Transsexual Analysis

11. Overview and summary

Overview

To answer the questions posed earlier:

• Why do some quite masculine males who are clearly not at that extreme end of the feminine scale - tall, strong, aggressive and excelling in fields like engineering or the military - seek to undergo genital surgery and change their sex roles?

• Why do some extremely feminine men and masculine women not seek to make the change?

The most likely answer to these questions needs to be made in two parts, for each of the types.

Emasculation trauma, which very likely has a large bearing on autogynephilic behavior, can affect young males who may be extremely feminine mentally and/or emotionally (as per standard human diversity).

In the case of homosexual/androphilic transsexuals, it would be fair to say that the very most feminine examples of these people make the change because it was impossible for them to find any male role in which they did not feel inadequate or ridiculous. After much rejection they essentially change over in order to gain greater social acceptance as human beings.

The main danger for such individuals is that male development can occur even up to age 20 or so, and some very small and unmasculine youths, without hormonal intervention, may eventually grow tall and bulk up. In a more tolerant social environment, these people may find more acceptance as gay males than in the past, although their choice of partners will tend to be limited by the strong emphasis in the gay community towards classic masculine physical beauty.

Hyper-feminine boys can experience problems described by both homosexual and autogynephilic transsexuals (to use Dr Blanchard's terminology). Parental denial may lead such children to deny their basic natures leading to internal pressures. In the face of both internal and external assaults such individuals may present with considerable psychopathology.

Ultimately, the existence of an autogynephilic or transvestic history should be no bar to a sex change applicant being given the go-ahead for a sex change. The bottom line must always be a decided on the basis of whether transition will improve the patient's wellbeing and functioning in society.

Some males who are quite masculine by nature can also experience emasculation trauma (with subsequent autogynephilic feelings), believing themselves unable to live up to the model of masculinity they encountered as children - due to their social environment and/or traumatic/sensitizing events.

It has been reported that up to 90% of males who ask their doctors for treatment for gender identity order (GID), at some stage change their minds and discontinue treatment. It would be safe to say that most of these would be reasonably masculine autogynephilic males who find the female role uncomfortable or difficult to fulfil.

Cognitive treatment for GID should include a focus on that sense of childhood emasculation, that is, the reasons why the patient seeks a sex change, as opposed to being a gay man or crossdresser.

The aim in treatment should not be changing the person's mind so much as raising self-awareness and helping to explore feelings.

If this exploration leads to a change of heart, then such self-knowledge may help the patient find a life path more suited to him/her. If the patient wishes to continue treatment s/he will at least have a better understanding of his/her needs and desires and perhaps be motivated to work towards less dependence on cross-gender behavior for happiness. Whatever, once people "face their demons", they are in a better position to make informed decisions.

Due to stigma, false morality, ignorance, and a failure to understand risk management principles, there is a widely-held belief that sex changes are wrong per se, and that therapists should try to talk gender reassignment applicants out of making the change. Some some therapists do, in fact, take a watered-down version of this approach, only recommending patients for surgery if they determinedly resist this subtle coercion and succeed in the 2-year real life test.

This win-or-lose "gatekeeper" approach only serves to undermine meaningful treatment of any underlying problems. It may at times raise competitive or rebellious instincts in sex change applicants, who are already oversensitized to judgmental attitudes, almost encouraging them to "prove the therapist wrong".

Many observers believe that transsexualism should be avoided at all costs and that therapy should be targeted towards either diverting androphilic types towards life as gay men and more masculine "heterosexual" autogynephilic types to recognize and embrace their masculinity. Given the issue of emasculation trauma, the only possible "cure" for transsexualism would be the complete removal of stigmas in relation to sexuality and differentiated social gender expression.

While these may be laudable goals, unfortunately they are not achievable in the short, or even the medium term, if at all. It is therefore unrealistic and cruel to expect transsexuals to offer themselves to be sacrificed on the altar of ideology. Given that transsexuals comprise of at most 0.01% of the population, their role in changing the gender consciousness of the public at large is minimal.

There is a common view that the human body is sacred and that cosmetic surgical changes to it are wrong, immoral or tragic. When emotive words like "mutilation", "false" and "fake" are used to describe surgical changes to a person's body, this indicates that the speaker/writer subscribes to this "body is sacred" viewpoint.

