I would like to tell you how much Alison and I have enjoyed living in our little neck of the woods for the last 18 years. We love our neighbors and our community. When we talk to others about what makes or neighborhood so inviting, invariably we speak about its diversity. We are quite a mix of backgrounds and ages and that makes Jerome Ave. and Clark Rd. an interesting and pleasant place to live. I am writing to you today to tell you that while there are major changes going on in my and Alison’s lives, we plan on continuing to be a part of this wonderful community. You see, I am transsexual and will after June 29th begin living my life as a woman, Deborah.

This was a difficult decision for me and it has, as you can imagine, also been stressful for my family. I hope that you will feel comfortable in continuing to welcome me and my family as neighbors. I realize that this may be awkward for some but, rest assured, I am not uncomfortable with honest questions or to mistakes in names or pronouns.

I understand that you may know little about transsexuality and so I have set up a website http://www.DavisSquareInfo.com to provide you with some basic information. The username is: Jerome and the password is: password (case sensitive). When you go to the site you will find some useful information on transsexuality there.

If you want to ask questions or share your feelings with me please do so, in person, by phone 617-230-7988 or email deb@DavisSquareInfo.com (Please note, that while my family has responded to these changes in a loving way, Naomi does not want to discuss her feelings in public.)

I can appreciate that you may have your own personal feelings about my transitioning to live as Deborah and I fully respect them. Regardless of how you feel personally about my decision please know that I and my family welcome your continued friendship and fellowship.

Sincerely,

Deborah Bershel (nee Roy Berkowitz-Shelton)

Notes on Gender Role Transition
By Anne Vitale Ph.D.
Rethinking the Gender Identity Disorder Terminology in the Diagnostic and Statistical Manual of Mental Disorders IV

This is an expanded and fully referenced version of the paper read at the 2005 HBIGDA Conference, Bologna, Italy
April 7, 2005

The overwhelming success gender role transition has enjoyed world wide in the last four decades, leads me to believe that the current reference to gender issues in the DSM IV---as a subset of the sexual disorders---is inaccurate and should be revised.

As a basis for my argument, I will--

1. Briefly review the history of how gender issues have been handled in past editions of the DSM.

2. I will Elaborate on the evolving concept of gender variance.

3. Briefly review several studies that lead us closer to understanding the role biology plays in establishing gender identity.

4. I will discuss the sociological and political ramifications of the increased number of individuals who have undergone gender role transition.

5. I will conclude by proposing that instead of Gender Identity Disorder- future editions of the DSM consider a less stigmatizing and more accurate descriptor of the gender variant condition --namely Gender Expression Deprivation Anxiety Disorder.

As we gain in our understanding of how gender identity is formed, the potential of there being a naturally occurring partial-to-full-negative correlation between gender identity and biological sex --in a significant segment of the population--has led many clinicians to advocate for a major rethinking of how we address the issue in the DSM.

Those who wish to see changes in the DSM regarding gender identity issues generally fall into two camps.

--Some clinicians advocate the complete removal of any reference to gender issues in the next edition of the DSM.

-- Others advocate a nonpathologizing inclusion that recognizes gender variance as a naturally occurring phenomenon requiring a combination of psychological and medical attention.

Members of the first group believe that the mere fact of inclusion in the DSM automatically induces psychological stigmatization encouraging cultural disapproval while the latter group worries that unless the issue is listed somewhere in a medical index of disorders, necessary medical procedures would then be deemed medically unnecessary especially in countries that have a National Health Service.

I side with those who feel that inclusion is beneficial, while advocating that the citation be moved from the sexual disorders to the anxiety disorders.
HISTORY-DSM I through DSM IV-TR

The American Psychological Association has published four benchmark editions of the DSM. It has also published two “Revised” editions. DSM I was published in 1952. DSM II was published in 1968. DSM III was published in 1980 and revised in 1987. The latest benchmark edition of the DSM, DSM IV was published in 1994 and revised in 2000. It is referred to as DSM IV -TR. (1, 2, 3, 4, 5, 6)

Although both the DSM I and DSM II mention “Transvestism,” neither manual addresses the issue of gender identity per se. Gender Identity as a separate issue does not appear until the third edition. In DSM III a new category of disorders entitled Psychosexual Disorders appears. It has four subsections: the Gender Identity Disorders, the Paraphilias, the Psychosexual Dysfunctions and Other Psychosexual Disorders, which includes the now-defunct, Ego-dystonic Homosexuality and Psychosexual Disorders Not Elsewhere Classified. The Gender Identity Disorders are further subdivided into three specific areas: Transsexualism, Gender Identity Disorder of Childhood, and Atypical Gender Identity Disorder.

The Gender Identity Disorders in DSM III ---Transsexualism

DSM III characterizes the Gender Identity Disorders first as a whole and a series of subgroups. As a group the Gender Identity Disorders are described as follows:

The essential feature of the disorders included in this subclass is an incongruence between anatomic sex and gender identity. Gender identity is the sense of knowing to which sex one belongs, that is, the awareness that ‘I am male’ or ‘I am female’. Gender identity is the private experience of gender role and gender role is the public expression of gender identity. Gender role can be defined as everything that one says and does, including sexual arousal, to indicate to others or to oneself the degree to which one is male or female.

On the whole I think this is a good definition.

They go on to include the following description of individuals with this condition.
• They usually complain that they are uncomfortable wearing the cloths of their own anatomic sex.
• They often choose to engage in activities that are generally associated with the other sex.
• They often find their genitals repugnant which may lead to persistent requests for sex reassignment by surgical or hormonal means.
• To varying degrees, their behavior, dress and mannerisms are those of the other sex.
• They have moderate to severe coexisting personality disturbances.
• They frequently experience considerable anxiety and depression.
• Without treatment, the course is chronic and unremitting.
• Their social and occupational functioning are often markedly impaired, depression is common and, in rare instances males may mutilate their genitals.

There is further sub-classification based on sexual preference. The sub-classifications are: asexual, homosexual (same anatomic sex), heterosexual (other anatomic sex), and unspecified.

Gender Identity Disorder of Childhood
In DSM III, Gender Identity Disorder of Childhood is defined, in part, as follows:

Paraphrasing high lights from the rest of the description:
• Girls with this disorder regularly have male peer groups, an avid interest in sports and rough-and-tumble play, and a lack of interest in playing with dolls.
• Boys with this disorder invariably are preoccupied with female stereotypical activities. They may have a preference for dressing in girl’s or women’s clothing, or may improvise such items when genuine articles are not available.
• Boys with this disorder have a compelling desire to participate in the games and pastimes of girls.
• Some children refuse to attend school because of teasing or pressure to dress in attire stereotypical of their sex.
• Most children with this disorder deny being disturbed by it except as it brings them into conflict with the expectations of their family or peers.
• Some of these children, particularly girls, show no signs of psychopathology. Others may display serious signs of disturbance such as phobias and persistent nightmares.

DSM III-R
In DSM III-R published seven years later, the category of Psychosexual Disorders was removed all together. Instead gender variant issues are covered under a heading of Gender Identity Disorders and it is listed alphabetically after the Eating Disorders. The definition of Gender Identity Disorders included in DSM III and noted above, is repeated, with Transsexualism given prominence in the body of the text.

DSM IV
In 1994, with the release of the DSM IV, the section entitled Gender Identity Disorders was replaced with the singular term, Gender Identity Disorder (GID) and subdivided into three, rather then four areas: Gender Identity Disorder in Children, Gender Identity Disorder in Adolescence and Adults, and Gender Identity Disorder Not Otherwise Specified.

The term “Transsexualism” was eliminated. Most importantly, perhaps is that GID was reclassified as being a sexual disorder rather then a psychological one. It is listed directly after Voyeurism and Paraphilia in the Sexual and Gender Identity Disorders section.

As a result of this change, a condition that was described in DSM III largely in terms of the psychological difficulties most gender variant individuals experience, became an abstract description of stereotypical cross-gender behaviors and implied abnormal sexuality. Only passing mention is made of the psychosocial difficulties inherent in being gender variant.

The placement change was explained by the DSM IV Subcommittee on Gender Identity Disorders in its Interim Report (7) published in the Archives of Sexual Behavior. They said:
A basic issue considered by the subcommittee, but was one that was not in its jurisdiction to alter, was the diagnostic category in which gender identity disorders should be placed. In DSM III, Transsexualism and Gender Identity Disorder of Childhood were placed under the larger category entitled Psychosexual Disorders. In DSM III-R, the category Psychosexual Disorders was eliminated, with many of the former diagnoses placed under a new category termed Sexual Disorders.

Apparently, the members of the subcommittee were aware of the negative implications of placing gender identity issues back with the Sexual Disorders but for reasons not offered, did not petition for a less stigmatizing placement.

There are other problems with the DSM IV description. One of the most obvious is the listing of stereotypical cross-gender behaviors as “symptoms”. No mention is made of the possibility that these cross-sex behaviors may be coping behaviors being used to relieve anxiety that experiencing a physical sex/gender discordance would naturally evoke. The authors of the DSM IV write about a preoccupation with cross-gender behavior as if the behavior is pathological.
For example;

• In boys, the cross-gender identification is manifested by a marked preoccupation with traditionally feminine activities.

• They may have a preference for dressing in girl’s or women’s clothes or may improvise such items when genuine article are unavailable. Towels, aprons and scarves are often used to represent long hair and skirts.

• There is a strong attraction for stereotypical games and pastimes of girls. They particularly enjoy playing house, drawing pictures of beautiful girls and princesses and watching videos of their favorite female characters.

• Stereotypical female -type dolls, such as Barbie, are often their favorite toys, and girls are their preferred playmates. When playing “house” these boys role-play female figures, most commonly, “mother roles” and often are quite occupied with female fantasy figures.

• They avoid rough-and-tumble play and competitive sports and have little interest in cars and trucks or other non aggressive but stereotypical boy’s toys.
• They may insist on a wish to be a girl and assert that they will grow up to be a woman.

• They may insist on sitting to urinate and pretend not to have a penis by pushing it in between their legs.

• More rarely boys with Gender Identity Disorder may state that they find their penis or testes discussing, that they want to remove them, or that they have, or wish to have a vagina.

