The writer of this article is a common-or-garden male-to-female transsexual, but not a medical, psychological or biological expert.  She does not consider herself competent critically to assess the merits of the scientific articles referred to.  The reader is cautioned accordingly.  No liability, express or implied, is accepted for the accuracy of the content of this page.

Other conditions besides transsexualism may lead to people to seek gender reassignment.  Transsexualism is discussed first then the other conditions.

It should be stated at the outset that there is no standard terminology.  Terms which were acceptable a generation ago are sometimes frowned on today.  Definitions can become obsolete because of new medical or scientific discoveries.  In addition, different people use words like ‘transgender’ to mean different things.  This unfortunately adds confusion to a subject that is already very baffling to its sufferers.

Gender Dysphoria

Dysphoria is a word of Greek origin meaning discomfort.  This discomfort with the sex one is assigned at birth can be mild or it can be very, very painful.

There is a whole spectrum of gender dysphoria.  Some otherwise apparently normal men feel a strong urge to live as women from time to time.  If this urge is thwarted, they become very distressed.  Attitudes to femininity in men are often hostile, so much so that men with mild gender dysphoria are forced to live out their femininity in secret.  Such people are not fundamentally unhappy to be men: but they are more than just men. 

There are also people who spend much if not all of their lives as women, even though they have male bodies, without having hormone treatment or surgery.  They may be perfectly happy to live like that.

Strong gender dysphoria is sometimes known as transsexualism.


The writer’s psychiatrist has written her a letter formally diagnosing her as a transsexual under the International Classification of Diseases (ICD-10), category F64.0. Under this classification 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

  1. 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

Non-transsexual causes of gender reassignment

There is a good article on intersexed people at http://en.wikipedia.org/wiki/Intersex.  According to this article, 1-2 babies in every 1000 are born with sufficiently ambiguous genitals that surgery is used to ‘correct’ the ambiguity.  Tragic mistakes are sometimes made.  The person may be assigned to one sex when they are only comfortable living as the other.

This issue may have a different cause from transsexualism, but many of the life experiences of intersex people who undergo gender reassignment are similar to those experienced by transsexuals.  Avon Trans Women welcomes enquiries from intersexed people who wish to change sex, already have transitioned or are in the process of transitioning.

Mental illness and gender dysphoria

Some schizophrenics have episodes of believing themselves to belong to the opposite sex1,2.  Such symptoms respond to medication3.  In rare cases where they do not, a double diagnosis of transgenderism and schizophrenia may be made.  A mental health professional would be able to recognise schizophrenia, and distinguish it from transsexualism.  This is clearly not a task for amateurs.

Transsexualism does not respond to medication or attempts to “cure” it other than gender reassignment.

In general, transsexuals show about the same incidence of mental illness as the rest of the population4.

Is transsexualism a disorder or disease?

Whether transsexualism is a disease or disorder, or merely a normal variant of human gender, is a hotly debated topic. 

The argument against it being a mental illness is that sufferers sometimes find the unfortunate stigma attached to mental illness distressing; and people confuse having something morally wrong with you with having a fault that needs fixing.  Even victims of cancer and heart attacks are not immune from stigma: they are accused of eating the wrong things, not exercising etc. 

The argument for classifying transsexualism as a disease is that a woman with a male body needs it fixing so that it is as female as humanly possible.  This is expensive, and the NHS will not pay for treatment if it is labelled as a lifestyle choice like whether to drive a Fiat Panda or a BMW.  Transsexuals will tell you that the desire to transition is a very strong and extremely distressing urge, in an altogether different league from choice of transport.  Classifying transsexualism as a mental illness also has advantages when it comes to negotiating time off for treatment with employers.

Can Transsexualism be Cured?

In a word, no5

The medical profession has a history of failed attempts.  The writer has met someone who was given electric shock therapy in an attempt to cure the desire to belong to the opposite sex.  This person, raised as a boy, now lives happily as a woman.  The electric shock ‘therapy’ failed totally.  Aversion therapy does not work.  It just makes distressed people even more unhappy.  Giving male-to-female transsexuals male hormones does not prevent gender dysphoria.  Nor does psychotherapy6.   Gender dysphoria is a lifelong condition. 

The only therapies that have proved successful have been those aimed at helping the sufferer to live with the condition.  In mild cases counselling may suffice.  In cases where the gender dysphoria is strong, the only viable treatment may be to enable he person to change sex to the greatest extent possible given the current state of medical technology.  Regret rates among transitioners are low7,8.

In short, the only effective treatment for strong gender dysphoria is gender reassignment.

Are Transsexuals and other Gender Reassignees Gay?

Everyone who undergoes gender reassignment spends part of their life as a male and part as a female, whether they transition in one direction or the other.  The question is therefore meaningless really: relative to which sex are transsexuals supposed to be gay?  The rest of the population contains people who are straight, gay, bisexual and asexual.  It should be no surprise then that people who undergo gender reassignment are sometimes attracted to men, women, both or neither.  The writer has talked to enough such people to know that this is so.  Some gender reassignees’ sexual preferences change as they transition.  The writer has heard one person say, “I was a straight man and now I’m a straight woman,” and another say that her preference switched from women to men soon after she had sex reassignment surgery.

