Transsexual

Norman Haire reported that in 1921 Dora Richter of Germany began a surgical transition, under the care of Magnus Hirschfeld, which ended in 1930 with a successful genital reassignment surgery (GRS).[14] In 1930, Hirschfeld supervised the second genital reassignment surgery to be reported in detail in a peer-reviewed journal, that of Lili Elbe of Denmark. In 1923, Hirschfeld introduced the (German) term "Transsexualismus",[15] after which David Oliver Cauldwell introduced "transsexualism" and "transsexual" to English in 1949 and 1950.[16][17]

Cauldwell appears to be the first to use the term to refer to those who desired a change of physiological sex.[18] In 1969, Harry Benjamin claimed to have been the first to use the term "transsexual" in a public lecture, which he gave in December 1953.[19] Benjamin went on to popularize the term in his 1966 book, The Transsexual Phenomenon, in which he described transsexual people on a scale (later called the "Benjamin scale") of three levels of intensity: "Transsexual (nonsurgical)", "Transsexual (moderate intensity)", and "Transsexual (high intensity)".[20][21][22]

The term transgender was coined by John Oliven in 1965.[2] By the 1990s, transsexual had come to be considered a subset of the umbrella term transgender.[23][2][3] The term transgender is now more common, and many transgender people prefer the designation transgender and reject transsexual.[24][25][26] Some people who pursue medical assistance (for example, sex reassignment surgery) to change their sexual characteristics to match their gender identity prefer the designation transsexual and reject transgender.[24][25][26] One perspective offered by transsexual people who reject a transgender label for that of transsexed is that, for people who have gone through sexual reassignment surgery, their anatomical sex has been altered, whilst their gender remains constant.[27][28][29]

Historically, one reason some people preferred transsexual to transgender is that the medical community in the 1950s through the 1980s encouraged a distinction between the terms that would only allow the former access to medical treatment.[30] Other self-identified transsexual people state that those who do not seek sex reassignment surgery (SRS) are fundamentally different from those who do, and that the two have different concerns,[22] but this view is controversial, and others argue that merely having some medical procedures does not have such far-reaching consequences as to put those who have them and those who have not (e.g. because they cannot afford them) into such distinctive categories. Some have objected to the term transsexual on the basis that it describes a condition related to gender identity rather than sexuality.[31] For example, Christine Jorgensen, the first person widely known in the United States for having had sex reassignment surgery (in this case, male-to-female), rejected transsexual and instead identified herself in newsprint as trans-gender, on this basis.[32][33]

A common argument in opposition to the term transsexual is that it over-medicalizes the trans experience, and/or focuses too much on diagnosis.[13]^{: 742–744} The term transgender emerged in part in an attempt to break the "medical monopoly" on transitioning that transsexual implied.[34]

GLAAD's media reference guide offers the following distinction on the use of transsexual:[35]

An older term that originated in the medical and psychological communities. As the gay and lesbian community rejected homosexual and replaced it with gay and lesbian, the transgender community rejected transsexual and replaced it with transgender. Some people within the trans community may still call themselves transsexual. Do not use transsexual to describe a person unless it is a word they use to describe themself. If the subject of your news article uses the word transsexual to describe themself, use it as an adjective: transsexual woman or transsexual man.

The word transsexual is most often used as an adjective rather than a noun – a "transsexual person" rather than simply "a transsexual". As of 2018, use of the noun form (e.g. referring to people as transsexuals) was often deprecated by those in the transsexual community.[36] Like other trans people, transsexual people prefer to be referred to by the gender pronouns and terms associated with their gender identity. For example, a trans man is a person who was assigned the female sex at birth on the basis of his genitals, but despite that assignment, identifies as a man and is transitioning or has transitioned to a male gender role; in the case of a transsexual man, he furthermore has or will have a masculine body. Transsexual people are sometimes referred to with directional terms, such as "female-to-male" for a transsexual man, abbreviated to "F2M", "FTM", and "F to M", or "male-to-female" for a transsexual woman, abbreviated "M2F", "MTF" and "M to F".

Individuals who have undergone and completed sex reassignment surgery are sometimes referred to as transsexed individuals;[37] however, the term transsexed is not to be confused with the term transsexual, which can also refer to individuals who have not yet undergone SRS, and whose anatomical sex (still) does not match their psychological sense of personal gender identity.

