In-order to label a person as a transsexual the following criteria need to be satisfied :

1. The person must experience a sense of discomfort and inappropriateness about his/ her anatomic sex.
2. The person must have a desire to be rid of his/her own genitals and to live as a member of the opposite sex.
3. The disturbance needs to have been continuous for at least 2 years and not limited only to periods of stress.
4. There must not be any genetic abnormality or congenital sex hormone disorders.
5. There should be an absence of coexistent mental disorder such as schizophrenia.

ETIOLOGY

The exact etiology of transsexualism remains largely hypothetical. Gender identity is very intimately interwoven with the self in all human beings. This makes scientific and logical analysis extremely difficult. Earlier it was thought that transsexualism was a result of the effect of sex-hormone exposure (or lack of it) on the fetal brain. Though this was proved to a large extent to be true in experimental animals, further studies in humans born with abnormal hormones have disproved this hypothesis.

Some psychiatrists view transsexualism as a form of delusional psychosis. This resulted in the treatment of some transsexuals with antipsychotic medications and electric shock therapy - but to no avail.

Yet another school of thought believes that gender identity development is a learning process that is superimposed on an undifferentiated gender matrix-i.e. gender identity develops as the result of "imprinting" and "conditioning" processes. Thus, transsexualism is viewed as a disorder resulting from improper learning and conditioning.

Some other studies have shown that transsexuals have a brain structure which is neuroanatomically different from what is expected of their biological sex. There is a particular area in the brain which is essential for sexual behavior. This area is known as the BSTC (bed nucleus of the stria terminals - central subdivision). A female type of BSTC was found in male transsexuals in a pioneering study conducted in the Netherlands.

Transsexualism is definitely not a mere whim on the part of the affected person. It seems to be the end result of a combination of abnormal neuroanatomy, superimposed on which are psychological, environmental & probably hormonal factors

Some studies have shown that mothers of female-to-male transsexuals lack a cohesive self and possess an opposite gender envy, which may all be communicated, albeit inadvertently, to the growing child. This results in the child wanting to belong to the opposite sex and identifying herself with her father.

Similarly, some psychoanalysts suggest that male-to-female transsexualism may be the result of failure to separate the self from the mother in early boyhood.

At the end of it all, science is still not able to clearly explain the exact etiology of transsexualism. Transsexualism is definitely not a mere whim on the part of the affected person. Though ill-understood, it seems to be the end result of a combination of abnormal neuroanatomy superimposed on which are psychological, environmental & probably hormonal factors.

Whatever the reason be, the transsexual's plight is not a happy one & he/she definitely needs empathy and support - not only medical, also social.

To summarise, it may be apt to say:

• That transsexualism has its foundation laid before the age of 3 years.
• That the transsexual brain is probably slightly different in its neuroanatomy.
• That a myriad of psychological factors are also operational.
• That rearing practices contribute to its development.
• That a lot more research is needed to understand completely the origin of transsexualism.
• That, like in many other areas of clinical medicine, treatment is often provided on empirical grounds rather than on the basis of a full understanding of the etiology.

HISTORY

Cross-dressing and living in the role of the opposite sex have been known to mankind for centuries. In the 17^th & 18^th century, it was not uncommon to find women who joined the army or worked as sailors, pretending to be male.

History has also seen men who dressed & behaved as women. Famous among these were the Roman emperor Calligula, King James I of England, Lord Cornbury - Governer of New York etc.. However, in all these cases, the gender dysphoric behavior was episodic. Today we would probably label them as trasvestites.

The story of Chavalier D'Eon, a nobleman who served the French King Louis XV as a diplomat in Russia is similar and slightly better known. The year before his appointment, he spent several months in disguise, presenting himself at the Russian court as his own (non-existent) sister Lea. He became very popular as a woman and no one ever doubted his self-assigned sex. Later, he served in England where rumor had it that he was in fact a woman. He refused to settle the question. On the royal order of Louis XV he was obliged to dress as a woman & live a female role until his death in 1810. The autopsy showed that he had the body of a normal male, much to the chagrin of the pubic & the people who knew him closely.

The last 4 decades have witnessed a gradually rising medical interest and research in this field.

Much as it might have been desired by patients thus afflicted, hormonal and surgical gender reassignment were impossible until the thirties of this century. Modern documented history of transsexualism and gender reassignment starts in 1930 with the first recorded adult sex change operation on a Danish artist in Germany. Einar Wegener became Lily Elbe.

