Information for the Family
Nothing in life had prepared me for that cold, windy day in
Portland, Oregon, when my 32-year-old son confessed to me that he
was a transsexual. First, the word had to be explained to me, for
this was not a word in my vocabulary. Then, after the realization
of what this meant with all its ramifications and complexities, I
experienced a whole range of emotions--fear, quilt, anger, despair
and even mourning. I wished that I could close my eyes and make
this strange, new problem in my life disappear. But no amount of
wishful thinking solves the dilemma, nor does rejection of our
What is needed is an understanding of the phenomenon known as
transsexualism, an acceptance of our loved ones who are unique in
this regard, and above all, love and support of our transsexual
member of the family or friend at a time when they need it most.
My daughter is now 36. The surgery was performed 3-1/2 years
ago. Electrology, hormonal treatment and psychotherapy were also
part of the transitional process. She is a productive, successful
person in her career and at peace with herself personally. All of
this would have been extremely difficult, if not impossible, without
the love and support of her family and friends.
Mrs. Jeanne Ebner
TRANSSEXUALISM: WHAT IS IT?
When a member of the family of a transsexual asks this question,
his interest in the answer is neither general nor academic. His
concern is a practical one. He is asking: how did my son or
daughter come to be as he or she is; is his condition reversible; if
not, what professional help is available to him, and how may I
help? The aim of this pamphlet is to provide you, in simple terms,
with specific information, derived from the latest medical research,
which will be useful to you. But it is important for you to
understand that professional help is only one ingredient in the
successful rehabilitation of the transsexual. The other, which only
you can supply, is the love, concern and acceptance that are
manifested by those people who are important to him.
When we say that man's gender identity is psychosexual in
essence, we refer not merely to his physical characteristics, but to
an intricate, variable complex of mental traits and tendencies,
subtle and emphatic. For most of us, these qualities and
characteristics resolve themselves into a harmony that declares
itself as predominately masculine or feminine. This psychosexual
identity which we present to the world satisfies our cultural
definitions, and many comfortably be taken for granted by us and by
those around us.
Not so for the transsexual. For him, the apparent sexual
balance, as expressed in the primary sex characteristics--i.e. the
genitalia, is deceptive. It does not reflect, indeed it
contradicts, the inner balance he strongly feels, and which to him
represents his true psychosexual identity. In some instances of
transsexualism, where the secondary sex characteristics--i.e. heavy
facial or body hair in the male, feminine hips and pronounced breast
development in the female--shade into those of the opposite sex, the
body itself has already begun to bear out this inner conviction.
But physical ambiguities are by no means general in every instance
in which an individual's powerful, intimate sense of self
contradicts his sex as recorded at birth.
There are other gender identity disturbances which are
sometimes confused with transsexualism, but which are distinct from
it. The homosexual and the transvestite experience some conflict
between sex and gender. But neither of these has any desire to
change his anatomy. The transsexual, on the other hand, feels that
he has been trapped in the body of the wrong sex and he seeks help
to be freed from this predicament.
How Did It Happen? Is It Reversible?
The best efforts of skilled, dedicated professionals in the
physical and psychological sciences have so far failed to uncover
the origins of the transsexual condition. The most impressive
hypotheses put forward to date, based upon careful and open-minded
clinical studies, indicate that several possible elements should be
considered together: functioning of the brain and of the endocrine
glands, neurological mechanisms, cultural and other environmental
Most, if not all, specialists in gender identity are agreed
that the transsexual condition establishes itself very early, before
the child is capable of elective choice in the matter, probably in
the first two years of life. Others believe it is set even earlier,
before birth during the fetal period.
These findings indicate that the transsexual has not made a
choice to be as he is, but rather that the "choice" has been made
for him through many causes preceding birth and beyond his control.
