When Sex and Gender Diverge

When Sex and Gender Diverge

Emma Martin
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Gender dysphoria is one of the most misunderstood of all medical conditions. How can a counsellor help a client who comes to them claiming that they have a gender identity problem? Emma Martin discusses the most serious form of gender dysphoria, transsexualism and how so often in the past transsexual people’s lives have been ruined by well-meaning but ill-informed professionals.

Lets start by defining ‘sex’ and `gender’ as used in the transsexual context. Sex is usually taken to signify a person’s physical characteristics such as genitalia, gonads and organs of reproduction, which will typically be consistent with the chromosomes. Gender or gender identity, is defined as a person’s innate psychological identification as male or female.
Where the gender identity experienced is severely incongruent with the other sex characteristics, transsexualism may be said to occur. It is still not entirely clear why some people are born with this condition, but science shows that the likely cause is an unusual hormone environment at critical moments during pregnancy’, such that the baby’s brain and its other sex characteristics develop in different directions.

Research in The Netherlands1 on the brains of transsexual and non-transsexual people has shown that the sex differentiation in the brain into male and female, which occurs throughout the population, is reversed in the case of trans individuals. Therefore the brains of male to female individuals (trans women or MtF) in the study fell within the female rather than the male range.
Following on from this, the work of Frank Kruijver2 and his associates has shown that these differences in size are related to different neurone (nerve cell) numbers in the relevant area, the central sub-division of the stria terminalis (BSTc). The neurone count of trans women (Mtf) fell within the female range whereas that of the one trans man (MtF) examined fell well within the male range.

This research is increasingly understood to indicate that transsexualism arises from a neuro-developmental condition of the brain which induces an innate gender identity that is incongruent with the apparent physical sex. The research was carefully screened to ensure that these differences in brain structure occurred, regardless of sexual orientation, hormone treatment, or hormone variations in association with illness or orchidectomy (removal of the testes).

Gender Dysphoria

Transsexualism is the profound and persistent form of gender dysphoria. Dysphoria is the opposite of euphoria and means an unease or mental discomfort The term ‘gender dysphoria’ therefore may be described as a profound unease with the gender assigned at birth in accordance with the appearance of the genitalia. It is the underlying gender identity that is the one with which a person is comfortable.As long as the physical sex appearance is wrong, so also is the gender role with which the individual will be expected to conform. Perhaps `gender incongruence’ would be a more accurate term.

Treatment involves a ‘transition’ process to align the body’s physical sex characteristics with the gender identity, by the use of hormones and, usually, surgery. People often associate transsexualism with sexuality, that is one’s preference for a male or female partner, yet there is no direct association between the two. Transsexual people can be straight gay or bisexual, just like anyone else.

What can happen though is that a person’s sexuality can shift during transition. For instance, individuals living as men in a sexual relationship with a woman may, after transition, be sexually attracted to a man. Unofficial surveys point to this switch happening in about 40 per cent of all male to female transsexual people. It can come as a tremendous shock to the person undergoing transition. Incorrect treatment can be the cause of serious psychological problems. Severe depression and suicidal feeling are commonly experienced in pre-operative transsexual people prior to sympathetic and appropriate treatment. Non-judgemental counselling can help to overcome this natural reaction of the client to their gender confusion.

The number of people requesting help for gender identity issues is on a sharp increase. This does not necessarily mean that it is becoming more prevalent merely that thanks to recent positive publicity3 the general public is becoming more sympathetic and accepting of the condition.

Also the law now offers greater protection to trans employees and the recent ruling in the European Court of Human Rights, Goodwin v the United Kingdom4, should ensure the introduction of further legal changes to protect the human rights of trans people. A similar increase happened in Sweden and other European countries when the condition had been properly recognised and legal precedents set, but this increase levelled off and it is assumed that a similar pattern will obtain in the UK.

Until 1970 it was legal in Britain for post-operative transsexual people to have their birth certificates amended. The case of Corbett v Corbett (otherwise Ashley) put an end to transsexual people’s rights. When April Ashley was declared to be a man by Judge Ormerod and her marriage declared null, the right to have birth certificates corrected was revoked. Despite the recent ruling in the case of Goodwin v UK (referred to above), Britain still hasn’t implemented the changes which would remove it from the company of Ireland, Albania and Andorra, who alone among the 40 European nations, still deny transsexual people the right to legality in their true gender.

