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Everything You Ever Wanted
to Know About Sex Change*
*but were afraid to ask

Last updated in 1997

Introduction to Sex Change

By Melanie Anne

Unlike it's frivolous name, this book is actually a serious look at the nature of transsexuality: what it is, why it is, and how sex reassignment is accomplished, both surgically and socially. You may be surprised to learn that one out of ten adults in this country believe themselves to be transgendered to some degree.

What does it mean to be transgendered and how does that relate to being transsexual? Before we can define transgenderism and transsexuality, we must first be able to define gender and sexuality without the "trans".

Surprisingly, although most everyone has a good feel for what these terms mean, hardly anyone has a good understanding of them. Before we try to describe the nature and process of sex change then, let us take a brief moment to examine human sexuality in general.

 

Human Sexuality 101

There are four aspects to Human Sexuality. They are:

1. Anatomical (physical) sex 2. Sexual preference 3. Gender Identity 4. Mental Sex

Anatomical sex

Anatomical sex is simply what body you are in: male or female. But it is really not all that simple. There are hairy women and very slender men. Facial features can range from more "male" to more "female" regardless of what's between one's legs. In addition, there is the chromosomal nature of being XX, XY, or even XXY. On top of that, we have hermaphrodites.

So, all things considered, each and every one of us can not simply be seen as wholly male or female physically, but truly occupy a range on a spectrum. And, we can alter our physical sexually characteristics (short or long hair, nose jobs, sex change surgery) so that the line blurs even more. True, most people gravitate to one end of the scale that the other, which creates an inverse "bell curve". However, the line from one side to the other is truly unbroken, with more than a few people right in the middle.

Sexual preference

This one comes in four flavors: same, opposite, both, or neither. Regardless of anatomical sex, any individual might be any one of these four. What's more, most people find their sexual preferences depend on context and may shift depending on the situation or the person. For example, a man who sees himself as attracted to the opposite sex might not be at all attracted to a female body builder. If he were honest with himself, he would probably find some level of attraction to a very pretty boy. It is the cultural training we have that leads us deny and not even experience the capacity to shift our perspectives here.

In addition, people change over time as well as in different contexts. Some start out being heterosexual, then shift to bisexual, then to same sex, then give up altogether, and then jump back in somewhere else. With the spatial and temporal flexibility in this area, each of us is fluid. But in the range of people as a whole, regardless of where you fall on the anatomical sex scale, any individual might at any time have any one of the four sexual preferences.

So, since anatomical sex does not determine sexual preference and sexual preference is independent of anatomical sex, the two factors are independent and can be multiplied together to determine a great range of human sexuality on these two points alone. Already we can see there are a tremendous number of combinations!

Gender Identity

Gender Identity describes where on the scale of masculine and feminine behavior an individual falls. Clearly this is a range. What's more, each of us changes in context as well. Men who are very macho on the weekend playing tackle football with friends might be very demure during the week at their job as a bank teller. And, over time, we all change. Most men are more masculine at age 35 than they are at age 80.

Gender identity for any one of us does not fall at a single point, but ranges in a segment of the masculine/feminine line. Which segment we define depends on our conditioning as a child which "locks in" somewhere between age 3 and 5. Then, for most of our lives, we move up and down that segment, feeling uneasy if we get close to one of the ends of our personal range.

Now, since masculine or feminine is a range and does not depend on sexual preference or anatomical sex (we all know masculine women and feminine men) then we can multiply that in as well and create an ENORMOUS number of combinations of human sexuality.

Mental Sex

In the 12th to 14th week of pregnancy, a developing fetus will get a wash of hormones over its brain. Boy babies get a flush of testosterone, girl babies get a flush of estrogen. Testosterone has a direct impact on the level of the neurotransmitter Seratonin in the brain. As testosterone goes up, Seratonin production goes up.

Seratonin is an "exciter" which stimulates the firing of the neurons. When they fire, the neurological activity of the brain takes center stage, and the biochemical aspect of the brain steps a bit into the shadows.

In contrast, estrogen increases the relative amount of the neurotransmitter Dopamine. Unlike Seratonin, Dopamine is an inhibitor, which means it lowers the tendency for neurons to fire. This does not mean it diminishes mental processes, but rather that the biochemical processes of the mind take center stage and the neurons step into the shadows.

