Transgender Health. This assessment is usually accompanied by counseling on issues of adjustment to the desired gender role, effects and risks of medical treatments, and sometimes also by psychological therapy. The SOC are intended as guidelines, not inflexible rules, and are intended to ensure that clients are properly informed and in sound psychological health, and to discourage people from transitioning based on unrealistic expectations.

Psychological techniques that attempt to alter gender identity to one considered appropriate for the person’s assigned sex are typically ineffective. The widely-recognized Standards of Care note that sometimes the only reasonable and effective course of treatment for transsexual people is to go through sex reassignment therapy. The need for treatment is emphasized by the high rate of mental health problems, including depression, anxiety, and various addictions, as well as a higher suicide rate among untreated transsexual people than in the general population. These problems may be alleviated by a change of gender role and/or physical characteristics. Many transgender and transsexual activists, and many caregivers, note that these problems are not usually related to the gender identity issues themselves, but the social and cultural responses to gender-variant individuals. Some transsexual people reject the counseling that is recommended by the Standards of Care because they don’t consider their gender identity to be a psychological problem.

After an initial psychological evaluation, men and women may begin medical treatment starting with hormone replacement therapy or hormone blockers. People who change sex are usually required to live as members of their target sex for at least one year prior to genital surgery, so-called Real-Life Experience (RLE) or Real-Life Test (RLT). Transsexual individuals may undergo some, all, or none of the medical procedures available, depending on personal feelings, health, income, and other considerations. Some people posit that transsexualism is a physical condition, not a psychological issue, and assert that sex reassignment therapy should be given on request.

Laws regarding changes to the legal status of transsexual people are different from country to country. Some jurisdictions allow an individual to change their name, and sometimes, their legal gender, to reflect their gender identity. Within the US, some states allow amendments or complete replacement of the original birth certificates. Some states seal earlier records against all but court orders in order to protect the transsexual’s privacy. In many places, it is not possible to change birth records or other legal designations of sex, although changes are occurring. Estelle Asmodelle’s book documented her struggle to change the Australian birth certificate and passport laws, although there are other individuals who have been instrumental in changing laws and thus attaining more acceptance for transsexual people in general.

In many countries, laws provide protection from workplace discrimination based on gender identity or gender expression, including masculine women and feminine men. An increasing number of companies are including ‘gender identity and expression’ in their non-discrimination policies. Often these laws and policies do not cover all situations and are not strictly enforced. California’s anti-discrimination laws protect transsexual persons in the workplace and specifically prohibit employers from terminating or refusing to hire a person based on their transsexuality. Some transsexual men and women choose to live completely as members of their target gender without being public about their past. This approach is sometimes called ‘stealth.’

Films depicting transgender issues include: ‘The World According to Garp,’ ‘The Adventures of Priscilla, Queen of the Desert,’ and ‘The Crying Game.’ The film ‘Different for Girls’ is notable for its depiction of a transsexual woman who meets up with, and forms a romantic relationship with, her former best friend from her all-male boarding school. ‘Ma Vie en Rose’ portrays a six-year-old child who is gender variant. The film ‘Wild Zero’ features Kwancharu Shitichai, a transsexual Thai actor. When the main character is conflicted about falling in love with a ‘woman who is also a man,’ Guitar Wolf tells him ‘Love knows no race, nationality or gender!’ Two notable films depict transphobic violence based on true events: ‘Soldier’s Girl’ (about the relationship between Barry Winchell and Calpernia Addams, and Winchell’s subsequent murder) and ‘Boys Don’t Cry’ (about Brandon Teena’s murder). Calpernia Addams has appeared in numerous movies and television shows, including the 2005 movie ‘Transamerica,’ in which Felicity Huffman portrays a transsexual woman.

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