A rarer, alternate spelling for transsexual has been transexual, with a single S. This variation is British in origin. This spelling was used by The Transexual Menace, an activist group, for example.[13]^: 738 This spelling has been used by some activists in an attempt to remove "pathologizing implications" from their use of the word.[7]^: 25 Another rare variation, a synonym for transsexual, is transsex.[38]

The terms gender dysphoria and gender identity disorder were not used until the 1970s,[39] when Laub and Fisk published several works on transsexualism using these terms.[40][41] "Transsexualism" was replaced in the DSM-IV by "gender identity disorder in adolescents and adults".

Male-to-female transsexualism has sometimes been called "Harry Benjamin's syndrome" after the endocrinologist who pioneered the study of dysphoria.[42] As the present-day medical study of gender variance is much broader than Benjamin's early description, there is greater understanding of its aspects,[43] and use of the term Harry Benjamin's syndrome has been criticized for delegitimizing gender-variant people with different experiences.[44][45]

Since the middle of the 20th century, homosexual transsexual and related terms were used to label individuals' sexual orientation based on their birth sex.[46] Many sources criticize this choice of wording as confusing, "heterosexist",[47] "archaic",[48] and demeaning because it labels people by sex assigned at birth instead of their gender identity.[49] Sexologist John Bancroft also recently expressed regret for having used this terminology, which was standard when he used it, to refer to transsexual women.[50] He says that he now tries to choose his words more sensitively.[50] Sexologist Charles Allen Moser is likewise critical of the terminology.[51] Sociomedical scientist Rebecca Jordan-Young challenges researchers like Simon LeVay, J. Michael Bailey, and Martin Lalumiere, who she says "have completely failed to appreciate the implications of alternative ways of framing sexual orientation."[52]

The terms androphilia and gynephilia to describe a person's sexual orientation without reference to their gender identity were proposed and popularized by psychologist Ron Langevin in the 1980s.[53] The similar specifiers attracted to men, attracted to women, attracted to both or attracted to neither were used in the DSM-IV.[54]

Many transsexual people choose the language of how they refer to their sexual orientation based on their gender identity, not their birth assigned sex.[43]

Several terms are in common use, especially within the community itself relating to the surgical or operative status of someone who is transsexual, depending on whether they have already had sex reassignment surgery (SRS), have not had SRS but still intend to, or do not intend to have SRS. They are, post-op, pre-op, and non-op, respectively.[55]

A pre-operative transsexual person, or simply pre-op for short, is someone who intends to have SRS at some point, but has not yet had it.[55][56]

A post-operative transsexual person, or post-op for short, is someone who has had SRS.[55]

A non-operative transsexual person, or non-op, is someone who has not had SRS, and does not intend to have it in the future. There can be various reasons for this, from personal to financial.[55] Having SRS is not a requirement of being transsexual. Evolutionary biologist and trans woman Julia Serano criticizes the societal preoccupation with SRS as phallocentric, objectifying of transsexuals, and an invasion of privacy.[57]^{: 229–231}

Although there are records of sex reassignment surgery (SRS) going back to the 2nd century, the first modern types of such practice first appeared in the 20th century.[64][65] In this context, Harry Benjamin suggested that moderate intensity male to female transsexual people may benefit from estrogen medication as a "substitute for or preliminary to operation."[20] In Benjamin's view, people may have had sex reassignment surgery even though they do not meet the definition of transsexual, while others do not desire SRS although they fit his definition of a "true transsexual". "Transsexuality" was included for the first time in the DSM-III in 1980 and again in the DSM-III-R in 1987, where it was located under Disorders Usually First Evident in Infancy, Childhood or Adolescence.

Beyond Benjamin's work, which focused on male-to-female (MTF) transsexual people, there are cases of the female to male transsexual, for whom genital surgery may not be practical. Benjamin gave certifying letters to his MTF transsexual patients that stated "Their anatomical sex, that is to say, the body, is male. Their psychological sex, that is to say, the mind, is female." Starting in 1968 Benjamin abandoned his early terminology and adopted that of "gender identity."[43]

Studies conducted on twins suggest that there are likely genetic causes of gender incongruence, although the precise genes involved are not known or fully understood.[71][72]