The following paragraph regarding girls reads similarly:

Girls with Gender Identity Disorder display intense negative reactions to parental expectations or attempts to have them wear dresses or other feminine attire. Some may refuse to attend school or events where such clothes may be required. They prefer boy’s clothing and short hair, are often misidentified by strangers as boys, and may ask to be called by a boy’s name. Their fantasy heroes are most often powerful male figures, such as Batman or Superman. These girls prefer boys as playmates with whom they share interest in contact sports, rough-and-tumble play, and traditional boyhood games. They show little interest in dolls or any form of feminine dress -up or role-play activity. A girl with this disorder may occasionally refuse to urinate in a sitting position. She may claim that she has or will grow a penis and may not want to grow breasts or to menstruate. She may assert that she will grow up to be a man. Such girls typically reveal marked cross-gender identification in role-play, dreams and fantasies.

The most disturbing aspects of these passages is that the description of childhood behaviors meant to describe an abnormal gender identity development, is not in fact representative of a majority of genetic male individuals who present in their adult years for gender reassignment assessment. At least 90 percent of the genetic male clients I have treated over the last 21 years have reported having what appeared to everyone else to be a normal boyhood.

At best it represents only those children brought into treatment centers by parents who disapprove of their child’s gender expression. To the extent that some of these behaviors may be present to one degree or another, a child’s own insistence regarding gender expression ought to be taken at its obvious face value, that is, as an indication that the child has at least in part the gender identity of the sex opposite to that assignment at birth.

Commenting on the DSM IV description, Katherine Winters (8) writes:

In the diagnostic criteria and supporting text of Gender Identity Disorder for Children, behaviors that would be ordinary or even exemplary for gender conforming girls and boys are presented as symptomatic of mental disorder for gender nonconforming children....It is unclear whether the intent of the DSM is to reflect such dated, narrow and sexist gender stereotypes or to enforce them.
Gender Variant

In recent years, contrary to the idea of regarding gender identity problems as a mental disorder, many clinicians who regularly work with this population have come to think of this phenomenon--not as a pathology--but as a naturally occurring variation to the common, binary male/female understanding of gender. To help in depathologizing the phenomenon, the term “gender variant” is gaining in common usage. For example, at the 2001 HBIGDA conference held in Galveston Texas, Lin Fraser (9), whose psychotherapeutic practice is in San Francisco --arguably the center of the gender community in the United States--stated:

Who we see in practice is a mix of people, some are in the binary, very traditional system of gender and some are not. They are gender variant, gender different, they are members of the queer community or are otherwise non-binry. There is much variation here.

And this from psychotherapist Rebecca Auge (10), who also practices in the San Francisco Bay Area:

Transgender clients in the San Francisco Bay Area are a diverse bunch. In general, one finds more variation in gender display, than, say, ten years ago; this was evident this past June when the LGBT Pride Parade in SF included Muslim, Armenian and Chinese participants. The variations of gender identity and role encountered are not limited to a strict binary (or two box) gender system. As a result, clients are helping us map the gender terrain. What is emerging is a panorama of possible solutions to transgender issues.

Developments since Publication of DSM IV

Along with a large number of papers noting the efficacy of hormone replacement therapy in treating the gender variant condition, there have been three major papers worth noting as having presented physiological data that propose that much of an individual’s gender identity may depend on biological events outside of anyone’s control.

In 1997 Zhou et al. (11) published a study wherein they examined the volume of the central subdivision of the bed nucleus of the stria terminalis (BSTc) of the brain of six male-to-female transsexuals. They found that a female-sized BSTc was found in all of the subjects. This led them to declare that a female brain structure exists in genetically male transsexuals, supporting the hypothesis that gender identity develops as a result of an interaction between the developing brain and sex hormones in utero. It follows, therefore, that the affected individual may have as a result, a partial to full sense of having a cross-sexed gender identity.

Krujver et al. (12), did a follow up study to that of Zhou. Krujver and his colleagues counted the number of somatostatin-expressing neurons in the BSTc of 42 subjects in relation to sex, sexual orientation, gender identity, and past or present hormonal status. They found, that regardless of sexual orientation, males had almost twice as many somatostatin neurons as females (P < 0.006). The number of neurons in the BSTc of male-to-female transsexuals was similar to that of the females (P = 0.83). In contrast, the neuron number of a female-to-male transsexual was found to be in the male range. By carefully chosen controls, they show that hormone treatment or sex hormone-level variations in adulthood did not seem to have influenced BSTc neuron numbers. The authors conclude: “The present findings of somatostatin neuronal sex differences in the BSTc and its sex reversal in the transsexual brain clearly support the paradigm that in transsexuals sexual differentiation of the brain and genitals may go into opposite directions and point to a neurobiological basis of gender identity disorder.”

To add to this, we now have six relatively recent papers published in the Proceedings of the National Academy of Sciences of the USA describing a peri-natal process known as defeminization --or the loss of the ability to display female-type behaviors in males and male behaviors in females (13,14,15,16,17,18).

This ongoing area of research, done on rats and mice, is based primarily on the fact that neonatal males --unlike neonatal females --produce androgens and estrodiol and that minute excess of either hormone present at a critical time of brain development, can disrupt the normal masculinization or feminization of the brain.
In 2000 Auger et. al. reported:

A central aspect of steroid-mediated differentiation of the brain is that, although testosterone secreted by the testis is the primary hormonal signal, once in the brain, it is metabolized into two principle ligands: dihydrotestosterone by 5 alpha reductase or estradiol by aromatase. The subsequent activation of either androgen or estrogen receptors mediates distinct aspects of the differentiation process in [ ] rats. For example, increased estrogen receptor activation is responsible for defeminization whereas increased androgen receptor activation seems to be responsible for masculinization . Blocking the aromatization of testosterone into estradiol interferes with defeminization but not masculinization in male rats because androgen receptors are still being activated.

Following the lead of Auger and others, Andrea Kudwa and her colleagues, after conducting a number of experiments on mice, confirmed that estrodiol was the priciple agent in the defeminization process. They report:

The development of neural sex differences is initiated by estradiol, which activates two processes in male neonates; masculinization, the development of male-type behaviors, and defeminization, the loss of the ability to display female-type behaviors.

The mere fact that there is a specific process of masculinization and defeminization in the brain of the developing fetus and that it is sensitive to environmental disturbance such as the accidental or purposeful introduction of exogenous hormones, [DES for example] gives added credence to the possibility of there being a gender variant condition in a significant number of the population.

The “John/Joan,” David Reimer case.
Finally, it’s helpful to review the well-known David Reimer(aka “John/Joan”) case, as new developments have come to light. Here is a summery of the case.

In 1972, John Money(19, 20) and his colleagues at Johns Hopkins University reported that they had successfully reversed the sex of one of a set of 8-month-old genetic male twins who had suffered the ablation of his penis in a circumcision accident (Money, 1972, 1975). In keeping with the then widely held belief that individuals are psychosexually neutral at birth and that healthy psychosexual development is dependent on the appearance of the genitals and the sex of rearing, Money advised the parents to give the boy a female name and rear him as a girl. A bilateral orchiectomy and preliminary neovagina surgery was performed on the boy to facilitate feminization and to aid the child and the family in thinking of the child as a girl. Management was reinforced with yearly visits to Johns Hopkins Hospital, where the doctors examined the child’s genitals and encouraged the child to play and act like a girl. In the literature the child was described as developing into a normal girl and accepting life as “Joan.”

The mainstream press picked up on the “success” being reported by Money, noting that this case provided strong support that conventional patterns of masculine and feminine behaviors can be altered by the way a child is raised. (Time Magazine, January 8, 1973). Sociological, psychological and even women’s studies texts began to reflect the notion that masculine and feminine behavior were more a factor of nurture then nature. We now know that, none of the so-called “success” of the case that the team at Johns Hopkins published and publicly reinforced over a period of 20 years were true.

The true facts of the John/Joan case came out in 1997 when Diamond and Sigmundson (21) published their paradigm-shifting paper, Sex reassignment at birth: Long term review and clinical implications, in the Archives of Adolescent Medicine. There they revealed that the long-watched gender-role-reversal case was in fact a tragic failure. The case was further reported at great length by John Colapinto (22) in his book, “As Nature Made Him: The Case of a Boy who was Raised as a Girl. The new knowledge about the gendered self revealed by these reports should result in new thinking about gender variation in the next edition of the DSM, I will briefly state the true course of this case.

Despite being raised as a girl, being told all his life that he was a girl, having what appeared to be female genitalia that he could compare with his twin brother’s penis (pointed out on their yearly visits to Johns Hopkins), and even after the administration of estrogen at puberty, David retained a strong sense of his male gendered self. Not only did he reject the concept of his being female, he also rejected the estrogen therapy soon after it was imposed on him. This is a clear and unrefutable example of what happens when an individual is deprived of his innate gender expression and forced to endure hormone replacement therapy. In an interview with Colapinto, David told him that the hormones made him “feel funny” and he detested the feminizing effect they had on his body. Please note: This is the exact opposite of what gender dysphoric males report when commencing into transition to the female gender role. When at the age of fourteen it became clear to David’s parents that the experiment had gone woefully wrong, David was told what had happened. He immediately stopped taking estrogen and started testosterone treatments. Although he went on to get married as a man and serve as a step-father, he never really got over the trauma of his ordeal. He took his own life in May, 2004.

Lessons from the Reimer Case: Phallic Inadequacy.
Prior to the publication of DSM IV, it was standard practice sanctioned by the American Academy of Pediatrics (23) to suggest that doctors “normalize” the genitals in all cases of genetic male neonates born with cloacal exstrophy and ambiguous genitalia. Parents were routinely advised that in order to prevent severe psychosocial dysfunction it would be best to reassign their male child immediately to female and have the child undergo surgical bilateral orchiectomy and construction of a vulva. The parents were further advised never to tell anyone, especially the child, of the child’s true genetic background. Three factors were dominant in this practice: the need for the parents to announce unequivocally the sex of their newborn; second, the fact that it is easier to fashion a vulva surgically out of the available material than it is to enlarge a micropenis; and third, since gender identity was believed to be a social construct, it was thought that the child would have a more satisfying life as a girl than a boy without a functioning penis.