When you fully understand that the condition is confirmed so early
in life, and that no individual can a make a conscious decision to
be a transsexual, this comprehension should allay some of your
anxieties and help you to deal with the transsexual with greater
sympathy. It will become clear, too, why psychotherapy is rarely,
if ever, successful after early childhood. Yet, some sort of
treatment is urgently indicated, for in many instances the
transsexual's suffering is so intense that suicide and
self-mutilation are not uncommon. Therefore, many professionals
have come to share the view of the distinguished doctor who said:
"If the mind cannot be changed to fit the body, then perhaps we
should consider changing the body to fit the mind." Thus
scientists, through painstaking clinical processes, have arrived at
the same conclusion to which the transsexual's suffering led him as
he desperately sought a remedy for his daily sense of dissonance
between his mind and body.
Physicians and psychiatrists have been deeply impressed with
the fortitude with which many of their transsexual patients confront
physical pain, economic sacrifice, and complicated social and
emotional adjustments in their commitment to the liberating process
of sex reassignment. Medical specialists who maintain a careful,
long-term follow-up on their transsexual patients have reported
that, where other efforts at treatment have failed, corrective
surgery has produced "subjective and objective improvement in life
adjustment in a majority of cases." The keys to success are: 1)
proper screening, 2) counseling, and 3) family support before,
during, and after surgery.
Is it reversible? The vast majority of medical practitioners
seriously concerned with problems of gender identity in the adult
have answered "No", not in the "true" transsexual. But to this
negative answer they have mercifully added positive suggestions for
treatment which offer relief and hope to the transsexual:
counseling, hormone therapy and surgery.
Highly qualified doctors of physical and psychological
medicine all over the world, working singly or in teams, are
increasingly concerning themselves with investigations into the
causes and treatment of transsexualism. Evidence as to causes, and
data as to effects of treatment, are accumulating, encouraging the
hope that earlier diagnosis and more effective preventive and
ameliorative procedures, as well as education of the general public,
will successfully reduce this source of human suffering.
But it cannot be too strongly stated that question "why" is
the scientist's proper job, his alone. It is harmful, and even
destructive for the family of a transsexual to look back for the
causes of his difficulties. Such a search based on one case only
and biased by emotional involvement may easily mask an assignment of
guilt either to yourself or to your child. It would be better to
look instead to the present, and share this present with him,
fulfilling his need for your love, understanding, and acceptance.
Earlier it was stated that each individual embodies in himself
a balance of contrary qualities, masculine and feminine.
Philosophy, religion and science are also agreed in this conclusion:
that each individual forms a constellation with every other, that we
are all members of the same body. If the fate of each influences
the fate of all, surely this is so to a heightened degree for those
whom circumstance has brought together in one intimate familial
environment and by one bloodline. It should then be evident that
what nature has united we may sunder only at great personal cost.
One may regard a problem such as a transsexual child as
something to be pushed aside and forgotten; but in fact, by
confronting such a problem one finds opportunities for growth, a
chance to learn about and appreciate qualities in one's child which
seemed undesirable when "out of context" in his male body, but which
not appear lovely. A difficulty avoided inevitably returns to
challenge us in a more acute form. So do not turn from a loved one
at the time of his greatest need.
No parent of an adult transsexual is wholly prepared for the
revelation of his condition. There have generally been numerous
clues, usually from early childhood and always from adolescence,
when the psychosomatic crises of that period produce distress
signals that are often most dramatic. You may have no doubt shared
in his embarrassments and traumas, when, since his natural behavior
was inappropriate to his genetic sex, he was rejected by his peers,
looked at askance in public, and finally retreated into a painful
isolation. Remembering your own discomfort on his behalf, recognize
that the primary and more intense suffering was his alone; just as
it is he who now bears the heaviest burdens of readjustment to a new
life. Now that he has finally found a way to correct those
conditions that created painful experiences for you as well as for
him, it should bring a sense of relief to you, too.
Almost any biologically complementary couple may participate
in procreation. You are called upon to assist at a re-creation;
your child's second birth. Mistakes are remedied so that he can
begin to fulfill himself personally and as a happily contributing
member of society. Through your vitally important, loving support,
you can be a participant in his adventure, sharing in the release
and liberation of his new life.
RESEARCH ON TRANSSEXUALISM
Although the causes of the transsexual condition are not yet
understood, extensive research in recent years has indicated some
possible biological and psychological factors which might render one
individual more vulnerable than another to develop in this way.