A 2008 study compared the genes of 112 trans women who were mostly already undergoing hormone treatment, with 258 cisgender male controls. Trans women were more likely than cisgender males to have a longer version of a receptor gene (longer repetitions of the gene) for the sex hormone androgen, which reduced its effectiveness at binding testosterone.[73] The androgen receptor (NR3C4) is activated by the binding of testosterone or dihydrotestosterone, where it plays a critical role in the forming of primary and secondary male sex characteristics. The research weakly suggests reduced androgen and androgen signaling contributes to trans women's identity. The authors say that a decrease in testosterone levels in the brain during development might prevent complete masculinization of trans women's brains, thereby causing a more feminized brain and a female gender identity.[73][74]

A variant genotype for the CYP17 gene, which acts on the sex hormones pregnenolone and progesterone, has been found to be linked to transsexuality in trans men but not in trans women. Most notably, transmasculine subjects not only had the variant genotype more frequently, but had an allele distribution equivalent to cisgender male controls, unlike the cisgender female controls. The paper concluded that the loss of a female-specific CYP17 T -34C allele distribution pattern is associated with transmasculinity.[75]

In 2013, a twin study combined a survey of pairs of twins where one or both had undergone, or had plans and medical approval to undergo, gender transition, with a literature review of published reports of transgender twins. The study found that one third of identical twin pairs in the sample were both transgender: 13 of 39 (33%) monozygotic or identical pairs of assigned males and 8 of 35 (22.8%) pairs of assigned females. Among dizygotic or genetically non-identical twin pairs, there was only 1 of 38 (2.6%) pairs where both twins were trans.[76] The significant percentage of identical twin pairs in which both twins are trans and the virtual absence of dizygotic twins (raised in the same family at the same time) in which both were trans would provide evidence that transgender identity is significantly influenced by genetics if both sets were raised in different families.[76]

Transgender brain studies, especially those on trans women attracted to women (gynephilic), and those on trans men attracted to men (androphilic), are limited, as they include only a small number of tested individuals.[77] Several studies have found a correlation between gender identity and brain structure.[61][78] A first-of-its-kind study by Zhou et al. (1995) found that in the bed nucleus of the stria terminalis (BSTc), a region of the brain known for sex and anxiety responses (and which is affected by prenatal androgens),[79] cadavers of six trans women had female-normal BSTc size, similar to the study's cadavers of cisgender women. While the trans women had undergone hormone therapy, and all but one had undergone sex reassignment surgery, this was accounted for by including cadavers of non-trans female and male controls who, for a variety of medical reasons, had experienced hormone reversal. The controls still had sizes typical for their sex. No relationship to sexual orientation was found.[80]

In a follow-up study, Kruijver et al. (2000) looked at the number of neurons in BSTc instead of volumes. They found the same results as Zhou et al. (1995), but with even more dramatic differences. One transfeminine subject who had never received hormone therapy was also included, and nonetheless matched up with the female neuron counts.[81]

In 2002, a follow-up study by Chung et al. found that significant sexual dimorphism in BSTc did not establish until adulthood. Chung et al. theorized that changes in fetal hormone levels produce changes in BSTc synaptic density, neuronal activity, or neurochemical content which later lead to size and neuron count changes in BSTc, or alternatively, that the size of BSTc is affected by the generation of a gender identity inconsistent with one's assigned sex.[82]

It has been suggested that the BSTc differences may be a result of hormone replacement therapy. It has also been suggested that because pedophilic offenders have also been found to have a reduced BSTc, a feminine BSTc may be a marker for paraphilias rather than transgender identity.[77]

In a review of the evidence in 2006, Gooren considered the earlier research as supporting the concept of gender incongruence as a sexual differentiation disorder of the sexually dimorphic brain.[83] Dick Swaab (2004) concurred.[84]

In 2008, Garcia-Falgueras & Swaab discovered that the interstitial nucleus of the anterior hypothalamus (INAH-3), part of the hypothalamic uncinate nucleus, had properties similar to the BSTc with respect to sexual dimorphism and gender incongruence. The same method of controlling for hormone usage was used as in Zhou et al. (1995) and Kruijver et al. (2000). The differences were even more pronounced than with BSTc; control males averaged 1.9 times the volume and 2.3 times the neurons as control females, yet regardless of hormone exposure, trans women were within the female range and the trans men within the male range.[85]

A 2009 MRI study by Luders et al. found that among 24 trans women not treated with hormone therapy, regional gray matter concentrations were more similar to those of cisgender men than of cisgender women, but there was a significantly greater volume of gray matter in the right putamen compared to cisgender men. Like earlier studies, researchers concluded that transgender identity was associated with a distinct cerebral pattern.[86] MRI scanning allows easier study of larger brain structures, but independent nuclei are not visible due to lack of contrast between different neurological tissue types, hence other studies on e.g. BSTc were done by dissecting brains post-mortem.

