This guide is aimed primarily at people who are not themselves transgendered, but have an interest in the area of gender confusion. This may be because they are a partner, friend, parent or child of a transgendered person, a caring professional or just interested or curious. It may also be of interest if you are yourself unsure of your own gender feelings. It does not attempt to be the 'be all and end all' of explanations, and although much of the following is generally agreed among professionals concerned with gender confusion, all opinions expressed are my own and should be treated as such. You may find some of my theories controversial. If they make you think twice, then they’ve served their purpose. I have tried to avoid technical language, terms and abbreviations wherever possible, but if there is anything you don't understand please contact me. I will also be happy to answer any questions that you may have, be they general or specific, to the best of my ability.
Most of this paper concerns male to female transgendered people, but remember that this is not just a one-way condition.

Why would any man in his right mind want to dress in women's clothes?
Why do I hate the person I see in the mirror?
Why would any man want to BE a woman?
Why do I hate my body?
Lots of questions, but is there an answer? Oh dear, there's another question.
Well the answer is quite simple, as all answers ultimately are. The only problem is that no one knows for sure just what it is. There are many theories and even a couple of very likely explanations, but no guaranteed answers. Before tackling these, let's just add one more question that I can answer.
What's the difference between a transvestite, a transsexual person and an intersex person or is there no difference?

Transvestism. A transvestite (TV or cross-dresser) is someone who gets enjoyment from dressing in the clothes normally associated with the opposite sex. It may be merely underwear, full clothing, or include makeup, wigs, jewellery and perfume. It is virtually entirely restricted to men. It does affect women but this is extremely rare. It is quite likely that this disparity is due to the far greater freedom that women have in dress and fashion. In the days before it was socially acceptable for women to wear trousers, although still rare, it was more common. Let's just try to explain male to female (MtoF) transvestism.

What do they get from it? If you ask a hundred men the prime reason for their cross-dressing, the vast majority would say that it enables them to relax and get away from the stresses of modern life. A number would say that they get sexual satisfaction from cross-dressing, and for some it is a combination of the two. The problem with the use of cross-dressing to obtain sexual satisfaction is that it causes further problems. Why? As a man climaxes, whether self-induced by masturbation or in a gay or male-female relationship, the male hormones take over the mind. This produces a strong ‘maleness’, which in turn produces a huge feeling of guilt and distaste to the transsexual about the female clothes that he is now wearing. This totally destroys all the gains that have been made from the relaxation gained by the initial dressing. The feeling of 'wrongness' can be extreme to say the least. In the right circumstances, cross-dressing can be a remarkable stress reliever.

How many men does it affect? It is now commonly believed that as many as one in fifteen men have transvestite tendencies.

When does it start? It’s probably at or before birth. It is generally recognised by the sufferer between the ages of 4 and 12.

Can a transvestite be cured? Many transvestites will deny their feelings and go through periods of rejection where they throw away their clothes. This won’t get rid of the problem. The feelings, however far repressed, will return. I'm sorry, but transvestism is for life.
Is it Illegal? In the UK no. There is no law that forces a person to wear particular clothes. The only offence that a cross-dressed person can be arrested for is ‘Behaving in a manner likely to cause or incite a breach of the peace’.

Transsexuality: A transsexual person (TS) is someone who wishes to change the physical sex into which they were born. Note the fact that although the word transvestite is a noun, transsexual is an adjective. A person can be transsexual, but not A transsexual. That is like calling a black person A black. Transsexuality is a recognised clinical condition, legally now classed as a serious illness. It is more properly called Gender Dysphoria (or unease with, and dislike of your own physical sex) or Gender Identity Disorder (GID). Transsexuality affects both sexes, but is again more common amongst men. If not tackled, it causes deep depressions and is a frighteningly common cause of suicide. It could with some considerable justification be said that if ignored it is a fatal condition. It is quite possible for transsexual people to conceal the truth, even from themselves, for many years. It will come out eventually, believe me. I failed to admit my true position for almost 50 years.

How many men does it affect?  There are some 6,000 post operative transsexual people in the UK of which around 4,500 are T2F (Trans to Female) and some 1,500 T2M (Trans to Male). If you add to that the estimated 10,000 transsexual people who have not yet completed transition and the probable 15,000 to 17,000 who are still fighting and denying their true status then the figures become more realistic, 1 in 1250 for T2F and 1 in 3750 for T2M. Most transsexual people consider themselves; quite correctly; to have been born transgendered and therefore the more commonly used terms of M2F and F2M are perhaps nowadays a little ‘politically incorrect’.