Experiments with animals suggest that the altering of hormone
balances, during certain limited, critical prenatal periods, will
affect those areas of the brain that regulate masculine and feminine
behavior. Other medications administered to the pregnant mother
(barbiturates for example) may also have an effect on the
development of the unborn child, as may certain intrauterine viral
Transsexual symptoms need not develop under such
circumstances, and of course, usually do not. Predetermining
circumstances may simply make the individual more susceptible to the
development of transsexualism. The postnatal determinants of
gender-identity--the child's relationships with those who form his
early social environment--may then supply the deciding factor, if
these relationships are seriously disturbed during the critical
postnatal period of gender identity formation.
Research over the past 30-plus years has shown that
pre-surgical transsexuals as a group are among the most miserable of
people, often exhibiting extreme unhappiness which frequently brings
them to the verge of suicide or self-mutilation. The transsexual's
problems are further complicated by a near consistent trend towards
rejection by both family and friends, harassment and/or
discrimination in varying degrees by most of society, and more often
than not, a refusal by many in the legal and medical professionals
to render services; either by reason of questioning the validity of
such a diagnosis, or fear of potential peer and/or community
Ineffective Modes of Treatment
If gender identity is set at an age that precedes the child's
ability to make a conscious choice, it is clear that he is without
responsibility for his disturbance in gender identity. To try to
coerce the child into behavior that conforms with his anatomy,
whether by threats, physical force, or the withholding of love, must
be seen to be barbarous, as well as ineffective. It could be fatal.
In medicine, this attitude has its counterpart in therapies
such as electro-shock and aversion therapies, with results that are
sometimes brutally harmful but which never "cure" transsexualism.
It is generally agreed that an adult transsexual will not
benefit from psychotherapy designed to change his identity. Whether
a child who shows signs of gender identity disturbance will or not
is not known, but it is usually advised so that all avenues of help
may be explored.
How Patients Are Chosen
The first step for an adult transsexual who seeks treatment
should be a consultation with a psychiatrist who has had previous
experience in working with transsexuals and adheres to the
"Standards of Care" developed by the Harry Benjamin International
Gender Dysphoria Association (HBIGDA). A practitioner who is
unfamiliar with the theory and practice of medical therapy for
transsexuals may flatly refuse help or blunder in the help he
offers. Thus it is of critical importance to begin with a
professional who has the necessary qualifications and experience.
Gender identity clinics are usually associated with a
university and are engaged in a variety of research projects in the
field of gender identity. If the individual applying does not meet
the precise requirements of the work in progress at the clinic of
his choice, he may be refused treatment there solely on these
grounds. This does not necessarily mean that he is not a good
candidate for sex reassignment, and should not discourage him from
applying to another clinic where help may be available to him.
Apart from the special restrictions of their research
programs, most gender identity clinics agree on certain criteria for
accepting the transsexual who is over twenty-one for diagnosis and
treatment leading to surgery. These requirements are designed to
eliminate candidates whose judgment is impaired or who are otherwise
too severely disturbed to benefit from sex reassignment; those who
are not clearly decided on this course and who might later regret
their decision; and those who, in the opinion of the consulting
staff might not, for a variety of reasons, make a successful
adjustment to the new role.
Major gender identity programs are located in San Juan
Capistrano, San Francisco, and Palo Alto, California, Minneapolis,
Minnesota, Galveston, Texas, Denver, Colorado, and Charlottesville,
Virginia. Additionally, an increasing number of physicians and
surgeons in private practice, are now providing treating.
In addition to the interviews, physical and psychological
tests and therapies, and electrolysis of the beard for the male
transsexual, there is one further essential element in the total
program of sex reassignment. After the patient is accepted as a
possible candidate for surgery, and while he is receiving hormone
therapy, both gender identity clinics and physicians in private
practice require that he dress, live and work in the new gender role
for a period of twelve months to two years. The patient then may
better judge, through direct experience, whether he will be able to
live comfortably, and without attracting undue notice, in the new
role. His physician will observe the degree of his social and
emotional adjustment, and estimate how convincing an appearance he
presents. This testing period is of prime importance in assisting
them both to make a final decision to proceed, or not, with surgery.