With the revelations of the Reimer case and the publication of other cases where intersex children rejected their assigned sex, some members of the medical world began to rethink the advisability of reassigning male children as females simply because of what was deemed penile inadequacy.

One of the more important studies was recently conducted by Reiner and Gearhart (24). Until recently both doctors were associated with the departments of Psychiatry and Urology at Johns Hopkins University. They assessed all 16 genetic males in their cloacal exstrophy clinic, ranging in age at that time from 5 to 16 years. As neonates, 14 of the 16 subjects had undergone social, legal and surgical sex reassignment to females. The parents of the other two subjects refused the reassignment and the children were raised as boys.

Using detailed questionnaires, the authors evaluated the sexual role and identity of the subjects as defined by their “persistent declaration of their sex.” They report that 8 of the 14 subjects assigned to the female sex had, over the course of the study, declared themselves to be male, whereas the 2 subjects assigned as male identified as male. They further note that “All 16 subjects had moderate-to-marked interest and attitudes that were considered typical of males.” , and they conclude:“Routine neonatal assignment of genetic males to female sex because of severe phallic inadequacy can result in unpredictable sexual identification. Clinical interventions in such children should be reexamined in light of these findings.”

These findings support the emerging thesis that despite the still too commonly held believe, the genitals are not the seat of a gendered self. Nor is sex of rearing especially effective in permanently establishing a sense of a gendered self. Indeed, Female-to-Male transsexual people also
bear witness to the power of a masculine psyche, regarless of genital
configuration.

As I said earlier, most male-to-female transsexuals are raised unremarkably as males. The successful treatment of thousands of individuals presenting with gender dysphoria and treated per the HBIGDA, Standards of Care reveal that cross-dressing and other cross-sex behaviors has been the client’s way of coping with a sense of a gendered self other than what was assigned them at birth. In the end the most common way of treating this anomaly in a gender variant individual, is to encourage healthy cross-sex behaviors, not eliminate them.

By listing the gender variant condition as Gender Identity Disorder with the implication that the individual is confused and unable to determine their true gender, and by describing the symptoms primarily in terms of cross-gender behaviors, the DSM IV-TR continues to ignore what gender specialists routinely see when gender variant individuals present for treatment. If the situation is critical, the therapists often find themselves treating some combination of depression, anxiety, depersonalization, fear, anger, an overwhelming sense of guilt and a very real threat of suicide. These secondary symptoms appear to arise as a result of the decades of forced social pressure to conform to a gender expression they innately know is wrong and can no longer tolerate. The life of David Reimer and his tragic suicide surely attest to the potential damage to the psyche decades of forced gender expression deprivation can have.

New thinking for DSM V
As the DSM prepares the next update, I urge the authors to consider that the cross-gender behavior typical of gender variant people is neither a sexual disorder nor a gender identity disorder. Rather it is an anxiety disorder secondary to physical and sociological gender expression deprivation. Rather than referring to the cluster of behaviors as “Transsexualism” or “Gender Identity Disorder” I propose as I have elsewhere (25), that the condition be refereed to as Gender Expression Deprivation Anxiety Disorder (GEDAD).

Advantages in the terminology:

• GEDAD tacitly recognizes that gender expression is a critical element in all that makes us human.

• GEDAD tacitly recognizes that gender expression is a dictate of birth. It is not negotiable.

• GEDAD tacitly acknowledges that gender expression-- as defined by the individual-- is vital to good psychological health.

• GEDAD moves the locus of attention from the sexological to the psychological.

• Unlike GID, GEDAD does not connote disorder or confusion in someone presenting with gender issues. This should take away using the DSM to foster religious/political objections to gender role transition as part of the treatment plan.

• GEDAD describes what the presenting individual is actually experiencing.

• GEDAD can be posted in a directory of disorders allowing National Health Service or insurance coverage without the negativity Gender Identity Disorder currently incurs.

• GEDAD does not differentiate between adults, adolescence, children, MTFs, FTMs, Intersex, androphilic or autogynephilic gender variant people.

Reviews of the treatment outcomes of cases wherein an individual’s secondary sexual characteristics have been changed to comply with their innate sense of gender identity and the subsequent success of the individual’s life has shown that it is long past time for clinicians to accept that this is not a problem of confused identity but a problem of gender expression deprivation.

The long history of successfully treating gender issues has shown that a significant number of people who have a deep sense of a gender/sex discordance have profited from a treatment that accepts their sense of gender as being the critical unchangeable element in the matter. Despite the fact that the prescribed and highly effective Harry Benjamin International Gender Dysphoria Association’s Standards of Care, triadic treatment plan leaves the individual’s gender and chromosomal sex discordant, permanent relief is commonly achieved. The exogenous administration of cross sex hormones has shown repeatedly to have a profound, almost immediate stabilizing effect on the gender variant individual’s psyche. The medication appears to resolve a hormonal imbalance in the brain that the individual’s endocrine system cannot otherwise provide. Indeed the testes in pretreated male-to-female individuals and the ovaries in pretreated female-to-male individuals may be playing a role in exacerbating the problem. Further relief is attained with optional surgery and re-socialization into the new gender role, eliminating gender expression deprivation as an issue.

We Can-and-Need to do much Better in DSM V.

If we start with the premises that only the individual can know their gender, we must acknowledge that a gender variant individual, adult or child, is right and justified in experiencing difficulty trying to cope in an unvaried binary gendered system. Gender identity appears to have no other function in the human psyche than to impose masculine or feminine expression. To be forced to adopt a cross-sex gender expression as a way of being in the world in order to be accepted by friends, family and society at large has been shown to be unsustainable. What else can explain the large number of people who in mid-life have risked all that they know and love to resolve their sex/gender discontinuity by transitioning to the opposite gender role? Further more, how else to account for the overwhelming number of successful outcomes if in these cases these individuals were not “right” about their gendered sense of self?

At the 2003 American Psychological Association (APA) conference in San Francisco, participants discussed whether Gender Identity Disorder should be removed from the DSM altogether. Citing the current APA thinking that homosexuality is not a mental disorder, participants suggested that lacking proof otherwise, the gender variant condition may also be a regularly occurring condition in humans.

Karasic and Kohler (26) reported,“There are a lot of problems with the way psychiatry has viewed transgender folks. In labeling an identity as a mental disorder, as opposed to identifying symptoms in the same way we do for, say, major depression, anxiety disorder or other disorders in the DSM, the consequence of this is pathologizing and really hurting our clients.”

After more than fifty years of treating gender issues hormonally, it is beyond dispute that despite some possible negative physical side effects, the introduction of cross-sex hormones has proven to be the center piece of a successful treatment regimen for this population. (27, 28) When SSRIs are prescribed for depression they are commonly considered psychothropic medication. In a similar manner, when cross-sex hormones are prescribed to a gender variant individual, what they are receiving is, for them, psychothropic medication.
Political Ramifications

In addition to the therapeutic concerns, there are political reasons to consider in this matter. As the transgender community has made gains in having their human rights acknowledged, the Christian Right in the USA has declared that helping people transition to their preferred gender role is immoral.

To add credence to their argument they note that the term Gender Identity Disorder comes from the DSM, a manual of mental disorders. They conclude, therefore, that since Gender Identity Disorder is a mental disorder, hormonal and surgical interventions leading to gender role transition should be replaced with long-term psychological care.

Here is one example of such writing from The Traditional Values Collation web site (29):

Our medical profession does no favors to sexually confused individuals by physically altering them so they can pretend to be something they will never be. Surgeons who mutilate men and women who suffer from a Gender Identity Disorder should be condemned by their medical associates.

.....Gender confused individuals need long-term counseling not approval for what is clearly a mental disorder.”

Jerry Leach, who describes himself as having “an international ministry to those afflicted with gender identity confusion, homosexuality, and sexual addiction” writes on his site Realityresources.com (30).“In transsexuality, not only is the sexual identity confused but there is also a gradually splitting off from one's God-given gender role. The end result being the total rejection of it and the taking on of a pseudo-feminine persona and role. “

Robert Knight, the director of the Culture and Family Institute, an affiliate of Concerned Women for America, chimes in. "Nobody is doing these poor confused people any favors by encouraging them to cultivate their disorder. We're talking serious dysfunction here."

Finally, Traditional Values Coalition founder, Rev. Louis P.Sheldon (31) took the time to write to the U.S. Internal Revenue Service in December 2004 on behalf of 43,000 churches in the coalition to complain about the Internal Revenue Service granting a male-to-female transsexual’s right to deduct sex reassignment surgery as a medically necessary, non-cosmetic medical procedure. Here is part of Rev. Sheldon’s letter. “The decision to give tax deductions for ‘sex change’ operations sends the wrong message to individuals who suffer from a Gender Identity Disorder. This is a mental condition, not one that needs surgery. In fact, by giving this tax deduction, your agency will be encouraging other mentally disturbed individuals to consider such surgery as an unneeded surgical procedure for what is a troubled mind.”
Conclusion
In DSM IV and DSM IV-TR, placing the term “Gender Identity Disorder” in the Psychosexual Disorders, implies to some practitioners, that the individual with this condition has a psychosexual disorder; that is that people with this disorder refuse to accept the body based reality of their gender identity for sexual reasons. Recent research, however, has clearly shown that most people who present with severe gender dysphoria have a sound sense of a gendered self and are acutely aware of that gendered self being discordant with their biological sex.

Concomitant with a gendered self is a need for gender expression. To be denied gender expression in virtually every aspect of one’s life typically leads to some combination of depression, anxiety, depersonalization, fear, anger, overwhelming guilt and a very real threat of suicide. Beyond this, the descriptive terminology used in DSM IV and DSM IV-TR, reinforces negative stereotypes of gender variant people. Moreover, despite strong evidence of the efficacy of hormonal and surgical interventions, the DSM IV and DSM IV-TR both fail to legitimize these interventions in cases where it may be the only logical treatment.