What options are there? A transsexual person does not want to become female/male, a transsexual person needs to become female/male. It is not possible to change the brain, but it is very possible to alter the body. No TS can, at present, ever be a complete woman/man, but the physical appearance can be altered enough to allow them to live happily in the role which their minds see as natural. Perhaps with the recent success of ovary transplants and other medical advances, this is a situation that may be different in the future. A transsexual person has no choice. I have often been told that I am very courageous to go through transition. I am not brave and neither is anyone else who is truly transsexual. We have no choice. Is it brave to run from a burning building?

How do they fight the condition? As I’ve said previously, transsexual people, particularly M2F, will fight the condition, often for many years, before finally admitting it to themselves. The standard approach is to ‘prove’ to themselves that they are ‘men’. Many enter the services, frequently the most macho units such as the Paras or SAS. They will often marry and have children (a disaster waiting to happen). Sometimes they will allow themselves to believe that they are transvestites, after all, that’s controllable, but they will tend to give themselves away. They will be extremely depressed the day after dressing, whereas transvestites will often retain some of the ‘release’ they gained the previous day and will be happy to be back in their normal male selves. Or perhaps they will call themselves transgendered, refusing to use the terms transvestite or cross-dresser.

Can a transsexual person get treatment on the (National Health Service) NHS in the UK? Only a short while age I would have answered NO in most cases. It was entirely dependent upon the area in which you lived. I believe that this came from a total lack of understanding by the medical profession of the implications of transsexuality and the effect it can have upon both the sufferer and those close to them. It is one of the most likely things to prompt suicide. I know, I have seriously attempted it myself, and it is only due to the love that exists between my wife and myself that I am alive today.
Surely this should have some bearing on whether it warrants NHS treatment; it is after all potentially life threatening.
However since the success in the courts against the NorthWest Lancashire health authority, transsexuality has been officially recognised as a serious illness. Illness is not in my opinion truly accurate. It is actually a condition that we are born with.
Serious it most definitely is.
On the negative side, NHS treatment is old-fashioned and very, very slow. One girl was recently told she would have to wait 15 years for surgery on the NHS. Fortunately the immense negative publicity against the authority that this attracted caused them to alter their minds about the timescale. Help given by GP’s is variable to say the least even in the same practice. I personally was told by my GP that “We don’t fund transsexuals” (note the use of transsexual as a noun!). He also admitted that he knew nothing about the condition. He clearly didn’t want to know anything either. Needless to say I changed my GP. My current GP has readily given me referrals for speech therapy and psychotherapy yet refused to allow me NHS prescriptions for seven months. The NHS does not have a good track record with transsexual people. In the 70’s they were using aversion therapy and producing a 0% success rate and a 30% suicide rate. I myself was treated to two years of totally useless and very strange group therapy, which was suddenly stopped without warning or any offer of further help.

What about private treatment? That is more readily available and is a faster path to transition, but at a cost.

What treatment is required for M2F transsexual people? There are a number of areas where treatment is necessary, although not every case is the same.
Hormone therapy: The introduction of the hormones Oestrogen and Progesterone, and normally three months later the introduction of Anti-Androgens which stop the body producing Testosterone (chemical castration).
Electrolysis: Obviously this is a vital part of transition. The permanent removal of facial hair is essential. Body hair; on the other hand can be controlled by waxing, shaving.
Psychotherapy: As I’ve said previously this is a time of huge stresses and counselling or psychotherapy is an essential constituent of the treatment for most people.
Speech Therapy: Some people are satisfied with a self-modified voice, but if they wish to live successfully as women, it is vital that their voice is modified quite dramatically. Only supervised speech therapy and lots of practice can achieve this.
Deportment: Despite there feelings, some people have great difficulty producing believable female body language. This should be included in most cases.
Facial Reconstruction: The main area where this can be important is in the shaving of the Adams Apple although other surgery such as nose and chin reshaping are common.
Breast Implants: The use of female hormones promotes breast growth, but in some cases this is very minimal. For these people breast implants are important.
Real Life Test (rlt): This is essential prior to surgery. It entails the person living in their chosen gender role for a period of time. Frequently 2 years under the NHS or more likely 1 year if treatment is private. The person has to prove that they can function in their new role, hold down a job (paid or voluntary work) and have a ‘normal’ social life. The idea is to weed out anyone who just can’t cope with the stresses. The hardest part here is holding down a job. Prejudices in the workplace often result in transsexual people being fired for no other reason than that they suffer from gender dysphoria.

