Transsexual Analysis

Nature vs nurture: humans are diverse  |   Diversity in society  |   Woman in a man's body?  |   Trauma can shape us  |   Emasculation trauma

Trauma and sexuality  |   Perversion or lifestyle choice?  |   How to treat?  |   Superficiality  |   Problems and reversion  |   In summary

10. Problems and reversion

So what of those who make the change and who later decide it was a terrible mistake?

Testimonies provided by these people often appear to revolve around discrimination and stigma. In one account in the media about a decade ago a transsexual said she regretted making the change due to her heartbreak at being rejected by her children, which also meant she could not keep in touch with her grandchildren.

Discrimination and the importance of support

While this is a terribly sad case, there was no evidence of misdiagnosis (in an admittedly superficial news article), only rejection. However, this does demonstrate the importance of support.

Changing sex, while generally thought to be a lonely path (and it may well be that at times), is far from being a solitary enterprise. The changes affect not only family, friends and workmates, but also involve to some extent every passerby and acquaintance who may "pick" her.

It is too easy to be glib and for a transsexual to say, "Well, that's not my problem. It's everyone else's problem". The trouble is that others' problems can become our problems because we are social beings.

There is an inevitable sense of trade-off with sex changes. While a person may gain by relieving internal tensions and emotional turmoil, they may also lose relationships and, quite simply, any peace in their lives. What they gain in inner peace may be offset by external turmoil. This is often the case during early transition, at least. Transitioning transsexuals need to be able to cope with the pitfalls of celebrity status - minus the money, glamour and prestige. Some revel in the attention. Others find it repellent.

To quote a former transsexual, when asked why he changed back, he answered simply, "I kept getting sprung". Again, he had no issue with the change itself, only with the discrimination.

Going stealth

The question is, how can anyone gain inner peace - generally the stated wish of any transsexual applicant - when the world around her is hostile?

This is where the "safe haven" of supportive family and friends can make so much difference. An exceptional sense of self assurance is another "haven". However this, by definition, is the exception. The continued stigmatization of transsexuals is the reason why so many "go stealth", hiding their transsexualism from some or all - if they are able.

Nonetheless, carefully hiding one's transsexuality carries its own problems; the need to be evasive when speaking of the past or when "women's issues"are raised in conversation with other women may impede the building of friendships or intimacy. It can also seriously limit the degree of intimacy in romantic situations. Transwomen who attempt to lead a normal woman's life without revelation may also be left wondering if their friends or lovers would still love them if they knew about their background.

Reversions after a long period of time

Some who make the change come to regret it, even after many years after transition. Transsexuals suffering from narcissistic personality disorder may be attractive as women in earlier years and enjoy the attention of men, in stark contrast with the homophobic abuse they may have experienced as youths. However, beauty fades in time, and once it is gone, they may feel that there is no longer any point in remaining female and that s/he has a better chance of being attractive as a male, especially if she has not had the operation.

One case in the news described a transsexual who reverted to the male role after 10 years of feminine life, claiming that s/he was misdiagnosed. His/her current treating psychiatrist publicly stated that his/her issues related to a lack of proper male role modeling.

On the face of it, this explanation sounds too simplistic to be credible. If a lack of male role modeling was the reason for the person's gender dysphoria, then why is it that so many males lacking accessible or desirable male role models have no issues with their gender? If lack of male role modeling creates transsexuals then, in the current environment of marriage breakdown, one would expect transsexualism to be rife, which of course is not the case.

However, inappropriate male role models may engender a feelings of inadequacy as a male in some boys, perhaps feeling unable to live up to masculine expectations, which could create emasculation trauma with resultant autogynephilia. After an extended period of outwardly successful life as a transwoman, it seems quite probable that a person may well have had good reason to doubt his masculinity. After all, only a small percentage of males have sufficient physical and emotional femininity to be capable of "passing" regularly over a sustained period.

There is clearly a danger of reversion in Type 3 transsexuals (as per the table in Chapter 9) - physically feminine and psychologically masculine - who were traumatized by their physical lack of masculinity and resultant bullying. again, therapists may be seduced by the fetching physical femininity of such individuals into glossing over their masculine mentality.


So there is a need for flexibility in thinking from both the patient and the therapist; there are not just two options for gender-crossed individuals. If the patient lacks that flexibility then the therapist must help him/her to see that there are a number of options available (as per Chapter 7).

To be fair, in the past these various options were less known, and the stigma surrounding options such as part-time transgenderism and androgyny was so intense at the time that therapists may have baulked at suggesting them, especially if the patient appeared to be sensitive / reactive to stress.