As an alternative, I purpose that in the next edition of the DSM, the dis-ease or dysphoria associated with being gender variant be moved from the Sexual Disorders category to its own heading as an anxiety disorder; specifically that it be termed, Gender Expression Deprivation Anxiety Disorder. The information listed thereunder would take for a basis that a person who has had a life-long struggle with gender dysphoria be accepted as being gender variant and a medical and psychological treatment plan be designed to alleviate their anxiety.

The authors of DSM IV-TR tell us’ “It must be noted that DSM IV reflects a consensus about the classification and diagnosis of mental disorders derived at the time of its initial publication. New knowledge generated by research or clinical experience will undoubtedly lead to an increased understanding of the disorders included in DSM IV, to the identification of new disorders, and the removal of some disorders in future classifications.” The time has come to remove Gender Identity Disorder and replace it with a new classification: Gender Expression Deprivation Anxiety Disorder.

Anne Vitale Ph.D.
P.O. Box 1023
Point Reyes Station, California 94956

REFERENCES

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(29) Traditional Values Coalition (undated) Transgenders Work to Overturn Biology, Retrieved from: http://www.traditionalvalues.org/modules.php?sid=105 [accessed on 10 January 2005]

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31. Sheldon L. P. Want a Tax Deduction? Have a sex change. The Conservative Voice , 14 December, 2004 Retrieved from http://www.theconservativevoice.com/modules/news/article.php?storyid=1516 [accessed on 16 December, 2004]

Transgendered- A person who does not feel as though they completely fall into the gender that they were born into. This is usually viewed as an umbrella term that would include crossdressers and transsexuals.

Crossdresser aka transvestite – A person who enjoys wearing clothes of the opposite
gender. They may or may not have gender identity issues.

Gender Identity – Whether you identify as male or female. This is not the same as sexual
identity.

Sexual Identity – Who you are sexually attracted to – women, men or both

MTF –Male to Female transsexual (sometimes referred to as a transwoman)

FTM – Female to Male transsexual (sometimes referred to as a transman)

RLE (Real Life Experience) Living fulltime in the new gender. Required prior to having
sexual reassignment surgery.

Sexual Reassignment Surgery (SRS) / alternatively Genital Reassignment Surgery
(GRS)- Genital surgery (vaginoplasty for MTF/ phalloplasy for FTM)

HBIGDA –(Harry Benjamin International Gender Dysphoria Assoc.)-Organization founded by the endocrinologist, Harry Benjamin, comprised of doctors and gender therapists involved in the research on gender or treatment of patients with gender identity issues.

What is Gender and Who is Transsexual / Transgendered?
by Carl W. Bushong, Ph.D., LMFT
When we speak of gender, in a context other than language, it is a recent concept in our culture, both lay and professional. It was not until 1955 that John Money, Ph.D. first used the term “gender” to discuss sexual roles, adding in 1966 the term “gender identity” while conducting his gender research at Johns Hopkins. In 1974, Dr. N.W. Fisk provided our now familiar diagnosis of Gender Dysphoria. Previously, one’s sexual role was considered one of two discrete, non-overlapping congenital attributes—male or female determined by one’s external genitals. These two mutually exclusive categories allowed for no variation. Of course, we acknowledged the cultural differences in sexual roles, but there still could be only two modes of expression - of being.
We then began to see one’s gender as a continuum, a blending, analogous to a “gray scale.” But, our distribution of gender was still bimodal, that is, most people are lumped at the two ends (see graphic) with only a minority in the middle. The great majority would be either male or female with all that implies.

But, my review of current research and experience with gender dysphoric, gay and traditional clients has led me to see gender not as a bimodal male or female dichotomy but as a matrix—a possible mix of male and female development within the same individual.
From research and observation, I have developed a list of five semi-independent attributes of gender, as a map to help you to understand this complex often hotly emotional issue of gender. Consider sexual identity/behavior (gender) springing from five semi-independent attributes:
• Genetic Gender — Our chromosomal inheritance.
• Physical Gender — Our primary and secondary sexual characteristics.
• "Brain Gender” — Functional structure of the brain, along gender lines.
• "Brain Sex” — Love/sex Patterns, How we relate to others on a social and interpersonal as well as sexual level. “Love Maps.”
• Gender Identity — Our subjective gender, our sexual Self-Map, how we feel ourselves to be: male or female.
It is my contention that it is possible for an individual to view oneself and function as male or female to varying degrees in each of the five sub-categories independent of the others.
From a few weeks after conception until two to three years of age, our brains develop gender in at least three independent dimensions which I have called “Brain Gender.” [How the brain is wired along gender lines.] “Brain Sex” How we perceive sex, relationships and goals along male or female sets] and Gender Identity [how we perceive ourselves-male or female.]
Not only are these three dimensions independent of each other, but of one’s Physical Gender as well. That is, a person can have a male body, male Brain Sex and Identity, but have female Brain Gender. [In fact, most writers and artists do.] Such a person would look, act and feel male, but have a female’s sensitivity to emotions, words and sensations: Although, they may overcompensate in public and in interpersonal relationships [e.g., Ernest Hemingway]
Like our Genetic and Physical Gender, our Brain Gender, Gender Identity, and Brain Sex, expression usually remains constant from childhood throughout one’s life.
Since each of these independent attributes is graded, it is easy to see the possible combinations and degrees number in the thousands. With regard to gender, we can be in a category of one—ourselves.
Perhaps only individuals who are homogeneously male or female at the highest degree in all five attributes could convincingly describe themselves as only a single gender— the rest of us are a matrix [a mixture].
As for the transgendered, they appear to be uniformly one gender in all three brain dimensions, but of the opposite gender, both physically and genetically.
Genes and Gender
The first sub-category, Genetics, is only beginning to be understood. What mechanism and to what degree does genetic influences effect one’s expression of gender? We do know that besides the traditional XX chromosome of a typical female and the XY of a typical male, that there are other combinations such as XXY, XYY, and XO.
A XXY combination results in 47 rather the 46 chromosomes. This condition is called Klinefelder’s syndrome and occurs in one in every 500 births. Individuals with Klinefelder’s are sterile, have enlarged breasts, small testicles and penis, and a eunuch body shape much like the “Pat” character on “Saturday Night Live.” They show little interest in sex.
Another 47-chromosome occurrence is XYY Syndrome. In this syndrome, the hormonal and physical appearance of the individual are evidenced as a normal male, but behavior is effected. Typically, XYY Syndrome people are bisexual or paraphilic (pedophilia, exhibitionism, voyeurism, etc.), and show very poor impulse control.
Where Klinefelder’s and XYY Syndrome are examples of an extra chromosome, Turner’s syndrome is a case of a missing sex chromosome. These individuals possess 45 chromosomes (written as XO), are unable to develop gonads, and are free of all sexual hormones, except that crossing over from the mother during fetal life.
Turner’s Syndrome people have external sex organs approximating a female, and their behavior is characterized as hyper-feminine, baby care oriented, and showing very poor spatial and math skills. The Turner’s personality, free of all influence from testosterone, tends to be in direct opposition to the typical set of “Tom Boy” traits.
But, none of the above conditions describes the transgendered individual. Transgenderism is far more subtle, involving probably only a few genes on a single chromosome.
Physical Gender
To discuss this aspect of gender we need to examine hormonal involvement, in particular testosterone. During fetal life, the amount present, or the absence of testosterone and other androgens determines our sexuality — physically, mentally and emotionally. There are key times or periods during development when the fetus will go towards the male or the female depending on the level of testosterone. These windows of opportunity may be only open for a few days and if the needed level of testosterone is not present, a basic female orientation develops regardless of the testosterone levels before or after this critical period, and the resulting sexual imprint.
The first critical period is at conception when the presence of the SRY gene (Sex-Determining Region of the Y chromosome) will determine our physical gender. The SRY gene is normally found on the short arm of the Y chromosome, but can detach making for a XY female (the Y missing its SRY gene) or a XX male (the SRY attaching to the X).

The SRY gene causes the fetus to release TDF (Testes Determining Factor) which turns the undifferentiated gonad into testes. Once testes have formed, they release androgens
Before the release of TDF, the developing fetus has two tiny structures, the mullerian and wolffian ducts, and two small-undifferentiated gonads, neither testes nor ovaries. WithouttWith the influence of TDF, the gonads become testicles and the wolffian duct forms the male internal sex organs, the mullerian ducts dissolve and the external tissue develop into the penis, scrotum, penile sheaths and foreskin. In other words, without testosterone all fetuses develop into females. Adam springs from Eve, not Eve from Adam.