Rametti et al. (2011) studied 18 trans men who had not undergone hormone therapy using diffusion tensor imaging (DTI), an MRI technique which allows visualizing white matter, the structure of which is sexually dimorphic. Rametti et al. discovered that the trans men's white matter, compared to 19 cisgender gynephilic females, showed higher fractional anisotropy values in posterior part of the right SLF, the forceps minor and corticospinal tract". Compared to 24 cisgender males, they showed only lower FA values in the corticospinal tract. The white matter patterns in trans men were found to be shifted in the direction of non-trans males.[87]

Hulshoff Pol et al. (2006) studied gross brain volume in 8 trans men and in 6 trans women undergoing hormone therapy. They found that hormones altered the sizes of the hypothalamus in a gender-consistent manner: treatment with masculinizing hormones shifted the hypothalamus towards the male direction in the same way as in male controls, and treatment with feminizing hormones shifted the hypothalamus towards the female direction in the same way as female controls. They concluded: "The findings suggest that, throughout life, gonadal hormones remain essential for maintaining aspects of sex-specific differences in the human brain."[88]

A 2011 review published in Frontiers in Neuroendocrinology found that "Female INAH3 and BSTc have been found in MtF transsexual persons. The only female-to-male (FtM) transsexual person available to us for study so far had a BSTc and INAH3 with clear male characteristics. (...) These sex reversals were found not to be influenced by circulating hormone levels in adulthood, and seem thus to have arisen during development" and that "All observations that support the neurobiological theory about the origin of transsexuality, i.e. that it is the sizes, the neuron numbers, and the functions and connectivity of brain structures, not the sex of their sexual organs, birth certificates or passports, that match their gender identities".[89]

A 2015 review reported that two studies found a pattern of white matter microstructure differences away from a transgender person's birth sex, and toward their desired sex. In one of these studies, sexual orientation had no effect on the diffusivity measured.[90]

A 2016 review agreed with the other reviews when considering androphilic trans women and gynephilic trans men. It reported that hormone treatment may have large effects on the brain, and that cortical thickness, which is generally thicker in cisgender women's brains than in cisgender men's brains, may also be thicker in trans women's brains, but is present in a different location to cisgender women's brains.[77] It also stated that for both trans women and trans men, "cross-sex hormone treatment affects the gross morphology as well as the white matter microstructure of the brain. Changes are to be expected when hormones reach the brain in pharmacological doses. Consequently, one cannot take hormone-treated transsexual brain patterns as evidence of the transsexual brain phenotype because the treatment alters brain morphology and obscures the pre-treatment brain pattern."[77]

A 2019 review in Neuropsychopharmacology found that among transgender individuals meeting diagnostic criteria for gender dysphoria, "cortical thickness, gray matter volume, white matter microstructure, structural connectivity, and corpus callosum shape have been found to be more similar to cisgender control subjects of the same preferred gender compared with those of the same natal sex."[91]

A 2020 paper[92] tried to investigate and differentiate between the two competing hypotheses of a neurodevelopmental cortical hypothesis that suggests the existence of different brain phenotypes vs a functional-based hypothesis in relation to regions involved in the own body perception.[92] Trans men, trans women, and cisgender women all had decreased connectivity compared with cisgender men in superior parietal regions, as part of the salience (SN) and the executive control (ECN) networks.[92] Trans men also had weaker connectivity compared with cisgender men between intra-SN regions and weaker inter-network connectivity between regions of the SN, the default mode network (DMN), the ECN and the sensorimotor network.[92] Trans women had lower small-worldness, modularity and clustering coefficient than cisgender men.[92]

A 2021 review of brain studies published in the Archives of Sexual Behavior found that "although the majority of neuroanatomical, neurophysiological, and neurometabolic features" in transgender people "resemble those of their natal sex rather than those of their experienced gender", for trans women they found feminine and demasculinized traits, and vice versa for trans men. They stated that due to limitations and conflicting results in the studies that had been done, they could not draw general conclusions or identify-specific features that consistently differed between cisgender and transgender people. The review also found differences when comparing cisgender homosexual and heterosexual people, with the same limitations applying.[93]