After that, it was only in 1953 with the story of the surgical gender reassignment of the American ex-GI George Jorgensen, who became Christine Jorgensen, that transsexualism received worldwide publicity.

The last 4 decades have witnessed a gradually rising medical interest and research in this field. In 1966, Dr. Harry Benjamin, who had carefully examined, treated & followed up several transsexuals for many years in the United States of America, published a treatise on his experience - " The Transsexual Phenomenon".

This work contributed largely to the understanding of transsexualism & enabled involved physicians to approach the matter in a more scientific manner. To honor him for this great contribution, the worldwide organisation of professionals who care for transsexuals has been named : The Harry Benjamin International Gender Dysphoria Association.

PREVALENCE

Transsexualism is seen all over the world. However, its expression varies from culture to culture.

In Oman, men who live as females are known as "xaniths". Their place in society is literally between that of men & women. They retain male names, wear clothing which is partly male & partly female & cut their hair medium length. They have the right to socialise with women (unlike other men). They also have the right to move unescorted in public (unlike women). They also have the right to live alone, to be hired as house servants & to work as prostitutes in a culture where prostitution is otherwise prohibited.

Another cultural variant of cross-gender behavior is seen among some American Indian tribes. A young adolescent boy displaying effeminate traits is known as a "berdache". After getting into a divine trance and receiving 'spiritual enlightenment', a berdache begins to dress as a female & engages in sexual relations with males or even lives as a berdache wife with a husband.

Hijras form a kind of a social institution, a religious cult with its own mother goddess, Bahuchara Mata.

In India we have the "hijra" community which is a motley group of people belonging to different religious communities. Many of them are male-to-female transsexuals but the group also consists of adolescent boys who have undergone early castration & children with intersex disorders. Traditionally, all hijras undergo amputation of the penis, scrotum & testis - a procedure performed extremely crudely by senior established hijras. Hijras form a kind of a social institution, a religious cult with its own mother goddess, Bahuchara Mata.

Male-to-female transsexuals in Burma group together similarly. They are looked upon as being possessed by a spirit of the opposite sex. They play a special role in temples and are known to participate in special semi-religious ceremonies.

The exact prevalence of transsexualism is difficult to assess because only a fraction (size being dependent on the socio-cultural ethos) of transsexuals seek therapy. However, in the USA, it is estimated at 1 in 100,000 for male-to-female transsexuals and 1 in 400,000 for female-to-male transsexuals. In England – 1 in 30,000 and 1 in 100,000 respectively. In Sweden 1 in 37,000 and 1 in 103,000 respectively. The ratio of male-to-female and female-to-male remains around 3:1, country notwithstanding.

MANIFESTATIONS

Most adult transsexuals confess to having experienced a hatred for their gender right from early life - well before puberty. Many remember puberty with abhorrence, because of the hormone-induced changes in body characteristics which they perceived as totally alien to their gender identity. Often, it is around the pubertal period that most transsexuals reinforce their determination to rid themselves of their primary & secondary characteristics.

In some cases, hatred for one's gender is seen at a very young age. It may manifest, for example, in a young boy as a desire to wear skirts & frocks and to play with dolls or kitchen sets. Retrospective and prospective studies have corroborated that such boys often grow up to be homosexuals and less often - transsexuals.

TREATMENT

Establishing a diagnosis of transsexualism is not very simple. Apart from a detailed clinical interview and physical examination, the individual has to go through rigorous psychological evaluation.

It is only after all the members of our gender team agree on the matter, that we take up the transsexual for gender-reassignment.

The process of gender-reassignment includes medical treatment with cross-gender hormones for a variable period of time (usually one to one and a half years). This is followed by sex-reassignment surgery.

CASE STUDY

Shanti (desired name Sushant) is a 23 year old female transsexual. (As a mark of our respect & empathy for their predicament, we prefer to use pronouns befitting their desired sex). He had a normal birth history. His memories of his hatred of his anatomical sex (female) dates back to his early childhood where he recalls his intense dislike for the school uniform (a pleated dress) that he was compelled to wear - so much so that he would wear shorts under the dress and literally rip open the dress as soon as he entered his home. The onset of puberty accompanied by the development of breasts and the beginning of the menstrual cycle saw him in great depression. It was then that he realised that he "felt like a man trapped in a womans body". That was also when he became firm in his resolve to find a solution to his problem. Around the same time he realised his affinity for female company & the fact that he was, in fact, sexually attracted to girls. This was almost 10 years ago and the last decade has seen him drift in and out of 2 romantic liaisons with girls. In the last 3 years or so, he seems to have found his soulmate in a very compassionate woman who he plans to marry as soon as his gender has been more or less completely reassigned.