It is not completely true to say that sexual and gender identities are entirely separate.  After all the majority of people who are sexually attracted to women are men and vice-versa.  However, they are largely separate.  Gay men are usually quite insistent that they are men; and lesbians are usually equally certain that they are women.

After transition, most male-to-female transsexuals are attracted to men.  A significant minority are not.  It is therefore fair to say that the fact that someone is a male-to-female gender reassignee does not enable you to predict what their sexual orientation will be.

What treatment is required for gender reassignment?

Treatments for male-to-female gender reassignment fall into the following categories9.

Hormone treatment

The female hormone estrogen10 (or estradiol) is taken as pills, a rub-on ointment or as transdermal patches.  Sometimes before surgery a testosterone blocker is also administered.  Examples of testosterone blockers are Spironolactone11 and Finasteride12.

In times past another female hormone, progesterone, was also given for gender reassignment.  It was found that it has a lot of bad side effects, and may even inhibit breast growth.  No real benefit ensued, so its use was discontinued13.

Hair removal

Hormone treatment will reduce male body hair over time, but has little effect on beard growth.  The beard must be removed.  Two methods exist: light based treatments such as laser, IPL or ELOS14; or electrolysis15.

Light based methods are quicker, but they only work for dark hair growing in pale skin.  Electrolysis works for all skin and hair colours, but it is slow because the hairs must be treated one by one.  It also has the disadvantage that three days’ beard growth is required, which can make life very difficult for gender reassignees living as women.

Voice therapy

Hormones also do not reverse the deepening of male voices.  It is surprising how much can be achieved with appropriate training.  Pitch is only part of the story, though.  Female voice mannerisms also have to be learned.  It is remarkable how differently men and women talk.  To practice as a speech therapist in England, you have to be qualified.  Some NHS trusts offer limited speech and language therapy.

There is a surgical procedure called cricothyroid approximation16 that can be used to raise voice pitch.  It does not always work, and you only get the benefit with speech therapy before and afterwards. 

The Adam’s apple can be smoothed off.  This operation is known as a tracheal shave17

Sex reassignment surgery

In a procedure known as vaginoplasty18, the existing genital tissue is used to create a vagina, clitoris and vulva.  The resulting organs look from the outside very much like what a lifelong woman possesses.  There is no cervix, uterus or ovaries.  Medical technology has not yet figured out a way to make those for us.

Approximately 80% of trans women are able to achieve orgasm afterwards, compared to 90% of lifelong women19.

Because the vagina, sometimes called a neovagina, is artificial, it has to be kept open for the rest of the patient’s life by a process known as dilation, whereby plastic inserts are placed in the opening for a few minutes perhaps twice a week, but much more frequently in the weeks following surgery.  The quality of the neovagina is critically dependent on the patient’s willingness to dilate regularly.

There is a slightly less drastic operation called a cosmetic procedure in which the clitoris and vulva are made, but there is no vaginal opening which requires maintenance by dilation.  This option is sometimes taken by older trans women.  It may also be the only option for some intersex patients or those whose penis never formed fully, or is very small: the penile skin is used as donor tissue.  A competent surgeon can advise you.

It is possible to use bowel tissue as donor tissue to make a vagina, although this is not common.  In circumcised patients, extra scrotal tissue is used to deepen the vagina.

Facial Feminisation Surgery20

The idea is to alter the bone and cartilage structure of the face to make it look less masculine and more feminine.  It is a major operation, requiring several weeks recovery time.

Most literature references to this topic are written by people trying to sell you their services.  The article at http://www.virtualffs.co.uk is no exception, but it is more informative than most, and its owner is only trying to sell you pictures, not surgery.

The NHS will not pay for facial feminisation surgery, which can cost up to £25,000.  This is beyond the reach of most transsexuals.

Decisions regarding facial feminisation surgery should not be taken until at least a year of doctor-supervised hormone treatment.  This is because estrogen will redistribute the fat in your face, and change the skin quality, making you look much more feminine than you did when you started taking hormones.

How do I access treatment?

Under the National Health Service, the first port of call is your GP.  You should ask him or her for a referral in the first instance to a local psychiatrist.  In the Avon area, such a psychiatrist might be Dr. Pradeep Agrawal, although we do not doubt that there are other good psychiatrists and psychologists locally.

If the psychiatrist or psychologist is convinced that you have gender dysphoria and not another mental illness such as schizophrenia, he or she will then refer you to a national gender identity clinic, almost certainly the West London Mental Health Trust Gender Identity Clinic, also unofficially known as Charing Cross GIC.  This referral process is explained at http://www.wlmht.nhs.uk/gi/gender-identity-clinic/how-to-be-referred.  Your GP cannot refer you to this clinic, and you cannot refer yourself.