What is the cost? Obviously these vary dramatically and not every M2F transsexual person will require such items as breast implants or wigs, but the figures below give you some idea of the cost. It’s not perhaps a huge amount for the NHS when compared to a lifetime of psychiatric treatment, but it’s a lot of money for an individual. Being somewhat cynical, I sometimes think that the NHS works on the basis that the ‘lifetime’ psychiatric treatment is very likely to be ‘short term’.

Electrolysis 100 to 300 hours at £20 = £2,000 - £6,000
Hormones £500 - £2000 dependant on time before GRS.
2 Wigs £100 - £1500
Speech Therapy 25 hours at £60 hour = £1,500
Thyroid Chondroplasty (shaving of the Adams Apple) £1,500

Breast Implants £3,000

Gender Reassignment Surgery M2F £8,000 - £10,000
F2M is far more expensive and far more dangerous and difficult.
New Wardrobe of clothes £?????
A total cost of around £20,000!
Having surgery abroad can make considerable savings.

How successful is Gender Reassignment Surgery? Current estimates are that the long-term success rate is up to 98%.

Intersex: What on earth is that? It is a condition whereby a child is born neither completely physically male nor completely physically female. At it's extreme it is hermaphrodism, but more commonly involves some male and some female physical characteristics and the possession of some of the genitalia of both sexes. Intersex children used to be rare, perhaps one in a hundred thousand, but in the UK today the birth rate is according to some sources down to a frightening one in a thousand. Why this dramatic increase? Two of the possible causes are environmental, and the fact that children survive today who years ago would have died, or even been put to death because of their abnormalities. Intersex is not limited to Humans. It is on the increase among Reptiles and has even been found recently in Polar Bears and Beavers. Intersex must be tackled early in life and although every case is different, the normal route and that which is most easily achieved is toward the natural sex, female.

Partners, Family and Friends: Perhaps the only thing that is worse than discovering that you are transgendered is discovering that your partner is transgendered. Suddenly you are presented with the fact that the man you love and perhaps married likes to wear your undies, or even worse, has discovered his need to be a woman.
Let's discuss the transvestite first. Your partner is still the same man you first met; in fact it's quite probable that it was his more gentle and understanding nature that drew you to him in the first place. You clearly have a number of fears. You now realise that he has been lying to you. The man you love and trust hasn't told you the truth. Just think for a minute why this might be? Nine times out of ten it's the same reason - He is scared of you. And why is he afraid? Because he loves you as much as you love him. It is not right to mislead a partner, but this is one area where it frequently happens. It's a reason, but it's no excuse.  Remember that he still needs the stress relief that he gets from cross-dressing and if he can’t carry on with your acceptance, he will carry on without it.

You are unlikely to discover that your partner is transsexual by accident. This is something that cannot be concealed for long. Once a transsexual person has admitted the fact to himself (and it is quite possible that he will have concealed it from himself for years) he is likely to feel compelled to tell you. This will either be because he wishes to be out of the relationship, or because he desperately wishes it to continue. Either way, concealing it from you will make him depressed to an extent that, if not acted upon, can easily lead to suicide. The shock of this revelation is likely to cause you great pain. You will almost certainly display all the signs of bereavement. But it is worse than that. For the man you love is not just dying, he is deliberately destroying himself. The fact that a loving female companion may replace him is no consolation to you. After all, you are heterosexual and married a man. Had you wanted a female partner, you would not be with him in the first place. It may seem like an unsolvable problem. If he truly loves you then it is certainly a 'no win' situation. He is likely to fight his need which will only make him more depressed, which will in turn make you more depressed, which will make him more depressed. And so it goes on.
There is only one answer as far as I'm aware, and that is to accept the inevitable. If your love is greater than sex, then there is a chance that your relationship will, although drastically altered, survive. Most partnerships where one member discovers their transsexuality do, however, break up. Is your love deep enough to last through such an Earth shattering change? The older you are when the admission is made, the more chance you have of survival, but it is still pretty unlikely. About 95% of couples do split up.

Family and friends go through a similar bereavement process. The transsexual person will certainly loose some of the people who are the most important to them. They will basically just not be able to accept the change even though it is the only thing that will allow the transsexual person to survive. Transsexuality destroys families.

Some men do continue to conceal their transsexualism from their partners and will even embark on hormone treatment without their knowledge. Personally, I cannot understand the logic here. Do they think that their partners are stupid and won't notice their developing breasts, altering shapes etc?