But this is not just the right to many; it is also an infringement of a person’s privacy. This manifests mainly in the workplace where having to disclose one’s past frequently leads to discrimination, jibes and abuse from employers, work colleagues and subordinates. The Criminal Records Bureau has recently introduced a procedure for searches under which such disclosure would not be made known to the employer. The Government is expected to amend legislation shortly: In the 1960s many transsexual people were subjected to aversion therapy; a process commonly using visual stimulants accompanied by electric shocks to `cure’ them of this condition. Some medical books still claim two successes from this therapy: What they don’t state is that the follow-up survey only lasted one year, and in the following year both these `successful’ cases committed suicide.

Macho Response

Many MtF transsexual people fight the condition by trying to be more ‘macho’ than they really feel. Joining the services, often the marines, SAS or the police force is surprisingly common. Marrying and having children is another disaster waiting to happen. Only a tiny percentage of married couples where one partner is finally able to admit their transsexual status manage to stay together.

Waiting lists are long on the NHS, not only for the operation but even for initial consultations. Seeking private treatment can be quicker but there are still procedures that should be followed5. Although there are many variants to the transition process for MtF transsexual people, the same basic elements are involved. The introduction of oestrogen and sometimes progesterone (hormone therapy), and anti-androgens to inhibit the production of testosterone, occasionally an orchidectomy (removal of the testes) will be done prior to more extensive surgery. Together these treatments help to feminise the features to a lesser or greater degree, by softening the skin and causing some breast development.

Although the introduction of testosterone to a FtM person causes the voice to `break’ and therefore become deeper, the reverse is not true for MtF people. Here the new voice has to be learned. Being able to make a phonecall without giving your name and yet be assumed to be female is the ultimate test. Another area where things differ for MtF and FtM people is that of bodily and facial hair. Removal of testosterone and replacement by female hormones does not stop facial hair growing whereas the introduction of testosterone for FtM people promotes hair growth allowing beard growth to occur.

Real Life Experience

One process which is vital to a successful transition, in virtually all cases, is that of the Real Life Experience (RLE). This is the period of one or two years when a preoperative trans person lives fulltime in the new gender role before irreversible changes are made. Being able to function `normally’ including socially and in one’s working life are key pointers to a likely successful future. The RLE is not intended as a diagnostic tool for the medical professionals but rather as a guide to trans people themselves, as to whether this is the right way forward for them.

The operation to align the bodily appearance more closely with the gender identity experienced, is reasonably straightforward nowadays, at least for MtF people. Although it is a long operation (four-five hours) there is a very high success rate, not only in the operation itself but also in the psychological condition of the patient. But as with all operations that involve long periods of general anaesthetic, if other medical conditions are present or a patient is overweight or smokes heavily, the dangers are multiplied and may prevent a trans person from undergoing the surgical aspects of transition.

Frequently social conditions, family commitments, career commitments etc. limit the extent to which an individual will be able to transition. Transsexualism is now legally and medically recognised as a ‘serious medical condition’6 that should be treated. Even so, many transsexual people still have difficulty in obtaining NHS treatment and have to resort to private treatment. Many people travel abroad for their operations.

Nature not nurture in gender identity

When Harry Benjamin introduced the condition to the medical world in the 1950s, he favoured a biological explanation. It was only some time afterwards that Professor Money’s findings seemed to trigger the change in classification to that of a psychiatric disorder or mental illness. For many years the experiment by Dr Money7 on a baby whose circumcision operation had gone tragically wrong, resulting in a mutilated penis, was believed to be proof that nurture played the vital role in the formation of gender identity. Dr. Money advised surgery on the boy to restructure his genitalia to look like a female and instructed the parents to raise the child as a girl.

This ‘treatment’ was reported by Money as having been entirely successful. It was only years later owing to the vigilance of Prof. Milton Diamond8 that the true ending to the story was revealed. The ‘girl’ had undergone a second sex reversal operations and had never been comfortable with the imposed gender, despite female hormone reinforcement. It then became clear that the overriding force is that of nature and that nurture plays at most a minimal role in gender identity development.

Counselling can play a vital role in the lives not only of transsexual people but also their partners and families. Many of the clients who come to me have previously seen other counsellors and describe how they have tried to talk them out of transition, saying such things as ‘You’re a man, you have a penis between your legs, you admit you are attracted to women’. ‘This is just a fetish that you will get through’. ‘You must realise that you can never be a real woman’. All this achieves is to destroy any confidence the person may have and leads to depression and worse. This is what happened to me in the 1970s followed by two years of really strange experimental group therapy to try and reinforce my ‘masculine’ side. It failed then, and it fails today: Transsexualism is a condition that can only be self-diagnosed, but that does not mean that everyone who presents with gender discomfort of any kind is transsexual. That’s where it gets tricky and why in the early stages of treatment, it is important to allow people to explore, fully, their own gender feelings without being pressured to follow a rigid treatment regimen.