As the primary sexual differentiation proceeds towards our physical gender, sometimes deviations occur. These anomalies are sometimes called “experiments of nature.” One such “experiment” is a condition termed congenital adrenal hyperplasia (CAH) when the female fetus releases a steroid hormone form her adrenal glands which resembles testosterone. The resulting child often has confusing genitals ranging from deformed female genitals to an appearance of male genitals. If the child is raised as male, following any “adjusting” surgery and given male hormones at puberty, the individual develops as a “normal” but sterile male with XX chromosomes. On the other hand, if the infant is surgically corrected to female and given female hormones, there is a 50/50 chance of lesbian or transgender expression. This “correction” is the source of much unhappiness, and most “intersexed” individuals have this condition.
Another revealing “experiment of nature” is Androgen Insensitivity Syndrome. In this case, there is a normal amount of testosterone circulating in a XY chromosome fetus, but each cell of its body is unable to react to it. This is similar to Turner’s Syndrome in that neither the mullerian or wolffian ducts (see above) mature and the external genitalia develops into an approximation of normal female genitals, but differs in that TDF stimulates the gonads into becoming functioning testicles in a XY chromosome body. The child is raised as a girl and is seen as a normal female until she fails to menstruate because she has no uterus. If her testes produce enough estrogen (excess testosterone is converted into estrogen), she develops into a completely normal appearing (but lacking a uterus and upper vagina), sterile female with XY chromosomes and internal testicles.
Brain Gender
Dr. Simon LeVay, in his book, “The Sexual Brain,” argues that one’s brain receptors for hormones may also play a significant role in our gender development. Dr. LeVay writes, “There is much to recommend...that there are intrinsic, genetically determined differences in the brain’s hormone receptors. This would provide a mechanism that involves hormone-induced brain differentiation (along gender lines) but does not require there to be differences in the actual levels of hormones, and there is opportunity for selective effects on different brain systems.”
At all times keep in mind that Physical Gender does not always indicate “Brain Gender,” while most physical male and female infants have Brain Gender matching their physical gender, a significant (but unknown) percentage do not. And in transgendered individuals, the Physical and Brain Gender are the opposite, and begin to express themselves at birth.
Even a few hours after birth, significant behavioral differences are noted between morphologically “normal” boys and girls. Newborn girls are much more sensitive to touch and sound than their male counterparts. Several day old girls spend about twice as long looking back at an adult face than boys, and even longer if the adult is speaking. A girl can distinguish between the cries of another infant from other extraneous noises long before a boy. Even before they can understand language, girls do better at identifying the emotional context of speech.
Conversely, during the first few weeks of infant life, boys are inattentive to the presence of an adult, whether speaking to the infant or not. However, baby boys tend to show more activity and wakefulness. At the age of several months, girls can usually distinguish between the faces of strangers and people they know—boys usually do not demonstrate this ability.
As infants grow into children, the differences seem to intensify and polarize. Girls learn to speak earlier than boys and do a better job of it. Boys want to explore areas, spaces and things, girls like to talk and listen. Boys like vigorous play in a large space where girls like more sedentary games in smaller spaces. Boys like to build, take things apart, explore mechanical aspects of things and are interested in other children only for their “use” (playmates, teammates, allies, etc.). Girls see others more as individuals—and will likely exclude a person because they’re “not nice,” and will more readily include younger children and remember each other’s names. Girls play games involving home, friendship, and emotions. Boys like rough, competitive games full of “‘zap, pow’ and villainy.” Boys will measure success by active interference with other players, preferring games where winning and losing is clearly defined. In contrast, girl play involves taking turns, cooperation and indirect competition. Tag is a typical boy’s game, hopscotch is a girl’s game.
As we grow into adults, these differences become both more subtle and entrenched.
Female brained individuals are naturally socialized, tend to prefer cooperation, group discussions and compromise, but are rigid rule followers. Male brained individuals need to be forced into a social conscience, see everything as winning or losing, and are very territorial (my idea, my place, my person, etc.). Competitive and keenly aware of their place in the pecking order, males view rules as something to avoid, ignore or use against others. (The legal profession is very male.)
Female brained individuals are very aware of emotional states, both in themselves and others, and have a gift for, and need to express themselves in language. These two needs/abilities combine so that there is a great deal of discussion and description of everyday things (food, experiences, involvements and other people) with an emotional context and value judgment.
Male brained individuals have great difficulty identifying emotional states of any kind beyond anger, fear and lust, either in themselves or others. Language tends to be restricted and used sparingly, and hardly ever to describe emotional states. But male brains do have superior spatial and non-verbal skills, such as mathematics, map reading, 3-D conceptions, and with increasing intelligence, abstractions.
In fact, for reasons not understood (at least by this writer), gender differences seem to decrease as our IQ points increase. One study indicated that one-third of physical females in graduate school had brains wired more like a typical male brain.
Transgendered folk tend to be born with a female brain gender, but shortly after eight years of age begin to forsake it for a makeshift male brain type of response. It is like abandoning a four-lane highway and taking a little dirt road beside it—and making the best of their choice. Why do such a thing? To fit in. Around eight or nine years of age, the differences between male and female behavior become obvious. In order to fit in, the physical male with a female brain begins to mimic and then perfect (as much as they can) a male response, leaving their natural female self unexpressed or underdeveloped.
Some transgendered physical males are very good at this subterfuge and produce a flawless macho male persona. Others are less successful, and some produce a “Swiss cheese” persona where glimpses or whole chunks of their natural female thinking showing through. But, no matter how efficient an individual is in hiding their natural gender from others, they will always be aware (at least at times and to some degree) of it themselves.
The non-transgendered would typically be able to live with their female gendered brain (most writers, artists, actors), forming some sort of truce or overcompensation which even they would usually come to accept as being true. But, alas, the transgendered also have a female gendered Brain Sex and Identity.
Brain Sex
There appears to be a male and female pattern of psychosexual behavior. These are modes of behavior—one male, one female which are laid down, like Brain Gender, in early life and seem to be independent of environment (how, where, and by whom we are raised) and can be independent of both Physical Gender and Brain Gender.
Before I delve into what Brain Sex is, let me state what it is not—it is not sexual orientation. While sexual orientation can be an attribute of Brain Sex, it is not a primary one. More on this later.
What is Brain Sex? Brain Sex is the primary hard-wired patterns which dictates how we view and relate to others on a social, interpersonal and sexual level. Although, like Brain Gender, most physical females will have female Brain Sex and physical males, male Brain Sex. But, this is far from absolute, and in the case of transgendered folk, it is the reverse. A physical male transgendered person will have female Brain Sex as well as female Brain Gender.
When referring to female and male brained individuals in this section, I will be referring to their Brain Sex regardless of the physical or Gender Brained states.
Female brained individuals cannot and do not separate how they feel about a person (good, bad, nice, boring, etc.) and how they see them sexually. They must feel positive about a person as an individual in order to sexually desire them. Male brained individuals have a distant disconnect between feelings about a person as an individual and as a sex object. Males can easily, sometimes preferably, have sex with a person they don’t know, don’t like or even actively dislike. Love and sex are two different worlds for the male brained. These two worlds can come together, and for most this is preferred, but it is not necessary, and for some, not even desired.
For female brained individuals, environmental factors are very important when it comes to sexual contact. Such things as lighting (candles, soft lighting), smells, sensual bedding, music and a “romantic” ambiance are important to erotic feelings and fantasies. Males can have sex anywhere, any time, any place with equal gusto. Sex in the bed, car or dark room with a stranger are all equivalent.
While environmental concerns are low on the male totem pole of desires, sensual attitudes come very high. How their partner looks, feels, even smells, is very important. Males prefer their partner young (or with young features), smooth and “sexy.” Looks and sensual components are much less important to the female brain, with social status and acceptance given greater weight.
The importance given to the senses in males and their disconnect between romantic feeling and sex objects, help explain male interest in pornography and their ability to have sex to orgasm almost indiscriminately (sex dolls) and often counter to the stated attributes of a desired partner (sex in prison).
While female brained individuals are highly influenced by what society expects or rejects in regard to their general and erotic behavior; males are often most influenced by what display value and “bragging rights” their behavior and partner possesses.
As for sexual orientation, this is an attribute which I feel to be limited to male brained individuals. I know this is heresy and very socially incorrect in some circles. But, allow me to illustrate my point. While male brained persons are capable (at least while young) of having sex with almost anything (animal, vegetable, or mineral), they are from an early age romantically and sexually drawn to a specific physical type, male or female. No matter what their socially influenced sexual activity may be, or for how long, their basic attraction (even if denied) is not acted on, their orientation does not change.
Female brained individuals, on the other hand, appear to be much more fluid and less physically restricted in their choice of sexual partners. Women routinely become romantically attached to each other, but physical expressions remain atypical for most. While periods of lesbian experimentation is not rare among women, for a straight male to become romantically involved with another male in mid-life without previous gay feelings unexpressed is all but unknown.
Female brained persons are far more influenced by a person’s personality and “niceness” than their body, and being great rule followers, they are highly influenced by what “society” expects of them. This society can be anything from the greater society to their neighborhood, family, friends, religious or social group. If a female brained individual meets an emotionally compatible woman in a socially accepting or nurturing environment, a romance can take place. A male might have sex, but never romance.
Because transgendered physical males have female brain sex, they lack a hard-wired sexual orientation. Therefore, while some transgender women retain a “lesbian orientation,” the majority, in spite of their behavior, feelings and expectations before transition, develop an attraction to males and desire a “normal” romantic and sexual relationship with a man. They follow the rules first as a physical male later as a physical woman.
Gender Identity
Crossdresser—
Those individuals with a desire to wear the clothing of the other sex but not to change their sex are termed crossdressers. Most crossdressers view themselves as heterosexual men who like to wear women’s clothing in private or in public, and may even occasionally fantasize about becoming a woman. Once referred to as a transvestite, crossdresser has become the term of choice.
Transgenderist—
Transgenderists are men and women who prefer to steer away from gender role extremes and perfect an androgynous presentation of gender. They incorporate elements of both masculinity and femininity into their appearance. Some persons may see them as male, and by others as female. They may live part of their life as a man, and part as a woman, or they may live entirely in their new gender role but without plans for genital surgery.
Transsexual—
Men and women whose gender identity more closely matches the other physical sex are termed transsexual. These individuals desire to rid themselves of their primary and secondary sexual characteristics and live as members of the other sex.
Transsexuals are diagnostically divided into the sub-categories of Primary or Secondary. Primary transsexuals display an unrelenting and high degree of gender dysphoria, usually from an early age (four to six years of age). Secondary transsexuals usually come to a full realization of their condition in their twenties and thirties, but may not act on their feelings until they are much older. Typically, secondary transsexuals first go through phases that would be self-assessed as being a “crossdresser or transgenderist.”