Non-Transsexuals: I had difficulty in thinking up a heading for this section, but it basically asks the question, Would a man wish to change sex for any reason other than transsexuality? What follows is purely my own opinion. I believe that there are a number of reasons why a man might want to take this path.
Multiple Personality Disorder: If a dominant personality is female a man may be tempted down this path. He would be unlikely to tolerate the adverse effects of hormone therapy for long.
Failed Male: A man who feels that he has failed miserably as a man may seek to find an easier life as a female. He will soon discover that there is nothing easy about transition and is unlikely to complete the course.
Unaccepting Gay: A man, whose sexuality is homosexual, but through upbringing or other factors refuses to accept this fact. He is quite likely to take this all the way through to Gender Reassignment Surgery (GRS) when his inherent homosexuality will suddenly become heterosexuality and therefore acceptable.

Summary: I hope that I have been able to explain the basic differences between transvestism, transsexuality and Intersex. There are, of course, many similarities and it is not always easy to know for sure which category a person falls into.
After all, Intersex is gender confusion on a physical level, but then surely so is transsexuality. Just because the brain can't be seen from the outside, doesn't mean that the differences are not physical.

Having explained these three major types of transgenderism; and I have deliberately limited myself to these three as they are the ones I know most about; perhaps I should expel a couple of myths and then go on to try and answer the questions at the head of this article.

Popular misconceptions: He wears women's clothes, so he must be gay! This is very far from the truth. In fact transvestites are actually less likely to be gay than are non-transvestites. Remember; transvestites and transsexual people are as they are because of their dislike of their own sex. It is true that many MtoF transsexual people will wish to develop a relationship with men after, or even before, undergoing surgery, but this is often due to the massive doses of female hormones received and is hardly the same thing as homosexuality as they see themselves as women. Having said this, a large percentage of TV's and TS's, particularly those who gain sexual satisfaction from their cross-dressing, will indulge in fantasies which involve relationships with people of their own sex. Given the opportunity to turn these fantasies to reality, most would back out.

He is a pervert! Again not true. As previously explained transgenderism is a recognised clinical condition. You might just as well say that deaf people are perverts, or red haired people are perverts. They are in the minority for sure, but they are just another of the many differences that makes the human race so exciting and amazing. A transgendered person is no more likely to abuse your children or go off with another woman/man, than anybody else.

How much does the general public know of transgenderism? Well, perhaps a little more than they did a few years ago. The documentaries on the intersexual girl, Joella and ‘Paddington Green’ have presented accurate images. But … ask a hundred members of the general public to name a transvestite or transsexual person. How many will reply Lilly Savage! The states above must never be confused with drag queens, who are invariably gay, and do not have the same feelings as any of the transgendered groups. There is still very little knowledge available. It is a sad reflection on the medical profession, but I have yet to meet a GP who knows anything about the condition.
 

Theories: Oh well, that's the easy bit done. Now for some of the theories and my personal opinion as to why people are transgendered.

Genetic:
Theory: Transgenderism is inherited. If you are transgendered, then your offspring are more likely to be transgendered.
Argument for: It was believed a while ago that a 'Gay' gene had been found and there are rumours that a 'TG' gene has also been discovered.
Argument against: TV's and TS's have difficulty in both making and retaining a relationship with members of the 'opposite' sex for many reasons, shyness, guilt, embarrassment, fear of discovery to name but a few. It is therefore less likely that they will have offspring and one would expect the condition to gradually die out. It is actually on the increase.

Environmental:
Theory: Changes in the atmosphere due to pollution, global warming etc., have upset the balance and caused an inherent condition to become more common.
Argument for: The incidence of Intersex is on a mind-blowing increase that coincides with changes in the atmosphere in the last fifty years. Transgenderism is also on a sharp increase. Female hormones are used widely in food production and this increases both the amount that we take into our bodies through food and drink, and the amount in the atmosphere which we breath in.
Argument against: It's hard to argue against this theory, as there is physical proof, particularly in cases of Intersex.
As far as transgenderism is concerned, is it on the increase? Is it not just a case of it coming out of the closet and becoming acceptable, like homosexuality has done over the last twenty or so years?

Decline in Moral Standards:
Theory: The decline in moral standards has allowed 'perversions and fetishes' to become more acceptable.
Argument for: Things that were totally taboo 50 years ago are now standard front-page fodder for the tabloid press.
There is far too much sex and violence on television, in films and in the media, and this makes the unacceptable, acceptable.
Argument against: There have always been transgendered people, and it is often more acceptable in countries where moral standards are high than it is in countries where they are low.

