What do these labels, ‘transsexual’, ‘transgendered’, ‘trans-women’, ‘gender dysphoria’ & so forth, really mean?  What’s it all about?  

The term ‘transsexual’ was popular early on in the era of trans-care but people took exception to its sexual overtones, assumptions and implications.  And as if that weren’t problem enough, the trans-process is actually not at all about sexuality but instead about identity, so the title is fundamentally inaccurate, therefore invalid, even misleading.  The next term to become popular was the word ‘transgender’, but it too had its problems, because while the sexual connotation had now been satisfactorily eliminated, two major problems remained. 

Transsexual or transgendered?

The first is that this newer term is so clumsy & awkward.  It works well linguistically when you say “she is a transsexual” but not when you say “she’s a transgender”.  We need to find a more appropriate word & for want of anything better I find myself calling my patients ‘trans-women’.  Over and above the clumsiness however, there is the clear fact that this new word ‘transgender’ is just as inaccurate as the old one & paints an equally false picture.  You see just as the trans-process isn’t about sex or sexuality, neither is it about gender, in either of its two opposing, male or female extremes.  The word ‘transgender’ is actually so misleading that it encourages people from outside the scientific & medical communities to fixate on false, loosely formed ideas such as ‘gender liquidity’, ‘gender neutrality’ and ‘third gender’.  These ideas are false, even ridiculous.  The trans-process is not about gender or genotype; it’s about identity, femininity & phenotype, and about being programmed rather than choosing.  There is no choice to make because you are what you are and your brain has programmed you to be this way since before your birth. 

Traditional forms of trans-care

When several decades ago I was first introduced to the trans-process, trans-women were being treated rigidly according to the arbitrary dictates of the Harry Benjamin guidelines which attempted to standardize the treatment of transsexuals so as to supposedly protect them from themselves & their supposedly twisted desires.  According to these toothless protocols one had to attend mandatory psychological counseling at great expense for a considerable amount of time before one could even begin to receive hormone therapy.  And one had to live full time as a thoroughly unfeminized woman for a minimal period before hormone therapy could be initiated.  How demeaning & how stress-generating it must have been?  And all of it was based on the false, ignorant, unscientific premise that transsexuality was a psychodynamic phenomenon, psychologically-driven.  It was being assumed for absolutely no good reason that transsexuals were a group who opted or choose to become transgendered, and of course it was all wrong.

Hard-wired, not chosen

The Harry Benjamin guidelines never made any sense to me and my opinions became reinforced within a few months as I noticed that a disproportionate number of my trans-women, in the neighborhood of 25% were left handed and/or ambidextrous.  They also tended to be generously above average in intelligence and were often unusually skilled in such complex fields as electronics, mathematics and logic.  I spoke to some of the professors at the Brain Institute in UCLA including Professor Frank Benson who then passed on the information to Professor Behan in Glasgow, the internationally prominent neurologist, and he wrote me acknowledging my observation.  My observation implied that the transsexual drive must be programmed, hard-wired into the brain rather than arbitrarily chosen. 

The trans-brain

Some years later the idea was validated at UCLA when Eric Vilain & his group examined the brain wirings of hormone-naïve trans-women, many of them referred by my office, using the advanced technology of high resolution functional MRI.  As the name implies, the study is of high resolution and involves the dynamic examination of function whereas a standard MRI only examines frozen structure.    Vilain demonstrated that the wiring of trans-women was different to that of non-transgendered genetic males, firmly validating the concept of hard wiring as opposed to psychodynamics. 

Nature versus nurture

Does psychology enter into the trans-process at all?  Of course it does!  What makes humans unique compared to all the other animals is their marked ability to override their instinctive cues, for social reasons.  Vilain then went a step further, asking himself why transsexuals were wired in this manner, dating all the way back to life in the womb.  Was transsexuality genetically inherited?  And he soon discovered that indeed it was, being linked to an abnormality in the specific genes that code, not for hormones but for hormone receptors, specifically the androgen receptors; those receptors that mediate the influences of testosterone on the body.  

The upshot of all this research is that we now know the tendency to become a trans-woman is inherited rather than chosen.  The trans-woman does not choose to travel the arduous trans-route, nature choses it for her.  Although this drive may be over-ridden with considerable difficulty, for a variety of cultural, family, religious & economic reasons, as life passes by this feminizing drive, rather than fading becomes louder & louder, fueling enormous conflict.  Those who chose to obstruct the trans-woman’s freedom to exercise this drive do so at the risk of fueling severe gender dysphoria, even to the point of exposing their loved ones to powerful suicidal drives.