The last of our five attributes, Gender Identity, is the last to be identified, and the least understood and researched. Gender identity is one’s subjective sense of one’s own sex. Like pain, it is unambiguously felt but one is unable to prove or display it to others.Gender Identity does not match their Physical Gender, the individual is termed Gender Dysphoric. Like minority Sexual Orientation, Gender Dysphoria is not pathological, but a natural aberration occurring within the population, like blue eyes. As with minority sexual orientation, the percentage of the population having gender dysphoria is in dispute, with estimates ranging between one in 39,000 individuals up to three percent of the general population. My experience leads me to feel that the higher figure (3%) is closer to the actual prevalence.
Physically male gender dysphoric individuals have been described, either by themselves or by others, as falling into three distinct groups: crossdressers, transgenderists and transsexuals.
While these categories are the generally accepted classifications both within the gender community and among helping professionals, during my work with gender folk I have come to the belief that there is only one cause, one conflict, one condition — but there are many reactions and adjustments to it. I have gradually come to the conclusion that one’s coming to terms with the conflict between one’s knowledge of their true gender and one’s need to be “normal” fosters the same conflict in all gender folk. Because a child’s greatest desire is to be normal (like everybody else), the great majority of transgendered individuals create an artificial self which meets this goal. They are often so successful at this that they not only fool everyone else but themselves as well — at least part of the time, in some way.
Once created, physically male gender folk live in their male role — a 3-D personality with its own goals, likes and dislikes, values, hobbies, etc. Although indistinguishable from the “real thing,” it isn’t themselves. It is an artificial creation for them to be able to fit in. This is achieved at the expense of denying, locking away, their natural female self. (See Brain Gender and Brain Sex.) Their desire to be “normal” has denied them their natural selves. But, as the nagging reality of the deception becomes harder and harder to suppress, one has to express their true gender somehow, in some way.
For most, dressing is the obvious compromise. If one cannot be female, one can at least express femininity. But the more one expresses one’s true self, the desire for more becomes greater. Some individuals continue expressing themselves more and more, others panic and purge only to start again later.
One’s gender identity classification (crossdresser, transgenderist, transsexual, etc.) is due to each individual’s adjustment to first the conflict between one’s natural gender and their need to be “normal,” and later to the conflict between one’s natural gender and their “male persona.” There is no objective “best solution,” only a subjective, personal best solution.
After years or decades of living, working and building within their male persona, it is often too “expensive” to give up the life, perks, family, etc., one has built up—in order to go back to basics and have an emotionally 12 year old girl grow up—and live in a once male 40+ year old body. But no one is too old to transition. I have had many people in their 40’s and 50’s transition very successfully. I have even had some clients in their 60’s and 70’s.
However far one is able to go toward dismantling the male persona and allowing their female subjective gender to develop, one generally seems to have the following three levels of transition:
1. Recognition that one’s Brain Gender is different from one’s Physical Gender —This first phase comprises the majority of transgendered persons (75 – 95%) and can take the form of seeing one’s self as a “woman trapped in a man’s body,” a need to express one’s “feminine side,” etc. This stage is mainly concerned with physical/surface changes such as crossdressing, passing, makeup, wigs, etc. In this first part, many gender folk don’t even venture from their own home in female attire or restrict their expression to undergarments (bra, panties) in public. They often have a juvenile (before age 15) and later, an adult phase. There is often years or decades between the two phases. This level is filled with confusion, conflict, guilt, panic, and purging. The so called “Primary Transsexual” is an individual who never constructs a male persona and therefore never accepts their male genitals or challenges their female Self Map/subjective gender.
2. Accepting one’s True Self— This stage is much more varied than the first, and has less emotional turmoil. This is the stage where one begins to accept their female self in some way and to make lifestyle changes to accommodate this acceptance. One may only accept the need to appear female, still denying their female true self (crossdresser) or begin to accept their true female self, but concentrating on a superficial physical level of change (transsexual, transgendered).
The self-identified crossdresser may begin to bring his significant other into his dressing, begin going to crossdresser meetings and events, or even going out into public. Those individuals more accepting of their true self will start to look for help in physical transitioning, such as hormones, electrolysis, and surgery, as well as wigs, makeup and clothes.
The major insight lacking at this stage is that they are still under the control of the male persona with all of its unnatural fears, drives, expectations, and knowledge. Even their view of their “female self” is his view, not their freed and autonomous female self. They are still trapped in the belief that physical form alone determines gender.
3. Becoming one’s True Self — This is the last but unfortunately least experienced part of transitioning. This is the stage when that little girl trapped inside an artificial male persona in order to fit in, breaks free, grows up and has her own life — often with markedly different values, temperament and interests.
It has been my observation that the female self needs little help in growing up and developing if the overpowering weight of the male persona is removed from it. The transgender individual has spent years, decades developing, reinforcing and living in their male role. Dismantling the male persona takes a great deal of time, effort and outside help. But, an individual’s sense of happiness and success is directly parallel with the degree they have dismantled their male identity, not on their age, physical size, hormones, surgery, etc.

Roy told me about his transsexuality two and one half years ago and, needless to say, the past few years have been difficult. Rarely are we forced to be so introspective. I have pondered the meaning of love, the role of gender, responsibility, sexuality, commitment, societal expectations, and my own needs. I have not come to any profound conclusions.

I know that I love Roy and that I have been happy in our marriage and that I expected it to last a lifetime. I also know that there was no way I could attempt or expect to change this path of events. I could only help Roy make sure it was what he really wanted and that he was aware of its repercussions.

I also know that I am heterosexual and enjoy and appreciate a relationship with a man. I actually like being a wife to a husband. What this means for our future together I still don’t know. Whether we will be” room-mates” or live separately I don’t know. That I will always we linked to Roy/Deborah is inevitable. There is something still wonderful about him (her). I am committed to helping him during his difficult times and I know he will always be available to me also. Our relationship will evolve, as it has over the past 25 years.

Concern for my children has been first and foremost in heart and mind. They have only had this news for a few months, but they have reacted with great sensitivity and insight. This path is often very difficult and my children need the opportunity to deal with this in their own ways. For Naomi this means you should refrain from bringing up this subject.

And what do I expect from you? To continue to be a friend, call me occasionally, join me for a walk, a cup of coffee, or a show. Accept the uncertainty, and support us, both separately and together, in our journey.

In this crisis I hope that my friendship with many of you will deepen.

Hold my hand when I falter, hug me if I cry, and laugh with me if you can.

Love,

Alison

By Charlie Anders

Razi was raised as a girl, in a feminist Jewish Revival synagogue. Nobody ever told Razi not to do the things boys did, but still Razi found religious events a source of discomfort. This was because Razi “felt too self-conscious in my own skin to wear the appropriate clothing” for ceremonies. Razi wanted to dress up, but didn’t feel comfortable. It was only when Razi grew up and transformed from a girl into a man that he discovered a new relationship with Judaism. Instead of being the bane of his existence, dressing up for synagogue became a thrill. “When I began identifying as male, I couldn’t wait to put on a tie and yarmulke and enter the community as a young Jewish man,” says Razi, now a college student.

As transgender visibility increases across Western culture as a whole, gender-transforming Jews have started to carve out a space for themselves in Jewish society. They’ve stared down gender preconceptions, paranoia, and misunderstandings. But in many cases, they’ve also found that transitioning has enriched their relationship with Judaism, and vice versa.

Trans Jews also have created their own communities on the Internet and elsewhere. These include a “TransJews” email group on Yahoo, a community on Livejournal.com, and an acclaimed zine called TimTum: A Trans-Jew Zine, written by tranny anti-Occupation activist Micah Bazant, who also wrote the Trans Manifesto, a well-circulated on-line call for the recognition of equal rights for the transgendered.

Inevitably, when a Jewish person changes gender, this changes his or her relationship to the religion. Israeli American Beth Orens completed her transition from male to female in 1997 and finds that her status is “a little different now.” Orens runs the Dina email list for Orthodox Jewish trans people.

“It annoys me when I know more about something than a rabbi does, but I have no authority,” frets Orens, herself an Orthodox Jew. Even before she transitioned, she lacked authority, but she feels this more keenly as a woman. At the same time, she says, “Judaism is all about distinctions,” and “difference does not have to mean inequality.”

 On the other hand, transitioning from female to male “made involvement with Judaism possible for me,” says Jerrold, a twenty-four-year-old man. “As a female, I had no connection to the religion at all. My Bat Mitzvah was a farce. I was the first girl to be allowed to read Haftorah at my shul but still wasn’t allowed to read Torah. None of it meant anything to me.” But as soon as Jerrold became a man, he felt as though he had a place in Judaism. His only awkwardness comes because he didn’t receive the upbringing and training that would have come with being raised as a male. He doesn’t know how to put on tefillin, and he only knows Haftorah trope, as opposed to Torah trope. He still feels “awkward about women’s roles,” such as the fact that women must sit on the other side of the mechitzah (the barrier that divides men from women in Orthodox synagogues). But as a man, he doesn’t feel it’s his place to raise these issues on women’s behalf.

Brooklynne Thomas, events coordinator for the Youth Gender Project in San Francisco, converted to Judaism from Catholicism at age nineteen. At the time, Thomas was a man in the process of marrying a Jewish man whose mother wanted Thomas to convert or leave her son. Thomas had already been “harboring secret desires to be Jewish,” so the ultimatum proved liberating. Thomas’ marriage to the Jewish boy ended some time later, and then she transitioned into a woman. She says she feels much safer as a Jewish transwoman than she would have as a Catholic. She feels that Judaism is more accepting and less concerned with creating distance between the priesthood and the laity than Catholicism.

Castration Anxiety, Sterilization Terror

Even if changing your gender makes you more comfortable with Judaism, there’s no guarantee that every Jew will accept your new gender identity. The majority of Orthodox rabbis refuse to recognize the gender identities of people who’ve had genital surgery (regarding it as genital mutilation), much less those of people who’ve merely taken hormones or taken on a genderqueer identity.

The majority of halachic authorities in Israel take the position that a person’s gender is irrevocably fixed at birth, according to a 1998 article in the Jerusalem Post. Not only that, but the article cites the influential 1977 opinion of Yeshiva University Professor J. David Bleich that genital reassignment surgery violates the prohibition on sterilization for women, or castration for men. The article also cites a “minority” view by Rabbi Eliezer Waldenberg, a judge in the Supreme Rabbinical Court in Jerusalem, that surgery does change someone’s gender. Often cited by Orthodox trans persons such as Beth Orens as an authoritative halachic position, Waldenberg’s opinion is not widely shared by other Orthodox rabbis.

However, even if, like Waldenberg, they accept that someone can change his or her sex, halachic authorities see a host of bewildering questions, according to the Post article, such as whether a female to male transsexual must be circumcized, whether a transgender person must get divorced, and what sexual partners are “appropriate” for transgender people.

Orthodox Jewish transphobia “makes frum homophobia look like nothing,” says Orens. And non-Orthodox Jews can be just as bad, she adds. Orens had one friend, formerly Orthodox but now intermarried, who stopped talking to Orens after she realized Orens was formerly male.

But Reform Judaism has been more accepting. Jonathan Edelstein’s blog HeadHeeb links to a 1990 responsa from the Central College of American Rabbis that says Reform Judaism should “accept the findings of modern science, which holds that external genitalia may not reflect the true identity of the individual.”