A 2016 review reported that early-onset androphilic transgender women have a brain structure similar to cisgender women's and unlike cisgender men's, but that they have their own brain phenotype.[77] It also reported that gynephilic trans women differ from both cisgender female and male controls in non-dimorphic brain areas.[77] The available research indicates that the brain structure of androphilic trans women with early-onset gender dysphoria is closer to that of cisgender women than that of cisgender men.[77] It also reports that gynephilic trans women differ from both cisgender female and male controls in non-dimorphic brain areas.[77] Cortical thickness, which is generally thicker in cisgender women's brains than in cisgender men's brains, may also be thicker in trans women's brains, but is present in a different location to cisgender women's brains.[77] For trans men, research indicates that those with early-onset gender dysphoria and who are gynephilic have brains that generally correspond to their assigned sex, but that they have their own phenotype with respect to cortical thickness, subcortical structures, and white matter microstructure, especially in the right hemisphere.[77] Hormone therapy can also affect transgender people's brain structure; it can cause transgender women's brains to become closer to those of cisgender women, and morphological changes observed in the brains of trans men might be due to the anabolic effects of testosterone.[77]

While MRI taken on gynephilic trans women have likewise shown differences in the brain from non-trans people, no feminization of the brain's structure has been identified.[77] Neuroscientists Ivanka Savic and Stefan Arver at the Karolinska Institute used MRI to compare 24 gynephilic trans women with 24 cisgender female and 24 cisgender male controls. None of the study participants were undergoing hormone therapy. The researchers found sex-typical differentiation between the trans women and cisgender females, and the cisgender males; but the gynephilic trans women "displayed also singular features and differed from both control groups by having reduced thalamus and putamen volumes and elevated GM volumes in the right insular and inferior frontal cortex and an area covering the right angular gyrus".[94]

The researchers concluded that:

Contrary to the primary hypothesis, no sex-atypical features with signs of 'feminization' were detected in the transsexual group ... The present study does not support the dogma that [male-to-female transsexuals] have atypical sex dimorphism in the brain but confirms the previously reported sex differences. The observed differences between MtF-TR and controls raise the question as to whether gender dysphoria may be associated with changes in multiple structures and involve a network (rather than a single nodal area).

Berglund et al. (2008) tested the response of gynephilic trans women to two steroids hypothesized to be sex pheromones: the progestin-like 4,16-androstadien-3-one (AND) and the estrogen-like 1,3,5(10),16-tetraen-3-ol (EST). Despite the difference in sexual orientation, the trans women's hypothalamic networks activated in response to the AND pheromone, like the androphilic cis female control groups. Both groups experienced amygdala activation in response to EST. Gynephilic cis male control groups experienced hypothalamic activation in response to EST. However, the trans women also experienced limited hypothalamic activation to EST. The researchers concluded that in terms of pheromone activation, trans women occupy an intermediate position with predominantly female features.[95] The transfeminine subjects had not undergone any hormonal treatment at the time of the study, according to their own declaration beforehand, and confirmed by repeated tests of hormonal levels.[95]

Fewer brain structure studies have been performed on transgender men than on transgender women.[77] A team of neuroscientists, led by Nawata in Japan, used a technique called single-photon emission computed tomography (SPECT) to compare the regional cerebral blood flow (rCBF) of 11 gynephilic trans men with that of 9 androphilic cis females. Although the study did not include a sample of cisgender males so that a conclusion of "male shift" could be made, the study did reveal that the gynephilic trans men showed significant decrease in blood flow in the left anterior cingulate cortex and a significant increase in the right insula, two brain regions known to respond during sexual arousal.[96]

A 2016 review reported that the brain structure of early-onset gynephilic trans men generally corresponds to their assigned sex, but that they have their own phenotype with respect to cortical thickness, subcortical structures, and white matter microstructure, especially in the right hemisphere.[77] Morphological increments observed in the brains of trans men might be due to the anabolic effects of testosterone.[77]

