Most Transgender Individuals Get Surgery | adult skills

Most Transgender Individuals Get Surgery. Throughout our lives we are constantly asked whether we are male or female. Our parents may have asked that question during a sonogram or in the delivery room (depending on the year we were born). Little kids may ask their parents if they see us walking down the street and they can’t make a snap judgment (right or wrong) by themselves based on our hair or clothes or makeup. Every form we ever fill out from entry into kindergarten to college application, from marriage license to driver’s license, and at every doctor’s office we go to, asks us to check a box: M or F.

Most Transgender Individuals Get Surgery
Most Transgender Individuals Get Surgery

For most of us this is an easy question to which no one (ourselves, our parents, our doctors) gives a second thought but for some it can get complicated. The answer to the question, are you male or female, lies in both our biological sex and our gender identity. Biological sex is relatively simple. It is made up of body parts and chromosomes. Under most circumstances a person who has two X chromosomes will also have ovaries, a uterus, a vulva, a vagina, and breasts and will be biologically female.

Most Transgender Individuals Get Surgery | adult skills

A person with XY chromosomes will have a penis and testicles and will be biologically male. In some instances, chromosomal anomalies occur and individuals have other combinations such as XO, XXY, or XYY which affect how their internal and external genitalia develop and appear.

In other cases, people have normal sex chromosomes but something happens during fetal development that means their internal or external genitalia do not develop along a typical male or female route. All of these issues are referred to as disorders of sex development and individuals born with them may be called intersex.

Here we focus on the other element of the answer to the ultimate M/F question — our gender identity, which is a person’s internal sense of being male or female. For most people this internal feeling matches their biological sex but for some it does not. This entry looks at some basic facts and long-held myths about what it means to be transgender.

Gender Expression
As we just mentioned, gender identity is someone’s internal sense of being male, female, or somewhere in between. Gender expression then is how an individual chooses to announce this identity to the world. Society has relatively rigid rules for how males and females should be different even as small children. These rules apply to outward appearance, speech patterns, and behaviors.

Most Transgender Individuals Get Surgery | adult skills

Girls are supposed to dress in pink, be pretty and shy, and play with dolls. Boys should gravitate towards blue, be rough and outgoing, and prefer trucks. We all notice when a young girl dresses in “boy’s” clothing and even more so when a young boy wants to dress “like a girl.” In fact, gender expression is the one aspect of gender that others can see automatically (biological sex is hidden under clothes and gender identity is a feeling).

Most people conform to expected gender expression often without really thinking about it. The cultural scripts that tell us how to behave are so ingrained in our society that it is often hard to discern what is a conscious decision to do what society says — does the 3-year-old girl want to wear a dress out of some natural drive to seem female, as a result of the images and influences she has been exposed to in her young life, or is it out of a desire to please adults around her who will undoubtedly tell her how pretty she looks?

Teich (2013) points out that we really don’t let our children choose their gender expression, at least not when they are young. We dress babies, for example, so that the world can know instantly whether these tiny beings with unformed facial features and bald heads are male or female.

As people grow, and become more aware of their own internal sense of gender, they may be more likely to choose how they want to express it to the world. Gender nonconformity is a generalized term for people who do not express themselves in the typical way that they “should” based on their biological sex. The man who wears makeup and high heels or the woman who cuts her hair short and wears tailored men’s suits are not conforming to society’s views of gender. This does not mean, however, that these individuals are transgender.

Most Transgender Individuals Get Surgery | adult skills

They may be completely comfortable with their biological sex but simply prefer the outward appearance associated with the opposite gender. It’s also worth noting that some people object to our binary system of classifying gender in which people only have two choices — male or female. In general we do not allow for variations that might fall somewhere between the two.

Some have argued that gender belongs on a continuum and people should be allowed to fall at any place between the two points. Individuals who feel they do not identify as either male or female sometimes refer to themselves as genderqueer (National Center for Transgender Equality, 2009). (Given the history of the word queer as a derogatory term for gay people, this is not a term we suggest using to describe anyone unless the person has told you that’s how they identify themself. Still, it is good to know.)

Gender Identity Is Not Sexual Orientation
In years past, people would look at a woman who presented a masculine image and say “Oh, well, she’s clearly a butch lesbian” or see an effeminate man and assume he was gay. This may be the result of cultural misunderstandings about sexual orientation that led people to believe that because gay men wanted to have sex with men their ultimate goal was to be a woman.

As Teich points out, this is a very heteronormative way of looking at the world — a vision in which feminine women marry masculine men and anything other than that is seen as somehow abnormal (Teich, 2013). Fortunately, as a result of the gay rights movement and the work advocates have done, much of society now has a better understanding of sexual orientation.