Clinical Treatment of the Transsexual
Surgery is not the first, but rather the last major step in
the remedial program. The wisdom of this may readily be seen. The
results of surgery cannot be reserved, the original anatomy can
never be restored. For better or worse, the individual must live
with his "new" body. On the other hand, hormone therapy, with which
treatment begins, produces physical changes which are generally
reversed, restoring the original appearance, after hormones are
Hormone therapy is beneficial in several respects. His
gradually altered appearance relieves the transsexual of some of his
conflicts and gives him a new sense of confidence. In addition to
the physical changes, hormones produce a tranquilizing effect in
It is usually required that the male transsexual complete at
least half of a course of electrolysis of the beard (usually
requiring a total of from one to two years) before surgery is
undertaken. If he fails to do this, he will risk radical confusion
as to his gender identity following surgery, with possibly serious
During this preoperative phase, it is important for the
transsexual to discuss his social and economic plans in order to
gain a practical basis for the new life he is preparing.
Professional counseling may prove helpful in supporting him through
this delicate transitional period. When the physician is satisfied
that the way has been well prepared in all respects, the patient is
ready for surgery.
Gender identity clinics will ask the transsexual to cooperate
in periodic meetings for some time after treatment has been
completed. This is for the purpose of studying and helping with his
social, emotional, sexual and economic adjustments to his new role.
By participating in these follow-up studies, the transsexual makes
an important contribution to the better understanding and treatment
of transsexualism. And if further therapy is indicated, his
physicians will be helpful to him in this regard.
Other Steps On The Way
The transsexual making the change from male to female, and to
a lesser degree his female counterpart, will need to study the
grooming and clothes of the chosen sex. His mirror and his friends
and family may supply all the help he needs. Or the male
transsexual may decide to apply to a charm school for expert
instruction. For the transsexual whose field of work will not
permit him to retain his old job, vocational training is essential
so that he may be fully self-supporting.
There will be legal adjustments to be made: The securing of
identification papers and other documents in his new name, and, in
the case of an individual who is married, a decree of divorce. All
gender identity clinics require that a divorce be obtained before
they accept a patient for surgery.
It may be advisable for the transsexual to relocate to one of
the urban areas where the necessary professional help is readily
available. Relocation may eventually be advisable in any case to
spare the patient the embarrassments of working out his new identity
under the public eye. After the final steps in the transition are
completed, he may decide to return home.
The financial burdens of sex reassignment, the cost of surgery
and other surgery, the loss of income during the period of
recuperation, may present the transsexual with a difficult or
insurmountable problem. If members of his family are able to share
this burden, hopefully the help will be received with gratitude.
A Final Word
Imagine that you, the father of a transsexual, awakened one
morning, looked into the mirror, and saw an unfamiliar reflection
returning your glance; that of a woman. Imagine your shock and
dismay. Your feelings were no different from what they had always
been; and yet you, with your masculine sense of self, were now
trapped in a body that contradicted all that you know yourself to
be. If you are a woman, perform this experiment in reverse.
Now you have a slight notion of what your son or daughter has
been experiencing daily, probably since earliest childhood.
Furthermore, he has been under constant pressure to keep up the
masquerade at school, in his social relations, in his job, and
perhaps even at home; in his total way of life. One day, the strain
began to be overwhelming. He felt that he could not sustain this
deception, this contradiction, for another moment. In his
desperation, he may have tried suicide. Or he may have realized
that skilled and understanding help is available to him, and set out
to find it.
It is little wonder that the adult transsexual who finds
himself in this impasse is determined to free himself from it. Once
he has decided on the course of sex reassignment, he probably will
never look back. If qualified doctors accept him for treatment,
the chances are that nothing will dissuade him, not even the
disapproval or entreaties of those he loves. When you have clearly
understood and felt the reasons for his determination to find help,
let him do so fortified by your support and love.
Information Services - 1986
JANUS Information Facility - 1982
Erickson Educational Foundation - 1977