Prenatal androgen exposure, the lack thereof, or low sensitivity to prenatal androgens are commonly cited as mechanisms to explain the above discoveries. To test this, studies have examined the differences between trans and cisgender individuals in digit ratio (a generally accepted marker for prenatal androgen exposure). A meta-analysis concluded that the effect sizes for this association were small or nonexistent.[97]

In people with XX chromosomes, congenital adrenal hyperplasia (CAH) results in heightened exposure to prenatal androgens, resulting in masculinization of the genitalia. Individuals with CAH are typically subjected to medical interventions including prenatal hormone treatment[98] and postnatal genital reconstructive surgeries.[99] Such treatments are sometimes criticized by intersex rights organizations as non-consensual, invasive, and unnecessary interventions. Individuals with CAH are usually assigned female and tend to develop similar cognitive abilities to the typical females, including spatial ability, verbal ability, language lateralization, handedness and aggression. Research has shown that people with CAH and XX chromosomes will be more likely to experience same-sex attraction,[98] and at least 5.2% of these individuals develop serious gender dysphoria.[100]

In males with 5-alpha-reductase deficiency, conversion of testosterone to dihydrotestosterone is disrupted, decreasing the masculinization of genitalia. Individuals with this condition are typically assigned female and raised as girls due to their feminine appearance at a young age. However, more than half of males with this condition raised as females come to identify as male later in life. Scientists speculate that the definition of masculine characteristics during puberty and the increased social status afforded to men are two possible motivations for a female-to-male transition.[100]

Historically, formal efforts by the medical community to provide transsexual healthcare were extremely focused on transsexual women, with little thought for transsexual men. Julia Serano suggests that effemimania (the idea that male femininity is more psychopathological than female masculinity) was the driving factor. She sees this as a kind of transmisogyny (hatred of trans women as an extension of sexism).[1]^{: 126–127} This effimimania conflates male homosexuality, transsexual women, and feminine gender expression, while treating them all as a disease.[1]^: 129 She points to the medical community's long love of now outdated theories such as autogynephilia.[1]^: 131

Transsexual individuals frequently opt for masculinizing or feminizing hormone replacement therapy (HRT) to modify secondary sex characteristics.

Sex reassignment therapy (SRT) is an umbrella term for all medical treatments related to sex reassignment of both transgender and intersex people. Sex reassignment surgery (such as orchiectomy) alters primary sex characteristics, including chest surgery such as top surgery or breast augmentation, or, in the case of trans women, a trachea shave, facial feminization surgery or permanent hair removal.

To obtain sex reassignment therapy, transsexual people are generally required to undergo a psychological evaluation and receive a diagnosis of gender identity disorder in accordance with the Standards of Care (SOC) as published by the World Professional Association for Transgender Health.[2] This assessment is usually accompanied by counseling on issues of adjustment to the desired gender role, effects and risks of medical treatments, and sometimes also by psychological therapy. The SOC are intended as guidelines, not inflexible rules, and are intended to ensure that clients are properly informed and in sound psychological health, and to discourage people from transitioning based on unrealistic expectations.

After an initial psychological evaluation, trans men and trans women may begin medical treatment, starting with hormone replacement therapy[3][4] or hormone blockers. In these cases, people who change their gender are usually required to live as members of their target gender for at least one year prior to genital surgery, gaining real-life experience, which is sometimes called the "real-life test" (RLT).[3] Transsexual individuals may undergo some, all, or none of the medical procedures available, depending on personal feelings, health, income, and other considerations. Some people posit that transsexualism is a physical condition, not a psychological issue, and assert that sex reassignment therapy should be given on request. (Brown 103)

Like other trans people, transsexual people may refer to themselves as trans men or trans women. Transsexual people desire to establish a permanent gender role as a member of the gender with which they identify, and many transsexual people pursue medical interventions as part of the process of expressing their gender. The entire process of switching from one physical sex and social gender presentation to another is often referred to as transitioning, and usually takes several years. Transsexual people who transition usually change their social gender roles, legal names and legal sex designation.