An alternative viewpoint would be that our psyches and social roles are more "sacred" than our bodies, which are essentially carriages with which to do the bidding of our minds and emotions. For many gender reassignment applicants, their cross-gender needs are so ingrained from such an early age that is easier to, as Dr Harry Benjamin once put it, "to change the body to fit the mind".

There is no tragedy in a person choosing to modify his or her body surgically if it relieves psychological, emotional or existential problems and allows him or her to "get on with life" and move onto more productive activities rather than wasting it agonizing over gender, or other distracting, issues.

Finally, it should be said that changing sex is such an extraordinarily difficult enterprise that those who successfully traverse its many pitfalls and hardships, and end up relatively unscathed, may well be endowed with some extraordinary personal qualities for having survived the experience. It could even be said one needs to possess some extraordinary qualities to survive the experience intact.

Chapter summaries

Chapter 1 - Nature vs nurture: humans are diverse

• There are many forces aligned against transsexuals - conservatives, rednecks, anti-trans groups run by ex-transsexuals, religious fundamentalists, radical feminists and non-empathetic gays.
• If transsexuals are to survive these assaults upon their credibility they need to start making clearer what transsexualism is and what it means, beyond the standard "woman trapped in a male body" cliches. [** key point **]
• Ever since prehistoric times there have been people or either sex who have taken on opposite sex roles in their societies /tribes / groups. [** key point **]
• There will necessarily be some females who are extremely masculine women and some males who are extremely feminine.This is standard diversity, and it can be found in all areas of nature.
• Gender diversity can be caused by intersex conditions, genetics, hormones, hormonal conditions during gestation and conditioning.
• It is the interplay between the biological and social that decides how a cross-gendered person chooses to deal with his or her situation.
• Society / customs play a role in sex changes.

Chapter 2 - Diversity in society

• Some tribal groups and small communities pragmatically accepted gender diversity, making the best possible use of their "human resources". They did not have the luxury of wasting the effort put into bringing up community members by forcing them into unsuitable roles.
• In societies dominated by Christianity and Islam, crossing gender boundaries has generally been thought of as "sinful" and "unnatural", and gender transgressors often became outcasts or were killed.
• Persecution of (especially) male-to-female gender transgressors is still happening to some extent, even in so-called "enlightened" Western societies. This is due to continuing patriarchy, where feminine traits are widely considered to be inferior to masculine attributes (reflected in the wage scales of teachers, nurses other caring professions. [** key point **]
• This persecution plays out most dramatically in schools, where masculine males are often abused.

Chapter 3 - A woman trapped within a man's body or autogynephilia?

• Most people don't see standard cliches like "I'm a woman trapped with in a man's body" or "I'm a woman inside" as credible.
• It is impossible for a male to actually become a female, being shaped by the imperatives of those who carry large sex cells (ovaries) as opposed to those who carry small sex cells (sperm).
• There are two main sex strategies in nature - "He-man" (dominant male with a harem) and "Domestic Bliss" (female forces a greater nesting / rearing investment from males). Both are present in human society and shape psychological "maleness" and "femaleness".
• The major differences between male and females can be broken into physical (gonads, size, body shape, skin texture, body hair, facial features, voice, voice intonation and mannerisms) and psychological & emotional (desire for closeness and approval, emotionality, sensitivity, empathy, forcefulness, competitiveness, use of language and our manner of speaking, decisiveness).
• Dr Ray Blanchard created a theory of autogynephilia - where transsexuals can usually be grouped into two categories - homosexual and autogynephilic. The homosexual type is at that extreme feminine end of the male spectrum. autogynephiles usually have a fetish history, marry and are "heterosexual" in their old lives and are sexually aroused by feminization.
• Autogynephilia need not be sexual in the usual sense of the word, just as intimate relationships need not be sexual due to factors such as familiarity, morality, etc.
• The autogynephilia theory's main flaw is the black-and-whiteness of Ray Blanchard's definitions. Being as diverse as any other group, many transsexuals do not fit neatly within one camp or the other. That is, focusing on extremes tends to exclude the majority of cases. [** key point **]
• There is little obvious consistency in the backgrounds of gender transgressors. This is because the consistency lies, not so much in the events gender transgressors experienced during childhood/youth, but how those experiences affected them. [** key point **]