If the effect of this flush of testosterone or estrogen only lasted for the two weeks the chemicals are present, it would have no lasting effect on the mind. But, for reasons we shall see later in this book, the brain "locks in" to a bias toward the neurology or the biochemistry. It is this bias that makes a mind more focused on logic or more concerned with feelings.

In truth, this hormone wash can vary in intensity from individual to individual, so that any given person may range from very heavily favoring the neurology or the biology to being more evenly balanced in which kind of processing takes control.

As nature would have it, again for reasons we shall later explore, most people are born very heavily biased to one side or the other. Still, this just indicates our preferred method of thinking - the kind of thought process we fall into first or most skillfully. Each of us, however, often employs the other manner of thinking when the first one is at a loss or when we need an internal second opinion.

The neural networks of the brain function in a binary fashion so those with a testosterone wash tend to see the world in more logical terms, more spatial terms. The biochemistry of the brain functions in a more wave-like fashion, so those with an estrogen wash tend to see the world in more experiential terms, more temporal terms. Spatial thinkers look outward and first see things in terms of their arrangement and where it leads. Temporal things first look inward and see things in terms of what they mean and how they are going.

Because men tend to fall toward the spatial end of the scale and women to the temporal, society has built up rewards to motivate the population based on the expectation of this bias according to anatomical sex. And, most nearly often, this is an accurate system. But when something causes an individual to get the opposite pre-birth bias than anatomical sex would suggest, he or she is technically a transsexual.

Why do I say "technically"? Because the practical definition of a transsexual would be someone who actual has surgery to change his or her anatomical sex, or at least someone who truly wants to. In truth, most of those born with the opposite bias are never aware of it, and would be appalled to even consider changing their sex.

In a like manner, there are many who have had sex change surgery (called SRS for Sex Reassignment Surgery) who are not mentally transsexual at all. Why? Because gender identity determines how masculine or feminine we wish to be, and society determines the range of behavior which is acceptable along that scale, based on anatomical sex.

So, a man with very feminine tendencies might wish to change their anatomical sex through surgery, whereas a man with a masculine gender identity might be quite comfortable as a male, even though he is true transsexual in the mental sense.

Finally, it must be considered that each of us has an inherent body map in our brains. This blueprint gives us a feeling for the shape in which we expect to find our physical selves. Even if we are typically matched between Mental Sex and Anatomical Sex, our body map may be for the opposite physical sex.

In psychology, stress caused by feeling one is in the wrong body is called genital dysphoria, and stress caused by feeling on is living in the wrong role is called gender dysphoria, which lumps gender identity and Mental Sex into one overall symptom.

Those who have enough pressures upon them from all four of the aspects of human sexuality may choose to remedy their uneasiness through surgical means. Other combinations of these tendencies will lead an individual to choose to cross-dress and experience femininity or masculinity occasionally, yet continue to live in the role which pleases him or her most of the time. The term "transgendered" describes both of these kinds of people. Those who elect surgery are transsexuals, and those who do not are cross-dressers (the term transvestite means the same as "cross-dresser", but is not considered politically correct.)

It should be noted that cross-dressers almost always know they don't want surgery, even though they may fantasize about it for erotic or adventurous purposes. In contrast, most transsexuals start out believing they are cross-dressers, and spend many years suffering an internal conflict wondering if it is something more, even while they try to deny it to themselves.

Having briefly explored the meaning and causes of transgenderism and transsexuality, it is time to outline the nature and methodology of the transition from one sex to another.

The Nuts and Bolts

In truth, there is much more to sex reassignment surgery than the surgery itself. Still, the nuts and bolts of the actual procedure seems to be a topic which most piques the interest. In deference to this interest, I'm putting a description of the specific of the surgery right up front. With that out of the way, we can continue or exploration into the whole phenomenon, including it's personal, social, financial, and legal ramifications.

What is Actually Done?

Technically, you cannot truly change one's sex. That's why the procedure is not really called "sex change surgery" but "sex reassignment surgery". The idea is to alter the physical appearance of a person's anatomy to approximate as nearly as possible the anatomic arrangement of the other sex.

