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from Gender Identity
Disorders

Transsexuality Explained

By Sander Breiner, M.D.
NARTH Scientific
Advisory Committee Member

Sander
Breiner, M.D.

The term
Transsexuality is somewhat confused in many people's minds
with the terms Homosexuality and Transvestism. These three
topics vary in complexity and dynamics for male and female
participants. To make this discussion easier to delineate, I
will initially deal with males; and leave the topics related
to females for a later exploration.

Simple direct definitions are: 1. Homosexuality -- primary
sexual attraction for members of the same sex by adults; 2.
Transvestism -- cross gender dressing to improve sexual
gratification and/ or reduce anxiety. 3. Transsexuality --
believing one's body is of the wrong sex (e.g. "externally I
am a male who inside is really a woman that needs to be
"changed" surgically and hormonally to be a woman.").

Homosexuality has many forms of expression. The essential
element is the emotion and psychological conception of an
adult that their primary sexual gratification would be in some
sexual activity with a member of the same sex. It does not
require any actual activity in fulfilling that desire. Like
any major psychological emotional force (dynamic) in an adult
you can have a variety of manifestations. The expression of
homosexuality is determined by two basic elements: 1. What
that particular society supports or restricts, and 2. The
degree of psychological health of the individual.

Transvestism is not just cross-dressing. Cross-dressing,
when a male dresses as a female, can be part of a Halloween
party, or some theatrical performance. It can be part of being
a way of seducing or manipulating some male to participate
sexually with them who has no interest in homosexuality and
thinks they're having some romantic activity with a female.
Wearing some makeup and some effeminate style of attire (but
still clearly being a male) also is not transvestism.

In fact, none of the preceding is transvestism.
Transvestism requires an emotional need that requires a male
to wear female attire to meet a sexual need or reduce one's
anxiety. There are various forms of transvestism which can be
either heterosexual or homosexual. To name just two forms (of
many) would be: 1. A heterosexual male who will wear a woman's
brassiere or panties while having some romantic activity with
a woman, and 2. A married man with children who, with the help
and support of his wife, will on occasion completely dress
himself as a woman (makeup, wig, etc.). There will even be
small conventions of people with similar family interests and
activities. These men have no interest in functioning
homosexually -- either in their fantasies and least of all --
in their sexual behavior.

An adult man who is psychologically a transsexual is in a
different category with a different expression of
psychological problems. It is far from rare and therefore
deserves some discussion. As a psychiatrist and psychoanalyst,
I have seen them in my private practice as well as while
working as a consultant to a university and medical school
program to evaluate and "treat" these individuals (with
surgery and hormone replacement).

Significant Numbers Of Homosexuals Seek Sex
Changes

There are a significant number of male homosexuals who
would like to be a female with a penis. There are others who
would like to be completely transformed into a female, but
can't arrange to have such a complex surgical procedure. Both
groups will obtain hormones from various sources; often it
will be illegally from some pharmacy.

The transsexual male, who was not part of a
university/medical school treatment program, will often take
hormone treatment (self-prescribed and administered); and play
a feminine role with unsuspecting heterosexual males (often as
a prostitute). They will play the part as if they are a
passive feminine object. Their approach has many masochistic
behavioral qualities. However, their thinking about how they
are tricking, fooling and using others has a clearly sadistic
dynamic. Their histories almost invariably demonstrate a
mother figure who is at least domineering, manipulative and
controlling.

They have little to no relationship with their family.
Unfortunately, their lifestyle has a clearly self-destructive
quality. These individuals usually do not stay in any adequate
psychotherapy program (i.e., once per week for at least three
months). These individuals have significant problems in
certain areas of reality perception that long-term intensive
therapy is the best choice; and long-term supportive therapy
with medication is the least they need to not destroy
themselves.

The smaller group of transsexuals include those individuals
who have been involved with a university-sponsored medical
school treatment program. They have had much more appropriate
study and evaluation. In general, what takes place is an
individual who has applied to the program, has agreed to
participate with full disclosure to one or more psychiatrists,
social workers, psychologists and various medical specialists
during the entire extended period of evaluation and treatment
and follow-up. This usually will extend for about one year
before the surgical treatment is completed. No medical or
surgical intervention is begun until there is prior evaluation
and clearance by the psychiatric and general and special
medical evaluations are completed. This takes months.

My clinical experience in participating with the Wayne
State University program has been corroborated by others at
the University as well as at Johns Hopkins University, a
medical school even larger and with a longer-lasting program.
The following will be a summary description of my experience
that is typical of the cases seen at both university
programs.

A single male in his middle 20s to early 30s with at least
one college degree and some adequate financial and
professional success applies to the program. He has had some
homosexual experience with partial gratification. He has
attempted heterosexual activity with little sexual
gratification, if any. His chief complaint is that as long as
he can remember he has never felt that his body was "right."
By that time he got to be an older teenager, he was certain
that something was wrong with his body. The more he thought
about it and explored the subject, the more he believed that
he was a woman inside that needed to somehow come out and be
expressed.

Cross-dressing did not make him feel more comfortable. He
recognized that cross-dressing could produce problems for him
socially and economically, so he avoided it.

He is a well spoken and reasonable, dependable historian;
well spoken and seemingly reasonable in all areas -- except
how he feels about himself in terms of his gender and his body
image. He describes himself as somehow feeling that something
inside is trying to come out -- that somehow or other -- the
real self is being restricted and limited.