GENDER REASSIGNMENT SURGERY

There is no hard and fast age limit for gender change operations. However, a few guidelines apply. Generally, patients present for surgery during late adolescence or early adulthood - an age group where sexuality must begin to manifest itself physically and the issue is no longer merely one of psychological and emotional conflict with one's sexuality.

The sexual urge in this age group of transsexuals is as strong as in those with normal sexuality. This is what causes frustration and depression. Many patients already have a sexual partner when they present for operation. It is important to note that transsexuals do not usually engage in homosexual activity. They would like to change their gender and have peno-vaginal intercourse.

Exceptionally, operation is undertaken in older patients. This is usually in those who were unaware of the concept of gender reassignment surgery. When they come to know that it is possible, they turn up for operation. If they fulfill other criteria and psychiatrists give the go ahead, they are taken up for operation.

PRE-REQUISITES TO BE CONSIDERED

Physically, the patient should be fit to undergo the rigors of anesthesia and surgery. Not only that, the patient wants to have sex after operation. Infirm patients can't have sex and must not be operated upon.

Mental health is important too. Normally three psychologists/psychiatrists need to certify that the patient has true and pure transsexualism and that he or she is strongly motivated not only to undergo surgery but also for the long journey to total rehabilitation. The patient should also be stable and must not be the type who might change his/her mind after operation, because the operation is irreversible.

The patient should also understand that we are dealing here with a situation that is not usual and is predominantly psycho-emotional rather than physical. Operation is only one of the steps. The patient should be prepared for the other sociological issues too. Miracles should neither be promised nor expected. Patients with an overlay of other psychiatric disturbances mustn't be offered operation.

Weight and height are generally not of especial consequence. There have been very tall, hefty men who have wanted to become women and similarly very short, diminutive women who have wanted to become men. As we have seen earlier, the primary problem is in the mind. If a 6 foot tall, muscular man thinks he is a woman and wants a vagina and breasts, it is our job to give it to him - provided other criteria are fulfilled.

RISKS AND COMPLICATIONS

Risks and complications are the same as in any other situation where anesthesia and operation are involved.

Additionally, in male-to-female operations we may, for instance, sometimes have the complication of vaginal stenosis. Occasionally, for anatomic reasons such as a narrow pelvis, the vagina is short and narrow. The labial flaps may sometimes require secondary revision for cosmetic purposes. There may be urethral stenosis in some patients.

In female-to-male operations, there may be problems with the flaps, such as necrosis or contracture. There may be a malfunction of prostheses. Urinary fistulae can occur. Sensations on flaps may be inappropriate and patients may be less than satisfied with the cosmetic appearance etc..

SUCCESS RATES OF SURGERY

Success rates are difficult to define because a number of parameters are involved.

Male-to-female conversions are generally more successful in terms of both operative technique and patient satisfaction in cosmetic appearance and sexual rehabilitation. Hospital stay is also quite short and the operation is one-stage. Dissatisfaction may creep in later because of disappointment with body hair, breast development or voice change.

Female-to-male operations are less than optimal in technique because the ideal phalloplasty has not yet been described (The Chief Medical Consultant of this site is currently working on a new technique). Most phalloplasties are multi-stage and cause physical, temporal and economic inconvenience to the patient. Also, many phalloplastic penises are incapable of either sexual sensation or performance (we hope to be able to make both possible). Also, ultimate success is a function not only of operative results but also of social acceptance, partner availability and total rehabilitation.

OPERATION REVERSAL ?

In case the patient changes his/ her mind and requests a reversal:

1. A male-to-female operation-failed patient can never become male again because both his penis and testes are removed.
2. If a female-to-male operation fails, the patient may or may not be able to use the vagina depending on the phalloplasty technique used. In some techniques, the vagina is used for neo-urethra construction.

But since these patients never had `normal' sexual functioning even before operation, the question of returning to one does not arise. There is just no way these people want to use their biological genitalia. This must be the first thing ascertained before operation.

------------------------------------
sources:- www.andrology.com
------------------------------------