Many transsexual people believe that gender is hard-wired in the brain before birth, arguing that being transsexual is an intersex condition, a congenital birth issue unseen by others due to its location in the brain: a mis-match in the sex of a person between that of the brain and that of the body. The main symptom of this condition is a unique type of depression, anxiety or even psychological pain: Gender Dysphoria. Commonly, transsexual people assert that their brain-based inner perception of their sexual self is their true identity and so change their physical sex in an effort to align their inner and outer self. If untreated, Gender Dysphoria can lead to mental and emotional problems[5], and sometimes suicide.
Most transsexual men and women desire to establish a permanent social role as a member of the gender with which they identify. Many transsexual people also desire various types of medical alterations to their bodies. These physical alterations are collectively referred to as sex reassignment therapy and often include hormone replacement therapy and surgery. The entire process of switching from one physical sex and social gender presentation to the other is often referred to as transition, and usually takes several years.
To obtain sex reassignment therapy, transsexual people are usually required to receive psychological therapy and a diagnosis of gender identity disorder in accordance with the Standards of Care (SOC) as issued by the World Professional Association for Transgender Health (formerly and until 2006 the Harry Benjamin International Gender Dysphoria Association). These are guidelines as the medical community struggles in how to deal with the treatment, and the nature of the treatment population changes, and are not obligatory. Some doctors may waive the psychotherapy requirement as an unnecessary expense in an emotionally mature and stable individual, or require only a psychological evaluation. The intentions of the standard are to prevent people from transitioning when such a transition would be inappropriate (as a dramatic example, a person seeking to transition in order to veil their identity from police), or ill-advised (e.g., a strong crossdresser, who still identifies themselves as their assigned gender), and other cases where if a transition were undertaken, it would be expected to have strongly negative consequences for the patient.
These standards are open to the criticism of being ineffective, or being too strict, discouraging genuinely transsexual people from seeking treatment. It is claimed that Meta-reviews of post-operative transsexuals prior to 1991 reveal a rate of serious regrets of less than 1% for transsexual men and less than 2% for transsexual women, while studies published after 1991 have reported a decrease in the rates for both, likely due to improved psychological and surgical treatments and increasing acceptance from society.[6] While such studies lend support for existing protocols concerning care of transsexuals, post-operative follow-up research is considered to be lacking. However a note on a report in the UK Guardian Newspaper states:
There is no conclusive evidence that sex change operations improve the lives of transsexuals, with many people remaining severely distressed and even suicidal after the operation, according to a medical review conducted exclusively for Guardian Weekend tomorrow.
The review of more than 100 international medical studies of post-operative transsexuals by the University of Birmingham's aggressive research intelligence facility (Arif) found no robust scientific evidence that gender reassignment surgery is clinically effective. [7]
Against the statistic above indicating that 1% to 2% of post-operative persons have serious regrets, the Report itself states:
Paradoxically, a growing number of post-operative transsexuals are scathing about their medical care. International research suggests that 3-18% of them come to regret switching gender.[8]
For both men and women, medical treatment typically begins with hormone replacement therapy. Transwomen are usually required to live as members of their target sex for at least one year prior to genital surgery (so-called Real-Life Test or Real-Life Experience), although this time may be longer if the psychotherapist has concerns about the transsexual person's readiness. Transmen must generally wait two to three years after beginning testosterone treatment in order to allow for sufficient clitoral growth. However, some transsexuals, especially among transmen, may not wish to have this surgery. Others can spend years or even decades saving up enough money to pay for it. Some transwomen may have only orchiectomy and forego vaginoplasty. There are many reasons why some transsexuals opt out of genital surgery. Among these are cost (female-to-male (FTM) surgery can cost up to $80,000), surgical risks, (including genital nerve damage), and acceptance of a certain amount of physical deformity.
For female-to-male (FTM) mastectomy and chest reconstruction, the requirement is only either 3 months of psychological therapy or the same amount of time of Real-Life-Test. The latter may be impossible for transmen with large breasts, and while binding smaller breasts is partially effective, this can cause many health issues if done over a long period of time. Many transsexuals find these requirements to be unjust as cisnatal men and women are not required to undergo any psychological evaluation or wait times to undergo chest reconstructive surgery. However, an 18 month requirement for transwomen to have breast augmentation is typically to allow enough time for breast development due to hormones. Breast augmentation before the breasts have finished developing can result in poor shape.
Currently, the causes of transsexualism are unknown, and estimates of prevalence vary substantially. It is commonly believed that it is a multifactorial condition, having many and different causes, some of which may include a naturally occurring variation in fetal sex differentiation and development. Causes may include some medications or hormones given to pregnant mothers, such as diethylstilbestrol. According to a medical advisory bulletin from Gender.org (Sep. 2002), as many as 25% of the FTM population has polycystic ovarian syndrome, a condition known to cause hormonal fluctuations.
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