More and more "it" is conceived as the woman inside him who
has somehow always been there. He thinks that some mistake in
genetic expression or development (in some not understood way)
has prevented the true woman's self from being expressed. It
is as if the real woman inside of him is imprisoned.

The individual is not passive and effeminate in bearing,
carriage or in his approach to life. He is assertive and
successful and competitive socially and intellectually as a
man (except in his pursuit of female companionship). He is
convinced that he is a woman who somehow or other is trapped
in a man's body. His external genitalia -- he believes -- is
an impediment. He wants the body configuration and genitalia
to be that of a woman. He desires the full quality of being a
woman with her curves and her qualities.

His discussion is not irrational. His desires and wishes
and feeling conception of himself is presented in a logical
manner. He does not have any scientific proof of his position;
he just "knows" that he was meant to be a woman.

All tests by psychologists and psychiatrists in testing his
judgment of reality (except in his body image) is within
normal limits. There is no evidence of psychosis or any
significant problems in any other area than his body image
(related to gender only). He is cooperative and patient and
helpful in his manner. His only area of insistence is
concerning his belief about his body and the need to become a
woman. He is not afraid of psychological and psychiatric
evaluation. However, he is not interested in intensive
psychoanalytic/psychotherapy for a period of months or years.
He firmly believes that his problem is not psychological but
that it is truly on an organic basis.

After the initial phase of evaluation and study, the
patient is instructed to begin dressing himself and living his
life (gradually more and more) as a woman.

During this entire period, the patient is followed by the
medical and surgical teams and by the psychiatrist. This
follow up continues during each phase of the program,
including the follow-up period after the completion of all
surgical and hormonal treatment. The next phase is the
beginning of hormone replacement.

This is followed by the addition of surgical change of the
perineum from that of a male to a female with a vagina. To
maintain the quality of a vagina, procedures are done to
maintain its qualities as a receptive organ and its
lubrication. This is followed by surgical intervention (if
needed, usually) for breast enhancement, etc.

Initially, there is less tension and discomfort
psychologically experienced by the patient. He begins to feel
better about himself and hopeful about his future as a woman.
Despite the physical, social and economic discomforts, he is
positive and cooperative in every way in the program. Upon
completion of the program and taking on a new life (which
usually includes a legal change of his name), he feels
relieved and hopeful and eager to continue his relationship in
the follow-up part of this research.

Between six months to two years following the completion
and healing of the surgery the surgeons begin to request more
evaluations from the psychiatric division of this program. The
surgeons do not understand what is transpiring because the
patient is now asking for more surgery.

During the entire pre-surgical treatment the only
psychological problems that were clearly defined were related
to body image. This is not insignificant from a psychodynamic
standpoint. It was considered understandable as a "logical"
response of somebody with this "organic" problem. Since there
was no obvious break in reality in any other area, the program
continued with each individual. However, now the surgeons and
other medical team members were observing that though this
patient was now a woman, he wasn't satisfied with the "job"
that was done. He felt that all he needed was something more
from "Medicine." He needed the size or shape of his calves,
his hips, his arms or his breasts, etc. "improved." More and
more it became apparent that no matter how successful was the
procedure and continued hormone replacement, it seemed that
each patient still felt that something was lacking -- that
though they were now a woman, it somehow wasn't enough.

After some minor attempts at surgical assistance by
surgeons and endocrinologists; the surgeons refuse to do any
more. In their judgment nothing further should or could be
done. In fact, they were all pleased initially with the
success of their transforming a man into a nice, if not a
beautiful, young woman. Now the medical staff was dissatisfied
with the patient's dissatisfaction; and they turned the case
back to the psychiatric division to "solve" the problem.

The Problem Is Psychological, Not
Organic

At this point in the process, I, along with other
psychoanalyst colleagues concluded that the disturbed body
image was not an organic at all, but was strictly a
psychological problem. It could not be solved by organic
manipulation [surgery, hormones], no matter how well
intentioned or brilliantly successful it was done.

In psychologically evaluating any patient it is always
important to understand how the patient sees himself. There
are certainly age variations as well as gender and cultural
elements involved in this evaluation. However, when an adult
who is normal in appearance and functioning believes there is
something ugly or defective in their appearance that needs to
be changed, it is clear that there is a psychological problem
of some significance.

The more pervasive and extensive is this misperception of
himself, the more significant is the psychological problem.
The more the patient is willing to do extensive surgical
intervention (especially when it is destructive), the more
serious is the psychological problem. It may not be psychosis.
It may not require psychiatric hospitalization. But the
significance of the psychological difficulty should not be
minimized by a patient's seeming success socially and
professionally in other areas. This principle of isolated
significant psychopathology indicating serious psychological
problems (despite their ability to function in all other areas
of life) is well known psychiatrically, historically, and by
the judiciary.

This conclusion became so well established at Wayne State
University that the program was eventually discontinued. The
much larger and more extensive program at Johns Hopkins
University and medical school in Baltimore, Maryland was
discontinued for the same reason. [See Dr. Paul McHugh's essay on his experience at
Johns Hopkins.]

Understanding of the psychological problems that are
focused on things related to gender need to be understood --
not denied.

Additional Reading: HOMOPHOBIA:
A Scientific Non-Political Definition; Latest Gay
Brain Study Scrutinized; Questions and
Answers, by Sander Breiner, M.D.; Two Differing
Obituaries for Dr. Charles Socarides; Gay-Affirmative
Public School Teachers/Curricula May Influence Brain
Maturation In Teens; The Desire For
A Sex Change

Updated: 13
March 2008

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