However, as mentioned earlier, the vast majority of unsuitable sex change candidates quit the process before or during the real life test. Only a small percentage go through the real life test, have surgery, and then have regrets later on.

The number of transsexuals who decide that they changed over in error has been assessed in various studies. The results range from 2 - 13%, depending on the study. The former is more likely a more credible figure. Importantly, many of those who expressed regret at the change experienced unsatisfactory surgical outcomes.

In this light, risk management principles (as described in Chapter 8) should be applied to the assessment process. It makes little sense to risk inflicting major harm (depression, self-mutilation or suicide) to between 87% and 98% of "satisfied customers" in order to protect the interests of the remaining 2% to 13%.

At some point, would-be transsexuals without major disorders must take at least some level of personal responsibility for their actions and take steps towards their own welfare. Once psychopathology has been ruled out, there is only so much a psychiatrist can do. While therapists may explore the issues surrounding a patient's stated need to change gender roles, they can only "lead a horse to water", especially now that the Internet provides plenty of information that can help would-be transsexuals to provide the "standard script".

A more enlightening statistic - not currently available - would be the percentage of those who regretted the change who did have successful surgeries and transitions. That is, how many transsexuals who both "pass" and who have adequate width and depth for heterosexual sex, along with full orgasmic ability and no physical pain, have regretted making the change?

Very likely this figure would be extremely low.

Quality of surgery

This raises the issue of success in surgery. Transsexuals need to go into this process with their eyes open [preferably not during the surgery itself - sic]. Gender reassignment surgery is extremely complex so things can easily go wrong. Does the patient have a contingency plan in case the surgery does not work out? Will she feel life is still worthwhile if she cannot enjoy normal sex or experience orgasm? Due to the risks involved, then surgery should not be performed until cognitive therapy is undertaken.

Statements of blind faith masquerading as positive thinking such as, "I refuse to even entertain the possibility" hardly suffice when the stakes are so high. While the mind is capable of affecting our physicality to some extent, one would be hard-pressed to see how a "positive attitude" could significantly affect a surgeon's performance on the day.

So, without a contingency plan, a transsexual whose surgery is less than ideal could leave herself vulnerable to deep, even crippling, disappointment if the surgery is performed badly. This can lead to disillusionment in the entire process, especially if the transsexual had high expectations of a fabulous love life post-op, and may then decide to "throw the baby out with the bathwater" and question the validity of the process per se.

Associated disorders and discrimination

A logical question to ask any transsexual who changes back after an outwardly-successful transition is - will s/he one day have regrets about their reversion as well? Could the reversion itself be the result of an inherent instability, as opposed to unsuitability? Double-reversion can - and does - occur, where the transsexual discontinues hormone treatment and reverts to the male role, only to change back over to the female role later on.

Only time can answer such questions, hence the risk management approach advocated earlier. Reversion should be treated with as much caution as the original change; a sex change is a sex change. Many transsexuals of religious conviction have reverted without proper consideration or professional help, relying on religious cronies' assurances that "God will provide".

Psychiatrists are well aware that some mental illnesses and/or disorders can lead a person to seek a sex change, along with internalized homophobia. It can take considerable analysis to determine whether a disorder has facilitated the desire to change sex, or if disorders are in fact the result of discomfort with the current gender role.

It is also possible that disorders can lead a person who would otherwise benefit from a sex change to blame the sex change for their problems. Few aspects of transsexualism are clear-cut or easy.

Wrapping up

Because of the complex issues surrounding transsexualism, few groups of people are more stigmatized or misunderstood (hence this website).

Few groups experience more human tragedy and heartbreak. Few groups experience such high levels of depression, unemployment and suicide.

And, of course, few psycho-sexual states have caused more confusion and perplexity amongst professionals. This makes the need for compassionate and flexible - as opposed to prejudiced and black-and-white - thinking all the more important in their treatment.

While attitudes within the psychotherapeutic community have greatly improved to this end over the fast few decades, there is a danger that current hyper-conservative and reactive elements within the broader community may undermine those improvements. Therefore the trans and therapist communities need to refine the current approaches to protect the gains made since "the sexual revolution" of the 60s.

As mentioned earlier, the first step to this end is to debunk the myths surrounding transsexualism - the misguided claims of bona fide womanhood as well as the biased and pseudo-scientific validations, invalidations and misguided claims of the "it's not natural" advocates.

This will allow us to review the situation with open eyes and see that, in the end, people have always been diverse and they have always altered their physical realities. It is simply a matter of deciding on the best approach on a case-by-case basis.

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