An individual’s sexual orientation is not tied to his/her own gender but to the gender of the people to whom he or she is attracted. Individuals who are attracted to someone of the same sex are considered homosexual, individuals attracted to someone of the opposite sex are heterosexual, and individuals who are attracted to either a same-sex or opposite-sex partner are bisexual.

The fact that gender and sexual orientation are different means that a person who was born male but feels female and is attracted to women can identify both as a transwoman and as a lesbian — she is a woman attracted to women. Similarly, the biological female who now lives as a male and is dating a woman would identify as heterosexual (Coleman et al., 1993).

So What Is Transgender?
Transgender is an umbrella term for a person who feels that their gender identity and biological sex do not match. Often when we use this term we are talking about a biological male who has always felt trapped in his body because he feels like a girl or a female who wants to live as a man. These specific examples may also be used as definitions for transsexual, an older term that describes a person who identifies as the opposite gender than the one they were assigned at birth. Though the term is still used, some don’t like it because of the emphasis on sex instead of gender (National Center for Gender Equality, 2009).

There are a myriad of other terms that fall under the umbrella of transgender and more accurately describe some people’s identity. For example, transman, transgender man, female-to-male, or FTM are all terms used to describe someone who was assigned female at birth but has transitioned to male.

Most Transgender Individuals Get Surgery | adult skills

Transwomen, transgender woman, male-to-female, or MTF would all describe the opposite case. (Language is continually evolving but for now the term transman or transwoman is preferred.)

Transitioning refers to the time when a person begins living as the gender with which they identify rather than the gender they were assigned at birth. This often includes changing his/her name; telling family, friends, and coworkers; and changing his/her appearance.

Though some transmen and transwomen may have always had a gender expression that didn’t match their biological sex, during their transition they often take this expression further so that they are not just presenting to the world as feminine, for example, but as a woman (Teich, 2013).

Once a person has transitioned and is living his/her life as the opposite gender to the one assigned at birth, he/she may want to drop all of these labels and just be a man or be a woman. Using male pronouns and referring to a transman in the way you would any other man is part of showing respect.

We also want to mention some terms that sometimes fall under the genre of transgender but may cause confusion. Cross-dressers, for example, are men or women who occasionally dress in the clothing expected of the opposite gender. Cross-dressers generally accept the biological sex they were assigned at birth and have no plans to live as the opposite gender but enjoy dressing that way once in a while. Cross-dressers used to be called transvestites but many think that word is derogatory at this point.

Finally, drag queens and drag kings are performers who dress as the opposite gender as part of their act. Again, most do not have any desire to be or live as the opposite gender but do enjoy the performance of it (National Center for Transgender Equality, 2009).

Transition Does Not Always Mean Surgery
One of the things people are most interested in when they learn that someone is transgender is what’s going on under his or her clothes. We have a fascination with genitals and a curiosity about all that is different so often we can’t help but wonder and even ask. Television host Katie Couric recently raised the ire of the transgender community when she asked transwoman and model Carmen Carrerra whether her “private parts” were different now. Had Carrerra been born a woman, it is unlikely that Couric would have asked about her vagina on national television. But Couric knew her audience’s interest would be piqued and she pressed on, asking the question again, despite her guest’s discomfort (Cooper, 2014).

The truth is that when you meet transgender people you don’t know what steps they have taken to transform their outward appearance or their genitals. The good news is that today there are options to help change bodies to match how transgender people feel. The bad news is that these options are often prohibitively expensive and not covered by insurance.

Most Transgender Individuals Get Surgery | adult skills

Some transgender individuals choose hormone therapy. Those transitioning from male to female have to start by suppressing testosterone because this male hormone is very strong. They can then add estrogen, which is one of the primary sex hormones in women. It is available as a pill or patch.

Transwomen on estrogen therapy can expect some breast growth though it may take a few years and will not result in particularly large breasts. Estrogen also helps redistribute fat in a more feminine pattern so that instead of holding it all in the middle like many men do (think beer belly), it will be distributed to the hips, butt, and thighs.

Though the hormone does reduce the production of body hair, it often doesn’t stop the growth of facial hair. Transwomen may have to use other means such as laser hair removal to get rid of their beards. Estrogen also does not change a woman’s voice — once someone has gone through puberty as a male, the deeper voice is there to stay. Transwomen may choose to work with a voice coach to train themselves to speak in a higher pitch with a more feminine
cadence (Teich, 2013).

