LEARN WHATS BEHIND THE IDEA OF GENDER REPLACEMENT

In 2015, a 65-year-old Bruce Jenner is making the transition from man to woman. In the late 1970s, Bruce Jenner was the poster boy for male virility and machismo … a gold-medal decathlete with dashing good looks and unabashed American charisma. For many people who remember Jenner from his time as the face of Wheaties and have little understanding of gender dysphoria, I’m sure Jenner’s need to transition is difficult to reconcile.

From a historical perspective, the transition from man to woman or woman to man is archetype. For example, transgender themes are prevalent in Greek mythology (think Caeneus or Iphis). On a related note, surgeons have been performing sex reassignment surgery for more than 70 years.

From a psychiatric perspective, the DSM recently changed the wording of its diagnosis from “gender identity disorder” to “gender dysphoria.” The term was changed because there’s nothing intrinsically wrong with or “disordered” about people who experience gender nonconformity and transgender issues.

Of note, gender nonconformity is defined by the World Professional Association for Transgender Health (WPATH) as the “extent to which a person’s gender identity, role, or expression differs from the cultural norms.”

Gender nonconformity can culminate in the feeling that you’re trapped in the opposite-sex body. In some, the stress or dysphoria associated with such nonconformity can be alleviated or resolved through gender-specific interventions including cross-gender living, hormones and surgery. Such treatment depends on the individual, and a person with gender identity issues should feel free to explore which gender role and associated sexual characteristics make him happy.

Here’s how the DSM 5 now defines gender dysphoria:

For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized. This condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

General transgender considerations

For people experiencing feelings of gender nonconformity with or without dysphoria, transitioning from man to woman or woman to man is an arduous but gratifying process. Classically, transitioning has been viewed as occurring in 3 steps:

cross-gender living
administration of cross-sex hormones
genital and other surgeries
Because gender identity can evolve and change during adolescence and childhood, many experts recommend that, in those who desire and need it, this process–especially irreversible steps like surgery–commence at 18 years of age or older.

Of note, psychotherapy is not necessarily recommended, needed or required of people hoping to make the transition. After all, gender nonconformity or gender identity concerns are normal processes in those who experience them–there’s no need to pathologize these phenomena. All that being said, however, meeting with a gender therapy team, support groups and therapists can definitely help a transgender person on her journey. More specifically, if you’re interested in gender reassignment, mental health professionals trained in gender identity or medical gender specialists can help monitor your progress, prepare you for next steps and assess your readiness for change.

Cross-gender living

According to the AMA Manual of Style, sex and gender are different:

Sex is defined as the classification of living things as male or female according to their reproductive organs and functions assigned by chromosomal complement. Gender refers to a person’s self-representation as a man or woman, or how that person is responded to by social institutions on the basis of the person’s gender presentation. Gender is rooted in biology and shaped in environment and experience.
Because gender is both a function of biology and psychology, people with gender dysphoria can adjust gender identity by choosing to adopt characteristics typically identified as either male or female. Such characteristics include dress, hair styling, gestures and speech patterns. For some, such intervention is satisfying without further intervention. But for others, cross-gender living is just the start.

Here are some reversible steps that can be taken to facilitate cross-gender living:

voice and communication therapy to help with gender-desired verbal and nonverbal skills;
hair removal by electrolysis, waxing or laser;
breast binding or padding;
genital tucking or penile prosthesis;
padding of hips or butt;
changing of name and sex on legal documents.

Administration of cross-sex hormones

As you can probably guess, the effects of hormone therapy vary according to your desired outcome.

Masculinizing hormones such as testosterone can result in cessation of menses, atrophy of breast tissue, growth of body and facial hair and an increase in muscle mass and decrease in body fat.
Feminizing hormones like estrogen and androgen-reducing medications can result in breast growth, decreased erectile function, increased body fat and decreased testicular size.
Although hormones effect individuals in a variable manner, you can expect noticeable change over the course of the first 2 years followed by lifelong hormone maintenance. Additionally, like any medical intervention, hormones may carry risk of adverse effects. These include circulatory adverse effects (hypertension and diabetes), psychiatric adverse effects (decompensation), cancer, liver problems (elevated liver enzymes) and weight gain.