Jerrold says that all his relatives reacted positively, although his parents were slow to adjust. His ninety-year-old grandmother was the second person to start calling him by his male name. And even his Orthodox extended family in Europe had no problems.

And then there are some who regard transgenderism as a special benefit. Razi tells of one Orthodox Jew who identified as bisexual but vowed he’d “take a gun to the head” before sleeping with a man. Someone brought up the issue of transmen, and the man became excited, because that would be perfect. “Because to me he’d be a man, but to G-d he’d still be a woman, so it would be allowed!” the man said. His interlocutors were horrified.

Some Orthodox rabbis, at least, would disagree with that reluctant bisexual that a transman is still a woman “to G-d.” Orens says she’s obtained two legitimate halachic opinions that she’s actually female.

Traditions Enrich Transformation

Judaism offers some rituals that help people add meaning to the process of transitioning from one gender to another. Before he had his chest reconstruction, Jerrold went to a Renewal rabbi, who performed a spiritual mikvah in his hot tub. It was “a great experience,” Jerrold says. Jerrold asked another rabbi to perform a hatafat dam brit for him, “but he thought it was unnecessary since I’m already Jewish.”

“Adapting traditional rituals for use in my transition, especially the surgery, helped me to feel safe, grounded, [and] settled about what I was doing,” Jerrold explains. “Because Judaism is so rich in life-cycle events, everything can be very easily adapted to provide a ritual framework for transition and celebrate what are truly joyous,

freeing occasions.”

Almost every story in Judaism is about transition, the most important one being from slavery to freedom, Jerrold adds. “It’s a great lens through which to view your own life and a means to draw lessons from your history.”

“My involvement with Judaism and spirituality has given me a chance to take issues of identity seriously, and has given me wise teachers with whom I can discuss the things in life that are important,” says Razi. Conversely, changing his gender has forced him to reconsider many things about his life, including his Judaism.

One online guide to running a progressive seder suggests asking everybody present which pronoun he or she prefers. If there are any transgender people present, this will put them at their ease. If not, it’ll make the participants think for a moment about how they take their own gender identities for granted.

And there are other ways that Judaism can help people seeking alternative ways of viewing their gender identity. “Did you know there are seven genders mentioned in the Talmud?” asks S. Bear Bergman, a writer and performance artist who deals with issues of Judaism and gender, and identifies as a butch rather than as a transsexual. The Talmud includes guidelines on incorporating different genders and sexes into Jewish society. Even if those multi-gendered guidelines aren’t followed today, they set a precedent for accepting non-binary genders in Jewish life, says Razi.

Because Judaism doesn’t have a hell, Jewish people can’t claim that transgenders will go to hell, notes Razi.

Exceptional Cases Illuminate the Rule

It’s often through the outliers that you see the true nature of the center. In the case of Judaism, transgender people often raise unusual questions that past generations of Jews might never have considered. And yet the answers to those questions reveal much about the heart of the Jewish faith.

Now that Thomas has converted from Catholicism to Judaism and from male to female, she mostly dates female-to-male transsexuals. If she chooses to have a baby with one of these transmen, most likely her partner will carry the baby in his womb. But Thomas will be the baby’s mother in every other sense. Such reverse-gender parenting situations are rare, but becoming more common in San Francisco, where transmen and transwomen sometimes date.

If the baby’s father is a gentile, will the baby be Jewish? It depends on whether you believe the mother is the person who gives birth to a child, or the child’s female parent. Or looked at another way, it depends whether you believe someone’s gender is their physical self, or their inner essence. “I’ve talked to several Jews and rabbis about this, because this is an important issue with me,” says Thomas. She says it boils down to the clash between biological sex and spiritual and mental gender.  The consensus among the people she’s consulted is that the latter is more important than the former, especially for transgender people. So Thomas would be her baby’s mother even if she didn’t give birth. “It’s the spiritual gender that you would follow to determine the Jewish status of the child,” Thomas concludes.

Jerrold identifies as a gay man, and isn’t sure how he stands with regard to Judaism’s marriage and purity laws.  “I struggle with what kind of marriage can be sanctified as kiddushin.” Like Thomas, he wants to become a parent and isn’t sure “what kinds of challenges there will be halachically.”

For Bear, who has become progressively more masculine and ended up with a self-described “Rorschach” gender, Jewish ritual has become a minefield. Often, Chabad people have made assumptions about Bear’s gender identity based on appearances and have “been quite insistent on showing me how to lay tefillin or daven,” or have tried to put gender-specific ritual objects into Bear’s hands.

When this happens, Bear’s identities “feel at war. Whose interpretation of my gender, my sex, do I honor?” Bear always resists the temptation to take on the male role and “defile” the ritual objects for anyone who thinks about sex and gender more conservatively. Bear would rather educate people about gender than show disrespect for someone else’s religious beliefs “in such a direct and dishonorable way.”

People whose gender either contradicts or reinterprets their birth assignment are working hard to create a space for themselves within Judaism. They’re finding that the variety and depth of Jewish traditions offer them opportunities as well as constraints.

“I love that Judaism contains a function for responding to current issues in responsa,” says Bergman. “I think of Judaism, especially Reform Judaism, as practical and compassionate, and I expect that the responsa surrounding trans issues will emerge in a similar spirit.”

But even Orthodox Jews whose rabbis have thrown roadblocks in their way have found ways to integrate their new gender identities into their faith. And in the process, they’re finding that religious faith, like gender, is greater than its component parts.

This Just In...

The Conservative movement has recently issued a policy statement on transgender Jews, which suggests that a wholesale change in Rabbinical recognition of the transgendered is afoot.  According to a United Synagogue Review summary of recent decisions of the Rabbinical Assembly’s Committee on Jewish Law and Standards circulated on the TransJews listserv, Rabbi Mayer Rabinowitz issued a responsum entitled “The Status of Transsexuals,” which took the following revolutionary positions:

1. Only those who have undergone full Sex Reassignment Surgery (SRS), including phalloplasty/vaginoplasty, are to be considered as having changed their sex status and should be recognized as their new sex by Jewish law.

2. A person who has undergone partial SRS is not deemed to have changed their sex status.

3. A brit of hatafat dam brit is not required for one who has had a phalloplasty.

4. A get (Jewish divorce) is not necessary if one spouse undergoes SRS since the kiddushin are automatically annulled. However, in the case of a Male to Female (MTF) person, a get should be given before the SRS is completed.

5. Recognition by the civil authorities of the new sex status is required in order to marry a person who has undergone SRS. This will prevent us from performing same sex marriages according to civil law.

6. A new name should be given to the person with a new sexual status by means of a misheberach.

The teshuvah was approved.

Feature: Transgenderism

Fall, 2005

Norman Spack, MD

Assistant Professor of Pediatrics, Harvard Medical School

Clinical Director, Endocrine Division, Children’s Hospital, Boston, MA



Transgendered individuals are people who, by all known biologic measures, are male or female, yet feel like a member of the opposite sex. The discomfort they suffer is called gender dysphoria. Theirs is a relatively rare condition and cannot be explained by factors such as chromosomes, prenatal hormones or toxin exposure, genital variability, postnatal circulating hormone levels, gender of rearing, birth order, or the presence or absence of same-sex siblings.

Is it possible that the brains of the transgendered are uniquely "wired"? Subtle differences between female and male brains have been reported for decades in research studies that identify gender-related size differences between specific brain nuclei by staining slices of post-mortem specimens.1 One recent study showed that the nuclei of transgendered male-to-females (MTFs) are the size of the nuclei of genetic females. 2 An earlier study revealed that males dying of prostate cancer who had been treated for years with female hormones, and females dying of virilizing adrenal tumors, had nuclei consistent with their genetic sex. 3 Their hormonal exposure did not affect the gender-specific nuclei of their brains.

Gender dysphoria is listed as a psychiatric condition in the psychiatric diagnostic coding manual DSM-IV. I believe that the psychiatric manifestations are a reaction to the situation, not the underlying condition. A transgendered individual who has not had hormonal therapy or surgery may require psychopharmacologic medications, but after a patient receives medical and/or surgical treatment, psychotropic medicines are often unnecessary.

Nearly all transgendered adults recall feelings of being in the wrong body early in childhood. Patient histories resonate with the common theme of dressing secretly in the clothes of the opposite gender during childhood. However, the age at which a transgendered individual fully acknowledges his or her gender identity varies from mid-childhood to middle age. Delayed acknowledgment can usually be traced to a fear of stigmatization and rejection by family, friends and employers.

The majority of children who express recurrent interest in being the opposite sex are not transgendered, although many become homosexual. 4 A small percentage of children who are emphatic and consistent in their desire to be the opposite gender (less than 20% of the above) prefer to be called by a pronoun and name consistent with their gender identity. Their friends, dress and activities correspond with that identity. Their greatest fear is puberty because of the irreversible changes that threaten how they are perceived (their "gender attribution"). During adolescence, when unwanted and permanent secondary sexual characteristics transform the patient’s body into an adult form that is asynchronous with the brain, depression and anxiety are typical reactions. When menses become a monthly reminder of femaleness in a teenager with a male identity, self-abusive behavior is common. The incidence of suicide among transgendered youth is high. 5 Adult transgendered individuals who find it threatening to acknowledge their gender identity publicly may adopt a lifestyle of marriage and parenthood that matches their genetic sex.  Inevitably, maintaining this charade takes its psychic toll.

Who is qualified to assess a patient’s condition for referral for endocrine treatment and ultimate surgery? "Standards of care" have been created by the Harry Benjamin International Gender Dysphoria Association, a professional society that includes mental health professionals, endocrinologists, internists and surgeons (http://www.hbigda.org). The standards define stages of treatment, beginning with "extensive exploration of psychological, family and social issues" by a mental health professional who has abundant experience working with this population, and only then moving to physical intervention, which should take place in stages, from reversible to irreversible interventions.