Chapter 4 - Trauma can shape us

• Many researchers believe that childhood trauma is the usual cause of displaced sexual desire. A common thread between the most profound traumas experienced is feelings of humiliation. [** key point **]
• Humiliation is one of the more intense sensations, as capable of creating trauma as it is of facilitating suicide and warfare.
• Intense humiliation during a person's formative years can shape their sexuality. Coping mechanisms can lead them to keep replaying the trauma later in life as a fetish or fixation - but with the important difference having some control over the replayed trauma. This has a short-term palliative effect. [** key point **]
• If the person doesn't understand the feelings that lie beneath his / her desires then the compulsion may become increasingly intense with age. The effects of his/her self-administered "cure" will become increasingly weak through familiarity. The person may then seek more intense "medicine". [** key point **]
• There is a direct analogy here with drug abuse, where people seek more and more extreme remedies to regain the intensity needed to properly "repeat" the trauma.

Chapter 5 - Emasculation trauma and autogynephilia

• The humiliation that creates "emasculation trauma" does not necessarily come from abuse (although it may do), but from the person's sense of self. [** key point **]
• The cause of traumatic emasculation may range from being a boy who is, in fact, highly feminine by nature but in denial. A highly homophobic / macho environment can also deeply affect a sensitive boy, as can bullying and/or abuse at school or at home, "petticoat training" - or any combination, or all, of the above. [** key point **]
• A boy's innate sensitivity is an important factor in how traumatic an event or series of events are perceived. Other traumas may sensitize a child further, such as family conflict, deaths, broken home, etc, making him more vulnerable.
• There are various ways a boy may cope with feeling emasculated to the point of trauma. Often the boy overcompensates - either trying to be exaggeratedly masculine or camp. Or he may seek refuge in privately living out the emasculating trauma - which them renders it under his control. In this instance he privately gives up the fight for masculinity while continuing to fight for it in public.

Chapter 6 - Trauma and sexuality

• Intensity is a common link between trauma and sexual response. The link between childhood/adolescent trauma and sexuality is a well-documented area of psychological enquiry. [** key point **]
• The coping mechanism of repeating the trauma carries its own problems, because it reinforces the behaviors, which can then become habitual. This can create all manner of complications in people's lives, including subterfuge, self-loathing, impediments to productivity, isolation and stigma.
• There is a distinction between "sexual experiences" and "masturbation" when dealing with autogynephilia (it is common for transsexuals to furiously deny sexual response to feminization). Masturbation is only one type of sexual experience and is not universal behavior in autogynephilic people. In this context "sexual experience" is an experience that serves to arouse or enliven or stimulate, which can be felt mentally and emotionally. It does not necessarily include genital arousal, stimulation or orgasm. [** key point **]
• Some people suppress the desire to masturbate due to religious or value-based (upbringing) reasons. If there is genital-based autogynephilia (desire for removal of the penis since it is seen as the root of the problem) then there may be an aversion to touching their genitals.
• autogynephiles may experience repressed sexual tension, so they merely feel comfort and relaxation from feminization (like a partner in a long-term relationship). This explains the comfort people report from fantasy or actual feminization[** key point **]
• Youths and teenagers who engage in of "emasculating" behaviors in private (crossdressing, folding the penis and scrotum into the body, creating pseudo-breasts by cupping the chest or with prosthetics, castration fantasy, etc) will generally gain some level of "payoff" or arousal from it - be it physical or emotional - or they wouldn't do it. It is also why they frequently do not seek a cure; it makes them feel good. [** key point **]
• Young person who unworriedly engage in public cross-gender behavior probably don't feel the same level fear or stress in relation to identity and will probably be less, or not, autogynephilic. Usually these individuals have no fear of parental authority.

Chapter 7 - Perversion or lifestyle choice?