Not all transsexual people undergo a physical transition. Some have obstacles or concerns preventing them from doing so, such as the expense of surgery, the risk of medical complications, or medical conditions which make the use of hormones or surgery dangerous. Others may not identify strongly with another binary gender role. Still others may find balance at a midpoint during the process, regardless of whether or not they are binary-identified. Many transsexual people, including binary-identified transsexual people, do not undergo genital surgery, because they are comfortable with their own genitals, or because they are concerned about nerve damage and the potential loss of sexual pleasure, including orgasm. This is especially so in the case of trans men, many of whom are dissatisfied with the current state of phalloplasty, which is typically very expensive, not covered by health insurance, and commonly does not achieve desired results. For example, not only does phalloplasty not result in a completely natural erection, it may not allow for an erection at all, and its results commonly lack penile sexual sensitivity; in other cases, however, phalloplasty results are satisfying for trans men. By contrast, metoidioplasty, which is more popular, is significantly less expensive and has far better sexual results.[5][6][7]

Transsexual people can be heterosexual, gay, lesbian, or bisexual; many choose the language of how they refer to their sexual orientation based on their gender identity, not their birth assigned sex.[8]

Psychological techniques that attempt to alter gender identity to one considered appropriate for the person's assigned sex, aka conversion therapy, are ineffective. The widely recognized Standards of Care note that sometimes the only reasonable and effective course of treatment for transsexual people is to go through sex reassignment therapy.[3][9]

The need for treatment of transsexual people is emphasized by the high rate of mental health problems, including depression, anxiety, and various addictions, as well as a higher suicide rate among untreated transsexual people than in the general population.[10] These problems are alleviated by a change of gender role and/or physical characteristics.[11]

Many transgender and transsexual activists, and many caregivers, note that these problems are not usually related to the gender identity issues themselves, but the social and cultural responses to gender-variant individuals. Some transsexual people reject the counseling that is recommended by the Standards of Care[3] because they do not consider their gender identity to be a cause of psychological problems.

Brown and Rounsley noted that "some transsexual people acquiesce to legal and medical expectations in order to gain rights granted through the medical/psychological hierarchy." Legal needs, such as a change of sex on legal documents, and medical needs, such as sex reassignment surgery, are usually difficult to obtain without a doctor or therapist's approval. Because of this, some transsexual people feel coerced into affirming outdated concepts of gender to overcome simple legal and medical hurdles.[12]

People who undergo sex reassignment surgery can develop regret for the procedure later in life, largely predicted by a lack of support from family or peers, with data from the 1990s suggesting a rate of 3.8%.[13][14] In a 2001 study of 232 MTF patients who underwent GRS, none of the patients reported complete regret and only 6% reported partial or occasional regrets.[15] A 2009 review of Medline literature suggests the total rate of patients expressing feelings of doubt or regret is estimated to be as high as 8%.[16]

A 2010 meta-study, based on 28 previous long-term studies of transsexual men and women, found that the overall psychological functioning of transsexual people after transition was similar to that of the general population and significantly better than that of untreated transsexual people.[17]

Poland's Anna Grodzka[28] is the first transsexual MP in the history of Europe to have had sex reassignment surgery.[29]

Laws regarding changes to the legal status of transsexual people are different from country to country. Some jurisdictions allow an individual to change their name, and sometimes, their legal gender, to reflect their gender identity. Within the US, some states allow amendments or complete replacement of the original birth certificates.[30] Some states seal earlier records against all but court orders in order to protect the transsexual person's privacy.

In many places, it is not possible to change birth records or other legal designations of sex, although changes are occurring. Estelle Asmodelle's book documented her struggle to change the Australian birth certificate and passport laws, although there are other individuals who have been instrumental in changing laws and thus attaining more acceptance for transsexual people in general.

Medical treatment for transsexual and transgender people is available in most Western countries. However, transsexual and transgender people challenge the "normative" gender roles of many cultures and often face considerable hatred and prejudice. The film Boys Don't Cry chronicles the case of Brandon Teena, a transsexual man who was raped and murdered after his status was discovered. In 1999 Brandon was memoralised in the first Transgender Day of Remembrance.[31] The Transgender Day of Rembrance is observed annually on November 20 by members of the transgender community and LGBT+ organisations across the world.[32][33]

Jurisdictions allowing changes to birth records generally allow trans people to marry members of the opposite sex to their gender identity and to adopt children. Jurisdictions which prohibit same sex marriage often require pre-transition marriages to be ended before they will issue an amended birth certificate.[34]