They insist on at least two examinations by different doctors before they will prescribe hormones.  They will also arrange sex reassignment surgery, but only after a two-year real-life test, in which you have to convince them that you can operate successfully in a female role. It is not enough to live as a woman ‘in the closet’: you are required to demonstrate that you are an active, participating member of your local community.  The gender identity clinic’s web site explains this:


Unfortunately the waiting lists for this process can be up to a year long.

There are hair removal clinics in Bristol, and in London.  Please see the ‘where to go’ page of this web site.

Some NHS trusts will fund limited speech therapy.  You can buy courses on speech therapy for transsexuals, although in the writer’s experience they are not as good as face-to-face speech therapy.  We will report group members’ experiences with speech therapy on the ‘where to go’ page of this web site.

if you are Pre Transition, in a marriage still or have a partner and are torn with indecision, then please go talk to your Gp and ask to be referred to a gender clinic so you can talk through your feelings. Going to a gender clinic does not mean you have to transition. they are there to help you to discover the real you and sort through the confusion.

support groups are good for meeting like minded people but we are not professionals and certainly do not listen to anyone claiming their way is the only way.

For help with successfully presenting as a woman, we can suggest is to sit in a street cafe or watch women in a super market or any other everyday place, then practice their movements the way they carry themselves, one warning don’t get carried away with over doing the body language and hand movements as this is a big give away. keep it natural.

If you already have women friends, they too can help: after all they have a lifetime’s training in how to be a woman.  Sometimes however, lifelong women are not necessarily experts in the fine art of disguising a male body well enough to pass unnoticed as a woman.  This is not just a matter of dressing appropriately for your age: it is also a matter of using the right body language and toning down masculine speech patterns.  It takes time to learn this, so please don’t panic if you don’t quite get it right at first.


1 Laurence Borras, Philippe Huguelet, and Ariel Eytan (2007). Delusional “Pseudotranssexualism” in Schizophrenia. Psychiatry: Interpersonal and Biological Processes: Vol. 70, No. 2, pp. 175-179.

2 N. Kar & G. C. Kar, Editors, Comprehensive Textbook of Sexual Medicine, New Delhi: Jaypee Brothers medical Publishers Ltd, 2005, pp. 431-433.

3 Rameez Zafar, Schizophrenia and gender identity disorder, The Psychiatrist (2008) 32: 316-317

4 Collier M. Cole, Lee E. Emory, Walter J. Meyer III & Michael O'Boyle, Comorbidity of Gender Dysphoria and Other Major Psychiatric Diagnoses, Archives of Sexual Behavior. Volume: 26, Issue: 1, 1997

5 P. T. Cohen-Kettenis and L. J. G. Gooren , Transsexualism: a Review of Etiology, Diagnosis and Treatment, Journal of Psychosomatic Research, Vol. 46, No. 4, pp. 315–333, 1999

6 Human Sexuality. The American Medical Association Committee on Human Sexuality. Chicago. 1972.

7 Landén M, Wålinder J, Hambert G, Lundström B., Factors predictive of regret in sex reassignment, Acta Psychiatr Scand. 1998 Apr;97(4):284-9.

8 Pfäfflin F, Junge A. (1998). Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991 (quotation from the Final Remarks section). (Translated from German into American English by Roberta B. Jacobson and Alf B. Meier).

9 P. T. Cohen-Kettenis and L. J. G. Gooren , Transsexualism: a Review of Etiology, Diagnosis and Treatment, Journal of Psychosomatic Research, Vol. 46, No. 4, pp. 315–333, 1999

10 Eva Moore, Amy Wisniewski and Adrian Dobs , Endocrine Treatment of Transsexual People: A Review of Treatment Regimens, Outcomes, and Adverse Effects, Journal of Clinical Endocrinology & Metabolism, 88 (8): 3467, 2003.   

11 http://en.wikipedia.org/wiki/Spironolactone

12 http://en.wikipedia.org/wiki/Finasteride

13 http://www.changelingaspects.com/PDF/The%20Lowdown%20on%20Progesterone.pdf

14 David J. Goldberg (Editor), Laser Hair Removal, Second Edition Informa Healthcare; 2nd edition, 2008

15 Angela Wheat, The Complete Guide to Electro Epilation, Hodder & Stoughton, 2002.

16 http://en.wikipedia.org/wiki/Cricothyroid_approximation#Vocal_surgeries

7 http://www.virtualffs.co.uk/Adam%27s_Apple.html

18 Karim R.B., Hage J.J. & Mulder J.W., Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility, Ann Plast Surg. 1996 Dec; 37(6):669-75.

19 Thomas, P., 2010, Unpublished talk at Transgender 2010 Conference, Norwich, England.

20 http://en.wikipedia.org/wiki/Facial_feminisation_surgery


Friday, 30 March 2012

Gender Reassignment: a Primer