Part of this procedure involves extended hormone therapy, which alters secondary sexual characteristics. In male to female transsexuals, it leads to the growth of breasts and the build up of body fat in particular areas. In female to male transsexuals it lowers the voice and causes body hair and beard to grow. (It should be noted that the male to female transsexual's voice is not changed by taking estrogen.) We shall fully explore the purpose and effects of hormone therapy later in this book, but for now we shall ignore this aspect in favor of a blow by blow description of the surgery.

The Long and the Short of it

Contrary to popular belief, the penis is not amputated during SRS. Rather, the internal penile tissue is mostly removed, but the outer skin is left attached, inverted and inserted into the body inside out as the new vagina. The testicles are removed, but the scrotal tissue is also left attached and used to fashion the vaginal lips or labia through standard plastic surgery procedures.

Here is how it happens. Once the patient has been prepped, sedated, wheeled into the operating room and anesthetized, the doctor slits the skin of the penis lengthwise from the head or glans down to the base on the underside. The skin is then peeled away from around the penis, but since the slit only opened the penis, the base of the skin is still attached.

The penile skin is then turned inside out, much like one might turn a sock inside out. When this is done, the slit is stitched back together, creating an inverted penis, which will ultimately form the new vagina.

Before this occurs, a rather miraculous, yet simple procedure is performed. Earlier, when the internal penile tissue was removed, a small stub of tissue was left behind, still attached. This is erectile tissue, which becomes stiff when stimulated, and also carries sexual sensation.

A tiny slit, perhaps a half-inch in length, is made in the new, inverted penis near the base where it is still attached. The stub of erectile tissue is pushed through the slit, forming the equivalent of a clitoris, and providing the opportunity for complete orgasm and sexual satisfaction after surgery. In addition, a second tiny slit is made below the one for the clitoris. The urinary tube is rerouted to this second slit to create a typical female urinary opening.

Once this procedure has been accomplished, the skin and muscles of the lower abdomen are lifted up with surgical instruments, providing a gap near the pelvic bone. The inverted penis is pushed into the gap, still attached at the base, so that it hinges down and into the proper location for a vagina.

To allow for proper vaginal contractions later, some of the abdominal muscles are repositions around to new vagina so that they can squeeze in on it, both by conscious control and also automatically during orgasm.

The new vagina is filled with surgical gauze to maintain shape, and then anchored in place with a thin surgical wire which enters the abdomen from the outside, runs under the pelvic bone, through the new vagina, back up around the pelvic bone and out the abdomen again. Once the vagina has healed in place, which takes approximately seven days, the wire is removed by the surgeon, who simply slips it out.

Post Op Information

The post op patient will remain in bed for seven to eight days. The pain of surgery is not at all as bad as one might expect. The only real pain comes if one sneezes, coughs, or laughs. The procedure does take a lot out of one's reserves, so that the patient drifts in and out of sleep and is too weak to roll over unassisted for the first day or so.

For the first three or four days, the patient is on a catheter for urinary purposes, which allows urine to drain through a tube to a bag on the side of the hospital bed. This is standard medical procedure for all urinary surgeries. In addition, any use of general anesthetic usually causes a shut down of bowel function for three or four days. Many post op patients require an enema to get the system flushed out and working again.

Urination after the catheter is removed is painful and difficult at first, but not to the point one cannot bear it. Over the course of the first few post op weeks, urination becomes increasingly easier, and the bladder is able to hold more and more until pre-surgical bladder capacity is usually recovered.

Most patients are back at work two to three weeks after surgery. The area of surgery will be sore for more than a month. Sexual sensation may return in as little as two weeks. Sexual intercourse can be allowed six weeks after surgery.

Hormones

Most everyone is familiar with the two principal categories of sex hormones: Estrogen and Testosterone. In fact there is a whole range of different specific hormones which are lumped into these two broad categories.

Hormones are very powerful, natural drugs. They strongly affect both mind and body. In concentrations too low, they can allow diseases to flourish, such as osteopleurosis. In concentrations too high, they can open the door to other maladies, such as blood clots and cancer. At normal levels, hormones determine our secondary sexual characteristics, such as breasts and beards as well as fat distribution and muscle mass.