Health-practitioner manuals, professional journalistic style guides, and LGBT advocacy groups advise the adoption by others of the name and pronouns identified by the person in question, including present references to the transgender or transsexual person's past.[35][36][37] Family members and friends who may be confused about pronoun usage or the definitions of sex are commonly instructed in proper pronoun usage, either by the transsexual person or by professionals or other persons familiar with pronoun usage as it relates to transsexual people. Sometimes transsexual people have to correct their friends and family members many times before they begin to use the transsexual person's desired pronouns consistently. According to Julia Serano, deliberate mis-gendering of transsexual people is "an arrogant attempt to belittle and humiliate trans people."[38]

Both "transsexualism" and "gender identity disorders not resulting from physical impairments" are specifically excluded from coverage under the Americans with Disabilities Act Section 12211.[39] Gender dysphoria is not excluded.[40]

Openly transsexual people can have difficulty maintaining employment. Most find it necessary to remain employed during transition in order to cover the costs of living and transition. However, employment discrimination against trans people is rampant and many of them are fired when they come out or are involuntarily outed at work.[41] Transsexual people must decide whether to transition on-the-job, or to find a new job when they make their social transition. Other stresses that transsexual people face in the workplace are being fearful of coworkers negatively responding to their transition, and losing job experience under a previous name—even deciding which rest room to use can prove challenging.[42] Finding employment can be especially challenging for those in mid-transition.

Laws regarding name and gender changes in many countries make it difficult for transsexual people to conceal their trans status from their employers.[43] Because the Harry Benjamin Standards of Care requires one-year of real life experience prior to SRS, some feel this creates a Catch-22 situation which makes it difficult for trans people to remain employed or obtain SRS.

In many countries, laws provide protection from workplace discrimination based on gender identity or gender expression, including masculine women and feminine men. An increasing number of companies are including "gender identity and expression" in their non-discrimination policies.[30][44] Often these laws and policies do not cover all situations and are not strictly enforced. California's anti-discrimination laws protect transsexual persons in the workplace and specifically prohibit employers from terminating or refusing to hire a person based on their gender identity. The European Union provides employment protection as part of gender discrimination protections following the European Court of Justice decisions in P v S and Cornwall County Council.[45]

In the United States National Transgender Discrimination Survey, 44% of respondents reported not getting a job they applied for because of being transgender.[26] 36% of trans women reported losing a job due to discrimination compared to 19% of trans men.[26] 54% of trans women and 50% of trans men report having been harassed in the workplace.[26] Transgender people who have been fired due to bias are more than 34 times likely than members of the general population to attempt suicide.[26]

Many transsexual men and women choose to live completely as members of their gender without disclosing details of their birth-assigned sex. This approach is sometimes called stealth.[46] Stealth transsexuals choose not to disclose their past for numerous reasons, including fear of discrimination and fear of physical violence.[26]^: 63 There are examples of people having been denied medical treatment upon discovery of their trans status, whether it was revealed by the patient or inadvertently discovered by the doctors.[47]

Nina Poon, a transsexual model who has appeared in Kenneth Cole ads, at the 2010 Tribeca Film Festival

Before transsexual people were depicted in popular movies and television shows, Aleshia Brevard—a transsexual woman whose surgery took place in 1962[48]^: 3—was actively working as an actress[48]^: 141 and model[48]^: 200 in Hollywood and New York throughout the 1960s and 1970s. Aleshia never portrayed a transsexual person, though she appeared in eight Hollywood-produced films, on most of the popular variety shows of the day, including The Dean Martin Show, and was a regular on The Red Skelton Show and One Life to Live before returning to university to teach drama and acting.[48][49]

Since 2004, with the goal of crowning the top transsexual of the world, a beauty pageant by the name of The World's Most Beautiful Transsexual Contest was held in Las Vegas, Nevada. The pageant accepted pre-operation and post-operation trans women, but required proof of their gender at birth. The winner of the 2004 pageant was a woman named Mimi Marks.[50]

Jenna Talackova, the 23-year-old woman who forced Donald Trump and his Miss Universe Canada pageant to end its ban on transgender contestants, competed in the pageant on May 19, 2012, in Toronto.[51] On January 12, 2013, Kylan Arianna Wenzel was the first transgender woman allowed to compete in a Miss Universe Organization pageant since Donald Trump changed the rules to allow women like Wenzel to enter officially. Wenzel was the first transgender woman to compete in a Miss Universe Organization pageant since officials disqualified 23-year-old Miss Canada Jenna Talackova the previous year after learning she was transgender.[52][53]