Physicians may be uncertain how to address transgendered patients who have not legally changed their name and gender but have transitioned to a gender role consistent with their gender identity. Some states require reconstructive surgery - genitoplasty or mastectomy - before allowing name and gender changes on documents such as driver’s licenses and health insurance cards. Whether or not patients have made legal changes or undergone surgery, they are entitled to the dignity of being referred to by the name and pronoun of choice. Male-to-female patients should be offered a gown in the exam room, and female-to-male (FTM) patients should be asked what they prefer to wear during the exam. No assumption should be made about the patient’s sexual orientation. Like anyone else, a transgendered individual may be straight, gay or bisexual. Sexual orientation reflects physical attraction, not gender identity.

The labeling of transgenderism as a psychiatric condition has the ironic effect of inducing psychological problems in transgendered individuals. This fuels the notion that a psychiatric disorder is at the heart of the condition, which influences the diagnostic coding and billing structure. Under the DSM-IV code, few health insurers in the United States cover the cost of hormonal replacement therapy. Mastectomies in FTMs, which cost $6,000 to $10,000, and genitoplasties (sex reconstructive surgery) in MTFs, which cost $15,000 to $25,000, are considered by almost all health insurers to be cosmetic surgeries on patients with a mental illness.

To enable patients to transition physically, endogenous gonadal sex steroid output must be lowered to levels consistent with the gender of choice, which may not be easy. Both MTFs and FTMs require supraphysiologic doses of "crosshormones": estrogen for MTFs, testosterone for FTMs. High dose estrogen poses a risk of blood clots, which can be fatal if they travel to the lungs (pulmonary embolism) and doses of testosterone sufficient to prevent menses can induce hypertension, cystic acne and excess red blood cell production with the risk of blood flow "sludging." Alternatively, endogenous sex steroids can easily be suppressed by GnRH analogues, which block pituitary gonadotrophin (LH and FSH) release, enabling cross-hormone treatment to be accomplished with safer physiologic doses of estrogen or testosterone. Unfortunately, GnRH analogues are prohibitively expensive in the US, and patients are forced to take the higher doses of sex steroids until they have their gonads removed. Genitoplasty in MTFs and reduction mammoplasty in FTMs are not covered by most health insurers, and patients may have to wait years saving for it.

In the Netherlands and Belgium, national health insurance covers all costs related to evaluation and treatment of transgendered individuals, including children. 6 Interdisciplinary gender teams evaluate patients psychologically, and patients become potential candidates for sex reconstructive surgery at government expense after living for at least a year in the gender of choice (the "real-life experience") while taking corresponding sex steroid hormones. This discrepancy in coverage across nations raises questions about US health insurance policy decisions.

Because treatment with cross-gender hormones has irreversible effects, challenging choices inevitably arise. For the MTF, estrogen produces breast enlargement and diminished sperm production. Some MTFs request sperm banking before estrogen treatment or gonadectomy just to maintain their reproductive capacity, regardless of who will receive that sperm. For the FTM, testosterone produces a deeper voice, facial hair, temporal balding. Loss of ovulation and menses ensue, and the ovaries become polycystic while retaining retrievable ova. When cryopreservation of ova becomes technically routine and successful, some FTMs will request the procedure to serve as egg donors for their partner or surrogate.

A significant ethical question in transgender care concerns potential intervention with children. Should transgendered children who have had a careful and protracted evaluation by a skilled gender specialist be compelled to complete puberty before being offered the same therapy used for adults? No national or international protocol exists, and there are opposing views on how to proceed. One side argues that physical intervention should be delayed until the completion of puberty because teenagers are more likely than adults to change their minds about their gender identity. The opposing view, with which I concur, argues for early endocrinologic intervention to prevent the severe depression that accompanies the onset of an unwanted puberty and to avoid the physically and psychologically painful procedures required to reverse puberty’s physical manifestations.

A model protocol currently employed in the Netherlands begins with a lengthy screening process in gender-variant pubescent teens at the "Tanner 2" stage of pubertal development: breast budding in girls and testicular volumes of 8 cc, preceding phallic enlargement in boys.  At this stage the pubertal manifestations are reversible. GnRH analogues are given for at least two years, potentially until age 16, when adolescents in the Netherlands are capable of giving informed consent to receive crosshormones. By blocking puberty, GnRH treatment buys time for FTMs to achieve a height more typical of males and for continued assessment of all patients’ desire to transition. If the Dutch clinical trial proves medically and psychologically safe, it will become the standard of care in the Netherlands, and treatment will be covered by the government health insurance.

Adoption of such therapy in the US, except by a research protocol, is unlikely to be reimbursed by most health insurers as long as transgenderism continues to be coded and billed as a psychiatric condition. The only alternative drug capable of achieving comparable gonadotrophic suppression is high dose progesterone, which has effects similar to high dose prednisone or cortisone and can produce ACTH suppression, fluid retention, "moon face," central obesity and insulin resistance.

"Precocious puberty" is the only approved indication for pediatric use of GnRH analogue therapy in the US. For a patient’s insurance to pay for this drug a physician would have to use this diagnosis for an 11-year-old FTM or 12-year-old MTF, even though the patient hardly meets the age criteria of sexual precocity. If the Dutch protocol is approved by the Harry Benjamin Society, would it be right for US health insurers to withhold payment for GnRH in properly screened transgendered teens?

Transgendered individuals have long faced discrimination in medical institutions, including physicians’ offices and hospitals. 7 Reminiscent of the medical/psychiatric approach to homosexuality not so long ago, some physicians and psychologists maintain that the goal of psychiatric treatment is to convince transgendered individuals to remain in the gender role of their genetic sex, which is an impossibility for most patients. Everyone involved in patient care should have some awareness of gender identity disorders, however rare they may be. Primary care physicians interested in providing hormonal replacement therapy for transgendered patients should consult the Harry Benjamin Society Standards of Care. Physicians and mental health professionals who are neither comfortable nor sufficiently knowledgeable to treat transgendered patients should refer them to more experienced colleagues.

Footnotes

1 Woodson JC and Gorski RA.  Structural differences in the mammalian brain: reconsidering the male/female dichotomy. In Matsumoto A (ed.) Sexual Differentiation of the Brain, New York and London: CRC Press, 2000.

2 Kruijver FP et al.  Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J Clinical Endocrinology & Metabolism. 85(5):2034-41, 2005.

3 Zhou JN et al. A sex difference in the human brain and its relation to transsexuality. Nature.  378(6552):15-16, 1995.

4 Zucker KJ and Bradley SJ. Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, New York and London: The Guilford Press, 1995

5 Kreiss JL and Patterson DL.  Psychological issues in primary care of lesbian, gay, bisexual, and transgendered youth. Journal of Pediatric Health Care. 11(6):266-74, 1997

6 Cohen-Kettenis PT and Pfafflin F. Transgenderism and intersexuality in childhood and adolescence. Making choices, Thousand Oaks and London: Sage Publications, 2003

7 Feinberg L. Transgender warriors, Boston: Beacon Press, 1996 Additional readings Boylan JF. She’s not there.  New York: Broadway, 2003

Additional Reading

Brown ML and Rounsley CA. True Selves:  Understanding transsexualism - for families, friends, coworkers, and helping professionals, San Francisco: Jossey Bass, 1996

Israel GE and Tarver DE. Transgender Care, Philadelphia: Temple U. Press, 1997

Available on the Web

Norman Spack, MD
Pediatric Endocrinologist at Children’s Hospital has written a thoughtful piece on transsexuality in the Fall2005 issue of Lahey Clinics
Medical Ethics Newsletter http://www.lahey.org/NewsPubs/Publications/Ethics/JournalFall2005/Journal_Fall2005_Feature.asp

Wikipedia - (on-line encyclopedia) has a wealth of information on Transsexuality
http://en.wikipedia.org/w/index.php?title=Transsexual

IFGE (International Foundation for Gender Education) - A advocacy and educational group for the transgendered http://www.ifge.org

NCTE- National Center Transgender Equality http://www.NCTEquality.org - A national transgender advocacy group

MTPC - (MassachesettsTransgender Political Coalition) http://www.masstpc.org - Massachusetts advocacy group devoted to protecting the rights of the transgendered

Fenway Community Health Clinic (Boston)Transgender Services Page (with excellent Links) –
http://www.fenwayhealth.org/site/PageServer?pagename=FCHC_srv_services_trans#Links

Books

Helen Boyd – My Husband Betty - Designed as a primer/support for spouses of crossdressers, this book covers the current medical theories/controversies regarding transsexual and transgender issues better than any I’ve seen. Does not pull any punches.

Helen Boyd - She’s Not the Man I Married - A poignant look at the Helen’s marriage to Betty. How her love and support for Betty collide with the uncertainty of Betty’s personal journey and Helen’s own needs as a heterosexual woman, makes for captivating reading.

Jennifer Boylan - She’s Not There – Professor at Colby College who transitions from male to female while she’s the chairman of the English Dept.  Depicts some of her struggles to find her identity while maintaining her family. Easy and, at times, humorous reading. If you can catch her at a book reading for her upcoming book (2008) “I’m Looking Through You” you will surely experience a treat.

Jamison Green- Becoming a Visible Man – Best autobiographical book on transsexuality that I have read.  Jamison is a transman but what he says will get you into the head of a transsexual like no other book can. 

Kate Bornstein - Gender Outlaw – Freewheeling, quixotic but informative romp through the transgender world.

Randi Ettner, PhD – Gender Loving Care – Designed for the health professional, this book give a compact yet comprehensive primer.

Randi Ettner, PhD – Confessions of a Gender Defender – Interesting snapshots of transgendered patients that Randi has provided care for.

Mildred Brown, PhD and Chloe Roundsley – True Selves – Good basic primer on transsexuality. Covers effects on friends and family well. Suitable for the lay or professional reader but I prefer Gender Loving Care.

Arlene Istar Lev, CSW-R- Transgender Emergence – A tome on transsexuality designed for the therapeutic community. She’s a wonderful woman but I could not get through her discussions of gender theory.

Noelle Howey – Dress Codes- At times, interesting book that revolves around the life of a young woman who grows up with a very unpleasant transsexual dad.  The second part of the book (after the father’s transition to living as a woman) is the most worthwhile.

Mary Boenke, Editor - Trans Forming Families: Real Stories About Transgendered Loved Ones - Enlightening stories written by the family members of transgendered people.