Hormones should be administered and monitored by a specialist physician, and the psychological effects should be monitored by mental health care professionals and medical gender specialists. In other words, please don’t buy hormones off the Internet and try hormone therapy on your own!

Genital and other surgeries

For some people who experience gender nonconformity or gender dysphoria, cross-gender living and hormones result in adequate contentment, and no surgery is desired. Please keep in mind that some people are happy living with a more androgynous gender identity. However, in those who desire and need surgery, despite what some may say, sex reassignment surgery is a medical necessity.

According to the Standards of Care, a seminal set of nonbinding protocols aimed at gender reassignment and published by the Harry Benjamin International Gender Dysphoria Association, as assessed by qualified medical gender professionals, travelers in transition should demonstrate readiness before undertaking surgery. Specifically, before genital surgery, WPATH recommends that you live for 12 months in the gender role which conforms with your gender identity.

After much thought and as a last step of transition, sex reassignment surgery provides relief and makes social and intimate encounters more comfortable and pleasurable. Because such surgery is often irreversible (think genital alteration), you must be sure that such surgery is right for you. Moreover, remember that ideally your surgeon is part of a larger team of primary care physicians, psychiatrists, medical gender specialists and mental health care professionals who will help you along.

For the male-to-female patient, procedures include the following:

genital surgery: vaginoplasty, clitoroplasty, vulvoplasty, orchiectomy and penectomy;
breast augmentation mammoplasty;facial feminization surgery;liposuction;voice surgery;
thyroid cartilage or Adam’s apple surgery (famously performed on Jenner in January 2015);
gluteal augmentation;hair reconstruction.

Obviously, women transitioning to men undergo different procedures:

genital surgery: metoidioplasty, phalloplasty, scrotoplasty, vaginectomy, implantation of erection or testicular prostheses;mastectomy and creation of a male chest;lipofilling;liposuction,pectoral implants.

From a “medical treatments” perspective, surgery for some of those with gender identity issues can be a wonderful option–a fact that is becoming apparent to researchers. Although organized efforts to provide reassignment surgery are grossly deficient in the American health care system, some options exist worldwide.

If you or someone you love is experiencing gender dysphoria or other gender identity issues, please remember that you are not alone. There are people and organizations out there who can help including Trevor Chat.

On a related note, although I completely support the efforts of GLAAD and think it’s a wonderful organization (please excuse my editorializing), it confuses me and other journalists to read the following in GLAAD’s media reference guide (quoted in context with GLAAD’s emphasis not mine): “Not all transgender people choose to, or can afford to, undergo medical surgeries. Journalists should avoid overemphasizing the role of surgeries in the transition process.”

Maybe GLAAD is cautioning us “journalists” to avoid overemphasizing surgery because such options might infuse false hope and are limited in some way. Or, maybe GLAAD is trying to get us journalists to de-emphasize surgery because some people don’t need or desire it. Who knows? But what I do know is that heeding GLAAD’s suggestion and sweeping sex reassignment surgery under the rug is a bad idea. The U.S. transgender community, federal government and medical community need to be on the same page and make all information and options for gender transition including surgery widely available, safe and covered by insurance.

On a more personal note, I’m excited for Bruce Jenner and hope Bruce finds bliss. Undoubtedly, it must have been difficult for Jenner to transition–having spent so many years in the limelight regaled as a superman and burdened by our expectations. Like many others, I’ve spent the past few years bemused by the Jenner-Kardashian clan’s antics and wondering how Kim’s booty shoots or baby North West’s sartorial statements benefit society. (Don’t most babies shop at Target and Walmart? Just saying …. ) Now, I see some redemption in all the attention allotted to this motley crew. Maybe Jenner’s story can inspire and help some other soul on her transgender journey. Maybe Jenner’s story will bring attention to a paucity of options available to the transgender community. Maybe Jenner will give a strong voice to the transgender community. Maybe ….