Mentally, hormones affect our intellect by making us more capable in the external or internal worlds. They also adjust out feelings, causing us to be more aggressive or submissive, more reasonable or emotional.

Certainly, any drug capable of all this is not to be taken lightly. That is why it is extremely important to use hormones only under the care and direction of a qualified specialist. Unfortunately, hormonal issues have historically been considered part of Women's Medicine, which has been traditionally ignored. So, although more and more studies are being done in this area today, there is not the wealth of information available for male medical issues of the same caliber.

For example, very little is known about the affects of different kinds of estrogens such as Estrone or Estinyl, on the mind. From personal experience, I have found that using only one of these hormones alone is not sufficient. Both are present in the female body. Estinyl is originally created, and then breaks down into a number of other hormones in the blood stream, including Estrone.

Estrone tends to make one feel more gentle, more graceful and feminine (regardless of how one may actually appear to others!) Estinyl causes one to look more toward external issue than internal ones. So, with Estrone alone, one becomes passive and internalized, often leading to depression or a lack of ability to accomplish real world tasks. But Estinyl alone makes one less feminine in thinking and at a male level of external assertiveness and rational thinking.

For me, after trying many levels and balances between these two, I found that an even balance between the hormones made me feel feminine as a person, yet motivated to accomplish. In addition, this balance allows me to have access to strong emotions, spontaneously when events warrant, but also to be reasonable in business or practical situations. This balance will not necessarily be true for anyone else, as the effects of hormones vary greatly from individual to individual.

Physically, I have found that Estrone alone slows body hair growth, softens skin, and adds a thin layer of fat all over the body. But it also makes one more sensitive to cold, lowers the metabolic rate, and robs one of energy. In contrast, Estinyl alone creates a higher level of musculature, hardens body lines, removes fat, and raises the metabolism, often making one feel hot when others are comfortable.

Once again, by balancing the two, a good physical compromise is reached, where there is enough muscle to feel well toned, but enough fat to soften the lines. One has a resistance to both cold and heat. Metabolic rate centers at a good, athletic level.

Of course, most people interested in hormones want to know:

Can hormones grow breasts?

Yes, but hardly ever as large as a normal woman. Usually the results end up at about an "A" cup, though if you are fat, you will get more apparent growth because the fat is redistributed to the breasts.

Can hormones grow beards?

Yes, for female to male transsexuals, beard growth is an immediate effect. Unfortunately, a long term effect is male pattern baldness!

Can hormones change the voice?

Yes and no. For female to male transsexuals, the voice will lower to normal male levels as the voice box or Adam's Apple increases in size. For male to female transsexuals, the voice must be altered, either by surgery or by a special technique in which one learns a new pattern of vocal chord muscle control, which is covered elsewhere in this book.

Can hormones change one's sex?

No. A penis or vagina will remain even with hormone therapy, although the penis may diminish somewhat in size, and the clitoris may enlarge significantly. The physical effects of hormones are primarily in the secondary sexual characteristics. Some of these effects are almost immediate, occurring a week to ten days after starting hormones. Other effects, such as muscle redistribution, continue for years.

There is a third kind or hormone with very special effects: Progesterone. Progesterone is the hormone associated with menstruation and pregnancy. In pre-menopausal women, it ranges from being almost absent from the system during the middle of a cycle to being the predominant hormone just before ovulation. Progesterone is what principally causes premenstrual syndrome (PMS). It also has many physical effects.

For a number of years, women undergoing hormone replacement therapy (HRT) have taken a combination of Estrogen and Progesterone to mimic the natural cycles of menstruation. In addition, it is thought that Progesterone helps reduce the elevated risk of uterine cancer often associated with HRT involving Estrogen.

The most commonly prescribed Progesterone is a synthetic hormone which is similar, though not identical, that which naturally occurs in a woman's body. For years, women on this therapy suffered leg cramps, shortness of breath, difficulty in sleeping, and many other serious and minor maladies before anyone thought to attribute these effects to the synthetic Progesterone.

