Transsexuals
FAQ
There are around 2,000 transsexuals in the UK. David Batty explains what a
gender change involves and what rules govern treatment
What is transsexualism?
Transsexualism is a gender identity disorder (GID) in which there is a strong
and enduring desire to live and be accepted as a member of the opposite sex.
Transsexuals feel a persistent discomfort with their anatomical sex and a sense
of unease in the gender role of that sex. They wish to have hormonal treatment
and gender reassignment surgery - a sex change - to acquire the physical
characteristics of their psychological sex.
How many transsexuals are there?
A report from the Interdepartmental Working Group on Transsexual People in 2000
estimated that there were 1,300-2,000 male-to-female and 250-400 female-to-male
transsexuals in the UK. However the transgender lobby group, Press for Change,
puts the numbers far higher. It estimates there are 5,000 post-operative
transsexuals in this country.
What treatment is there for transsexuals?
The currently accepted and effective model of treatment involves hormonal
therapy and surgical reconstruction, and may include counselling and other forms
of psychotherapy. The course of treatment depends on the individual's needs, and
is usually negotiated between the patient's GP and the psychiatrist and surgeon
providing specialist care.
What does hormonal therapy involve?
Male-to-female patients treated with oestrogens can expect to experience: breast
growth, some redistribution of body fat in line with a more feminine appearance;
decreased upper body strength; softening of the skin; a decrease in body hair;
slowing or stopping of loss of scalp hair; decreased fertility and testicular
size; and less frequent, less firm erections. Female-to-male patients treated
with testosterone can expect the following permanent changes: a deepening of the
voice; clitoral enlargement; reduction in breast size; more facial and body
hair; and male pattern baldness. Reversible changes include: increased upper
body strength; weight gain; increased sex drive; and decreased hip fat.
What surgery is performed?
Depending on the appearance and health of the patient, surgery for
male-to-female transsexuals may include: removal of the penis (penectomy);
construction of a vagina (vaginoplasty); removal of the testicles (orchidectomy);
construction of a clitoris (clitoroplasty); and possible breast augmentation;
nose reshaping (rhinoplasty); cosmetic surgery such as hair transplants or
facial remodelling; shaving of the Adam's apple (thyroid chrondroplasty) and
raising the pitch of the voice (crico-thyroid approximation). For female-to-male
transsexuals, surgery may include removal of the womb and ovaries (hysterectomy
and oophorectomy); removal of the breasts (bilateral mastectomy); and possibly
construction of a penis (phalloplasty).
What other treatments are there?
Male-to-female transsexuals may undergo electrolysis to remove their beard and
body hair. Transsexuals might also seek speech therapy to help attune their
voices to their acquired gender.
Are there any rules governing this treatment?
Although there are no legally binding rules, standards of care have been drawn
up by the Harry Benjamin International Gender Dysphoria Association (HBIGDA).
The association has established standards of care for the treatment of GIDs,
which are generally accepted by psychiatrists across the world. These standards
are revised to take into account new scientific information, and were last
updated in 2001. They provide "flexible directions" for the treatment of
transsexuals, which may be modified in line with a patient's particular needs
and circumstances. They include minimum eligibility requirements for some
procedures, such as the prescription of hormones and sex change operations.
What do the guidelines state?
With regards to hormonal therapy, the
HBIGDA guidelines set
three criteria. Firstly, patients should be over 18. Secondly, they should be
aware of the effects and risks of taking the drugs. And thirdly, they should
have documented proof that they were living in their desired gender role for at
least three months (known as the "real life experience"); or have undergone a
minimum of three months of psychotherapy. With regards to surgery, there are six
eligibility criteria, the most important of which are that the patient should be
a legal adult; have had 12 months of continuous hormone therapy; and have lived
in their desired gender role for a year. There are also two readiness criteria.
Patients should demonstrate that they are consolidating their gender identity,
and enjoy better mental health as a result of dealing effectively with work,
their family and relationships. Psychiatrists are required to check that
patients meet these criteria.
Why are the guidelines important?
Some of the procedures are irreversible, so patients need to fully understand
and be prepared for treatment. Some of the side-effects of hormone therapy, such
as an increase in blood clotting, can be life threatening to patients in poor
health, for example those with heart disease. Some people with psychotic
illnesses may mistakenly believe they are transsexual, but a thorough
psychological assessment should prevent misdiagnosis.
Are the guidelines officially recognised in the UK?
The standards of care are "generally supported" by the Royal College of
Psychiatrists (RCP), though it does not formally recognise them. There is
disagreement among psychiatrists over the period patients should spend living as
their desired sex prior to hormone therapy and surgery. Dr Brian Ferguson, a
member of the RCP's working party on GID, said many psychiatrists would consider
it "reasonable" for patients to live in their desired gender role for two years
before surgery - twice the length of time recommended by the
HBIGDA. The college
is working towards drawing up UK guidelines in partnership with the
transgendered community.
What do transsexuals make of the guidelines?
Again, there is not a consensus of opinion. Some transsexuals believe that
psychiatrists stick too strictly to the
eligibility criteria, without taking into account the circumstances and
history of the individual patient.