Modern Stress Levels:
Theory: Stress in today's society is at an all-time high and people need an escape.
Argument for: The stereotype male role is to be a provider. To achieve this he must be aggressive and dominant.
A way of escaping this stress, be it only temporarily, is to adopt the stereotype female role of subservience and gentleness.
One of the countries where transvestism is most common is the ‘macho’ land of Australia.
A country where it is relatively rare is the ‘anything-goes’ country Sweden.
Argument against: What about FtoM transvestites and transsexual people? Are they looking for more stress? Wasn't the hunter/gatherer life style of our distant ancestors just as stressful, if not more so? What 'male type' stresses does a five-year-old have? (The age when most TV's and TS's realise that they are different from the 'normal').

Brain Differences:
Theory: The brains of TV's and TS's are different from non-transgendered people.
Argument for: The brains of men and women are actually very different in the way they work. It is now thought that transsexual brains are also different in makeup to those of 'normal' men. They are not the same as those of females, but do have many similarities. They are in effect somewhere between the two. To say that transsexual people have the brain of women and the body of men would be wrong, but it is not a million miles from the truth. Recent research shows a marked difference between the hypothalamus of M2F transsexual people and other males. They are much more like the hypothalamus of women. Those of gay and heterosexual men are identical.
Argument against: There is very little argument against this theory, as post mortems have backed it up. There have, however, only been a few such post-mortems and I do not know whether they were carried out on pre or postoperative TS's.

Brain Wiring:
Theory: The brains of transsexual people are ‘wired up’ differently to ‘normal’ men. This may be connected with the theory above but is subtly different.
Argument for: It is quite amazing how many transsexual people work in the computer industry, particularly on the creative side. At least 14 of the world’s top computer games designers are M2F transsexual people. Is there something about the brain that makes these particularly visualistic people also transsexuals? Is it the female element of their brain that allows their visualisation and creativity?
Argument against: This is my theory and it is therefore up to you to put up arguments against it.

Female is the Natural State:
Theory: The male sex was a mistake by nature that it is now beginning to correct. An evolutionary step is under way which will mean that the male sex in humans will be a thing of the past before 2200. I believe that evolution happens in sudden jumps (over a couple of hundred years) rather than gradual changes over millennia. OK, it’s ‘off the wall’ and I don’t really expect anyone to agree with me.
Argument for: There is really no need for human males in the world today. Science can maintain the human race without the need for males. The 'default' sex is always female but the sex of a child is not determined until a couple of weeks after conception. The likely sex is dependant upon many factors such as hormonal balance in the mother, ambient temperature (a two degree temperature rise has been proved to make all alligators born to be female), and many others. Nature has a way of performing corrections to ensure that the Earth survives despite what we do to try and destroy it. Is it working towards eliminating the aggressive, destructive male from the human race?
Argument against: This is my theory and it is therefore up to you to put up arguments against it.

Unborn Twin:
Theory: It is now well known that many pregnancies start off as twins, but that one twin survives only for a very brief time.
Argument for: If a 'twin' fails to survive, would not the 'soul' seek refuge? Perhaps it is easy to find refuge in the other twin's brain?
Argument against: This is another of my theories so it is up to you to put up arguments against it.

What do I believe? I'm sure that it is a combination of a number of the above theories together with others as yet unformulated. I do believe that the natural state is Female. It has been thought so for millennia, Mother nature, the Earth Mother etc., but I also feel that changes in climate, pollution, the ability to keep children alive who would have died in the past and many other factors come into play. The crux of the matter is that it exists. When it occurs, it is always a severe problem or even disability for both the sufferers, their families and their loved ones, but it can also be something that brings joy, gentleness and calmness to a frightening world.
I hope that what I have written here has been both informative and perhaps provoked some deeper thoughts; I'm sure that you will have found some of it a bit controversial. I have written it honestly to the best of my ability. I will be happy to enter into any discussions or answer any questions that you may have.

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Emma Martin is a qualified counsellor and hypnotherapist specialising in support for the transgendered community and is membership secretary of the National Association of Counsellors, Hypnotherapists and Psychotherapists (NACHP).
She is currently writing her first book ‘Penny For Your Thoughts’ based on her own life story merged with the ‘past life’ experiences which were one of the main events that helped her finally admit the truth about her condition. She is also Chief Executive of Diamond Edge Enterprise Systems, a software company specialising in computer systems for small businesses.
She can be contacted by phone on 01353-698397 or by e-mail emma@cwcom.net

This guide can be freely copied on condition that copyright is acknowledged, and that this restriction is included.
© Emma Michelle Martin and Elevated Therapy1999/2000 et al.