• Since sublimated or actual sexual feelings for feminization start very early, people with these feelings have had a "self-relationship" for some years by the time they start acting on those feelings in a serious way.
• People can go through great, even crippling, grief and pain when they break up after many years together. The analogy holds if an autogynephilic person, who has been in a "self-relationship" since an early age, feels that the "relationship" is no longer viable (perhaps due to ageing or life situations). So cross-gender identity or fantasy can be extremely important to transvestites and autogynephiles. [** key point **]
• The scorn and abuse such people experience is based on misunderstanding of their motives. They are often not sexually or dubious intention, just regular people who have developed the habit of using an unusual psychological support mechanism to alleviate the emasculation trauma experienced during formative years.
• There are a number of lifestyle choices available for gender transgressors in these relatively liberated times : [** key point **]
  · surgical transsexuality
  · non-surgical transsexuality
  · part-time cross-living
  · androgyny / "genderfuck"
  · crossdressing with gay, bi or hetero sexuality.
• Each solution carries its own problems. Prejudice often shapes the life choices non-normal people make.

Chapter 8 - How to treat transsexuals?

• Assessing psychiatrists tend to base their decisions on whether the change would be in the patient's best interests , taking into account the alternative options listed above in Chapter 7. Whether a patient is autogynephilic or not is only one factor.
• There can be no certainty as to whether a diagnosis of transsexuality will be correct because some transsexuals change back much later, even up to 20 years later on.
• Treatment by ideology (ie. a black and white view that transsexual wishes are the result of a curable mental illness) was proven to be ineffective at best, and dangerously damaging at worst, decades ago so we have to accept that it is inevitable that a small minority of patients will regret the change. As with any other endeavor in life, risk management principles should be applied to transsexual assessment. [** key point **]
• A large majority of transexuals report benefiting from the change. The risk of not treating needs to be balanced against the risks of treating. Not treating can lead to dire consequences in some cases. [** key point **]
• The "woman trapped in a male body", "I am a woman" and "I will become a woman" cliches are impediments to realistic assessment and should be challenged by assessing psychiatrists. Such comments either demonstrate a disconnectedness with reality and/or a desire to gloss over deeper issues. [** key point **]
• Transsexual males can become women - for all practical means and purposes. However, they can never be quite like genetic women due to biology and conditioning. While this fact does not invalidate patients' cross-gender needs, it needs to be reinforced to keep expectations realistic. [** key point **]
• M2F Sex change applicants can validly say that:
  · they are mostly feminine in their thoughts and feelings
  · they feel their various personal qualities and attributes are better suited to a feminine life
  · if they had their time over they would have preferred to be born female
  · they have felt uncomfortable and/or miserable in the male role
  · they are tired focusing on cross-gender issues and the complications of swapping over.
• Psychiatrists and other professionals not only have a responsibility towards their patients, but also to the community. The psychiatrist needs to make a decision based on the belief that a sex change will most likely help a patient become a more useful, better functioning and productive citizen. [** key point **]
• There appears to be little discussion, either in the medical or trans communities, of the relativity of emasculation trauma. While bringing to light an important concept, Ray Blanchard's overly black-and-white presentation of his hypothesis has been counter-productive. [** key point **]
• The real issues in dealing with autogynephilia are examining the roots of early emasculation feelings to make them more tangible and to attempt to channel those desires into more human-to-human sexual orientation, if that is the patient's wish.
• The conflict of interest between the dual roles of helper and gatekeeper is frustrating for sincere assessing psychiatrists. When the assessment is free of ideology, cognitive approaches like P-A-C (transactional analysis) may help consolidate treatment, without threatening a positive diagnosis.

Chapter 10 - Problems and reversion

• When transsexuals express regret at their change, it is usually because of prejudice, lack of support, poor surgical outcomes, or rigid ideas of what the feminine role entails. (This rigidity is expressed with comments like "I don't want to wear makeup, stockings and heels any more", as if this is a compulsory requirement for women).
• Transsexuals need to have a contingency plan pre-surgery so they have a fallback position if the surgery is unsatisfactory. [** key point **]
• There is a need to debunk the myths surrounding transsexualism - the misguided claims of bona fide womanhood, the biased and pseudo-scientific validations and invalidations, and wrongful claims that it is unnatural.

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