What & who is a trans-woman?

What & who then, is a trans-woman?  This is a difficult question to answer because male to female (M to F) transsexuals are a mixed group & will probably be later categorized as belonging within different subgroups, each group having its own underlying nature.  One thing is clear however.  Only the transsexual truly understands transsexuality.  Everyone else is merely an observer.   
My personal vision of transsexuality (for want of a better word) goes something like this.  An M to F transsexual is a person who happens to possess the unambiguous reproductive system of the genetic male, including testes & masculine secondary sexual characteristics such as body shape, fat distribution, hair distribution & so forth, yet spontaneously & naturally identifies as a woman, without any agenda.  There is a mismatch occurring here between hard-wired, inherited programs of self-identity on the one hand, and physical reality, on the other. 

An inherited, undeniable, unsolicited, irresistable drive

The transsexual drive is inherited through a link with one’s androgen receptors. The androgen receptor anomaly in turn fuels erratic dips and surges in testosterone levels. These erratic androgen surges must stimulate some part of the brain, thus fueling the transsexual drive. It is probable that those parts of the brain relating to obsessive-compulsive disorder (OCD) and its particular variant known as body dysmorphic disorder (BDD), including the basal ganglia and other brain elements involved in executive processing and behavioral determination are involved since they tend to be exquisitely sensitive to the influences of estrogen, progesterone, testosterone and cortisol.  OCD-related behaviors become amplified under the influence of androgens.  Thus, OCD worsens in the springtime, as testosterone levels rise.

Easing the anguish of gender dysphoria

It follows that eliminating surges of testosterone and dips in estrogen might reduce the volume of the transsexual drive and this does indeed seem to be the case. Over the years some of my patients, for pragmatic reasons relating to family or finances, have requested I try to reduce their transsexual drive and their resultant gender dysphoria without causing them to become overtly feminized, in a sense trying to survive in a stealth mode. While trying to do this my first observation was that in those trans-women whose hormone therapy is ineffective or highly erratic, characterized by frequent testosterone escapes, they do not experience any reduction in the trans-drive or in their gender dysphoria.  In contrast steady-state, expertly delivered hormone therapy certainly can reduce these disturbing & intrusive mental feelings which we term 'gender dysphoria', but the actual trans-drive remains operative though at a lower volume. It follows that effective feminizing hormone therapy, when expertly delivered can eliminate gender dysphoria and lower the volume of the trans-drive whereas ineffective and/or erratic forms of hormone therapy fail to do so.

Conflicting forces

What is this business of gender dysphoria? Gender dysphoria is a suite of mental symptoms experienced by the transgender patient who has been unable to feminize or deliberately obstructed from doing so. It appears to be a testosterone-driven and testosterone-dependent experience. The word dysphoria means feeling badly. Thus whereas transsexuality is a label describing an anomalous sense of self identity, gender dysphoria is a label describing a mental syndrome. I believe that both of these processes share a common driver, the presence of testosterone surges. Testosterone, acting upon the brain in a non-sexual matter that is independent of classical genomic mechanisms exerts its influences in a high-speed fashion upon the brain.  Because these mechanisms are high speed, patterns such as surges & dips are as important as levels.

Criticality of hormonal patterns

When we treat transsexuals with long acting hormone pellets that effectively lower testosterone down to castrate levels, gender dysphoria vanishes only to reappear as these hormones drop below a certain threshold level, manifesting in the form of an increasingly distorted body image and diminished self-esteem & self-confidence. In contrast, patients who obtain injectable feminizing hormones that wax and wane, thus facilitating testosterone escapes, tend to be associated with persistence in their gender dysphoria even while the patient is being effectively feminized.

In the hands of a real hormone expert

The upshot of all this is that feminizing hormone therapy urgently needs to be administered with expertise and precision, since the object of medical treatment goes far deeper that simply helping people to appear more feminine through surgical modifications or even to truly become more feminine through hormone therapy. It also means to bring to the patient a sense of inner peace & tranquility, by reducing or eliminating the manifestations of OCD, BDD & gender dysphoria.  That is why at my clinic we don’t treat transsexuals, we treat people.