Lately, several studies have revealed that the synthetic variety is indeed the culprit of these problems. The solution is to use natural Progesterone instead, which occurs in such organic sources as Mexican wild yams. One can get these supplements from most health food stores, but the quality and concentration of the Progesterone content varies widely. I have chosen, for the time being, to avoid using them altogether, and so far have suffered no noticeable ill effects.

Recently in the news is some disturbing information about Premarin. While Estinyl is also synthetic (though apparently without serious side effects), Premarin is a natural hormone. It is purified from the urine of pregnant mares, hence it's name: PREgnantMAReuRINe.

The problem is, that to get the urine, the mare are kept constantly pregnant, then locked into small stalls an attached to machines much like dairy cows. For most of each year, they remain confined, often in the dark, acting as living factories without any kind of normal life. For a few brief weeks a year, they are let out to pasture so they can become pregnant again.

Some women have boycotted Premarin until more humane methods are implemented. But, since a Premarin/Estinyl mix is essential to a well balanced life, one must weigh the moral implications against ones personal needs and arrive at a decision for oneself.

In other areas, the whole notion of HRT is being questioned as a plot against women. Recognizing the tendency of post-menopausal women to be more assertive, and considering the fact that menopause is a natural occurrence, some women's groups are speaking out against the whole concept, branding it as an attempt to keep women docile and rob us of our elder wise women. Again, one must make this assessment at a personal level, rather than simply going with a crowd in either camp or trying to impose either point of view on everyone.

Requirements for Surgery

There are several reputable sex reassignment surgeons in the world today, and none of them will perform the procedure without sufficient proof that an individual has met the requirements. These requirements are not law, but are based on a set of Guidelines originally proposed by a Dr. Harry Benjamin.

As applied today, these guidelines require that a person seeking SRS must meet the following specifications:

  1. Live for at least one year full-time in the new gender role (called Real Life Training or RLT)

  2. Engage in hormone therapy for at least one year (which can be simultaneous with the full-time experience)

  3. Gain the recommendation of a psychologist or therapist after an appropriate series of sessions.

  4. Gain a recommendation of a psychiatrist that surgery is not contrary to the mental health of the patient.

When all these qualifications have been met, each surgeon also requires an HIV test to read negative (which they have performed at their facilities) and a personal interview so that they may verify your mental and physical condition personally.

These guidelines are not arbitrary, yet often seem so to those who are so motivated and sure of their feelings. But the surgery is not the big issue in the long run. The real issue is the kind of life you will have to lead afterward. If you were to have surgery before RLT only to discover that you really hated the new role, well that would be a life disaster.

On the other hand, it should be kept in mind that even if one were to have surgery, the option always remains to continue to live in the original role, since exposing one's genitals publicly can usually be avoided, therefore no one would have to know. In fact, I have met one such person who felt a deep personal need to change his physical sex, while continuing to live in the old role. For him, it works just fine.

Digging Deeper

Having briefly outlined the basics, it is time to look deeper into our subject. What follows is a series of essays regarding all aspects of sex change and gender identity. Some will cover the material already presented in greater detail. Others will explore whole new topics ranging from the conceptual to the practical. Still others will provide personal commentaries written by those who have taken this journey themselves.

There are those of you reading this book who are simply interested in the subject of sex change, but have no desire to follow that path yourself. There are others who are seriously contemplating this course, or have perhaps already started down it. As we begin to dig deeper into the subject, the material presented will hold a different meaning for each of you.

For those who are simply interested, you will find a much wider variety of concerns than you have likely imagined. For those who are faced with this path, you will find these essays both a road map and a recipe book.

To help guide you to the specific areas in which you are interested, the remainder of this book has been divided into three principal sections, followed a series of questions and answers.

Section One deals with practical issues regarding transition, surgery, and post op living. It includes essays on developing a female voice, hormone use, information provided by the most noted surgeons, discussions of legal rights and concerns in the workplace.

Section Two explores personal issues through the stories of those who have taken this journey themselves, related in their own words.

Section Three examines social ramifications of sex change, as well as providing useful information for dealing with situations such as harassment or how to tell one's parents.

The Questions and Answers come both from those in the transgender community and those who have stumbled across it.

You can purchase the complete 194 page book for only $19.95!

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