Transwomen may also find that estrogen lowers their libidos. Moreover, transwomen who use hormone therapy but choose not to change their genitals will find that estrogen lowers the amount of ejaculate during orgasm and may affect sperm production as well.

For transmen, hormone therapy begins with testosterone which can cause many of the same changes that boys see at puberty: their voices will get lower, they will get more body hair, including facial hair, and their body fat will redistribute into a male pattern. (Speaking of male pattern, they may start to notice typical male baldness too.) Testosterone may also enlarge the clitoris and increase libido. And, notably, it will stop menstruation. Hormone therapy, however, does not typically decrease breast size.

Many transmen and transwomen stop medical interventions at hormone therapy either because they feel this is sufficient for their transition or because they do not want or cannot afford surgery. Those who do choose surgery have a number of options. What was once called a “sex change” operation is now better known as gender reassignment surgery though some prefer the term gender affirming surgery because the purpose isn’t to change a person’s gender but to change his/her body to match it. Whatever you call it, it usually involves more than one surgery and transmen and transwomen can choose which and how many they want.

Most Transgender Individuals Get Surgery | adult skills

For transwomen, the surgeries could include breast augmentation to make the breasts larger, facial feminization surgery to make the face appear more feminine, and a trachea shave to make the Adam’s apple less prominent. Transwomen who choose to have genital surgery may have a vaginoplasty which creates a vagina by turning the penis inside out.

In some procedures, surgeons use the glans (the head of the penis) to create a clitoris which can be successful because this is the most sensitive part of the penis. This is accompanied by an orchiectomy, the removal of the testicles. The scrotal sac is then used to make the labia majora (Teich, 2013).

Transmen have a harder time with genital surgery because while surgeons have become very good at making vaginas out of penises, the reverse is much more difficult. Gender reassignment surgery for transmen often starts with removal of the breasts in a mastectomy. This is sometimes referred to as top surgery and may be the only surgery a transman chooses. Others may also choose to have their internal reproductive organs — the uterus, ovaries, and fallopian tubes — removed (Monstrey et al., 2011).

For those who want to alter their genitals surgically to be more masculine, the first option is a metoidioplasty and is for transmen who have taken testosterone and seen enlargement of their clitoris.

If the clitoris is large enough, the surgeon can free it from the clitoral hood and reroute the urethra through it so it resembles a small penis. The surgeon can then close the vagina, make a scrotal sac out of existing tissues, and put testicle implants in the sac (Teich, 2013).

The other option is a phalloplasty in which the surgeon creates a penis out of skin and tissue from elsewhere in the body, lengthens the urethra, attaches the nerves, and then attaches the new penis in its proper place. Though ideally this is done in one surgery, for many transmen it takes a few surgeries and there is a risk of scarring and loss of sensation. Once sensation has returned to the tip of the penis, which usually takes about a year, the surgeon can implant a penile prosthetic, which can help the man become erect, as well as prosthetic testicles.

Most Transgender Individuals Get Surgery | adult skills

Make Room for Variation
We can’t say for sure what percentage of transpeople have surgery because no statistics exist on how many transpeople there are in the population let alone the choices they make. The truth is that unless you are the loved one, close friend, or partner of a transman or transwoman it shouldn’t really matter what they choose to do.

Everyone is entitled to determine their own gender expression and gender identity and, if this does not match their biological sex, they are entitled to make whatever changes they feel necessary to their appearance, behavior, life, and body. Those around them can seek to know what they have gone through (as long as it comes from a place of empathy and understanding and not just curiosity and voyeurism) but the most important thing is that we respect their choice.

Most Transgender Individuals Get Surgery
Most Transgender Individuals Get Surgery
Most Transgender Individuals Get Surgery

Transgender individuals face huge obstacles in all aspects of their lives when transitioning — social (family and friends who refuse to accept the change), legal (trying to change birth certificates or driver’s licenses can seem impossible in some places), medical (hormones can have side effects and surgeries can be painful), and financial (insurance does not cover many of the medical expenses and some face discrimination on the job and even job loss).

Moreover, transgender individuals also face increased discrimination and violence (Grant et al., 2011). We need to work together to ensure that all people regardless of gender can live free of discrimination and violence. We think that one place to start actually involves stopping — we have to curb our instinct to categorize people and expect or demand that they fit neatly into our categories.

We have to let people choose their own categories, make their own labels, and even decide to have none at all. And we have to stop focusing on (and wondering about) what’s in between somebody’s legs. It’s not really any of our business and most of the time (unless we are planning on getting intimate), it really doesn’t matter.

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