Treatment should be patient led and allow for flexibility. Those who wish to continue towards the goal of transition should be given appropriate support and validation of their feelings, but those who discover along the way that this is not for them, should be allowed to change direction again without being made to feel that they have failed. They will still need a great deal of emotional support.

Understanding a client’s condition

How can we tell whether a client is transsexual, transgendered or merely has transvestite desires? Another tricky question, as all these conditions overlap to some degree and the client could well not know which category they fit into or even try to fool themselves into thinking that they are transvestite when they are really transsexual or vice versa. It’s only after years of talking to friends and clients from all these areas that I find their words giving away the truth of their situation. The same stories repeat themselves time and time again. The same feelings of alienness, ‘One day I’ll wake up on some distant planet and someone will say “It’s OK, The experiment is over, You’re home”‘.

The Computer Industry

There is a predominance of left-handedness or multi-handedness9 amongst transsexuals and a huge numbers of engineers and computer experts, far out of proportion to the rest of society. Seven years ago, in a small survey, I realised that there seemed to be far too many ‘trans’ people working in the computer industry10. Four years later, an article in an American on-line magazine11 stated that 15 of the world’s top computer games designers were MtF transsexual people. I have spoken about this phenomenon with Prof. Milton Diamond of the University of Hawaii, perhaps the world’s leading expert in transsexual and intersex conditions. In a recent email from him his reply was ‘Absolutely, I have no doubt there is a connection’.

The main role of a counsellor in dealing with transsexual people is to help their client explore the possibilities and alternatives available, investigate the effects that these will have upon their clients and their family, friends, and of course their career prospects. Although it is illegal to discriminate on grounds of gender identity, many transsexual people find it impossible to find employment12. It is very important to let clients know that this is no easy option. How would they tell their work colleagues, their partner, their parents or their children and what reaction would they receive? How would people feel about them using the female toilets? How would they react to snide comments and laughter or even physical abuse in the street? How would they survive if unable to find work? Do they realise the hours that they will have to spend ‘learning’ how to speak as a woman, the years of electrolysis needed to remove facial hair and the many other new areas of life they will have to learn? And what about the cost? Private treatment, including facial feminisation, electrolysis, the operation itself and other associated procedures, can easi1y add up to £30,000 for a MtF transsexual person and even more for a FtM trans person embarking on the immensely complex reconstructive surgery:

[Editor’s note: Please note, that most of these questions and concerns are irrelevant for FTM trans people to consider. There are other issues for FTM transpeople.]

The need to change

It is almost impossible for a non-transsexual person to understand the ‘need’ to change sex, and for a true transsexual person it is a need, not merely a wish or whim. How would you feel if you had spent your life knowing that you were male yet had a female body or vice versa? But let us not forget the unfortunate partner who is told by her husband that he really is a woman – a woman who has been acting an artificial role, often for many years. In order to gain a degree of empathy with a transsexual client or a client who is the partner of a trans person you need to put yourself in those roles.

Most transsexual people start transition with all the best intentions. ‘I won’t go full time until I can really pass’. ‘I’ll wait until the children are older’. ‘I won’t skimp on the time I live “in role”, just to make sure I can hack it’. The trouble is that once the first step on the road has been taken it is very hard to keep to these promises. The mind plays tricks on you, the mirror shows a perfectly passable woman when the reality is something very different. And yet it is confidence that is the key factor to a successful transition confidence, but not over confidence.

In a strange quirk of fate, it was while I was counselling a postoperative transsexual client that I finally admitted the truth to myself. A simple question from my client ‘What is it for you? Is it the clothes?’ and my immediate reply, ‘No, It’s just right, It’s natural, It’s how things should be’. After 51 years of fighting against the condition, my struggle was suddenly over. I knew the truth and at long last I was actually able to accept and admit it to myself. But perhaps that is when the real struggle starts. That is when a totally non-judgemental counsellor can come into their own.

This article represents the views of Emma Martin and not necessarily the views of people or groups with which she is associated. She would like to thank those who provided critiques prior to publication.


Gooren, Swaab, Zhou et al. A sex difference in the human brain and its relation to transsexuality. Nature November 1995
Kruivjveret al – Male to female transsexual individuals have female neurone numbers in a limbic nucleus. Journal of Endocrinology and Metabolism 2001. This paper received the GIRES research prize for 2002
Changing Sex – Channel 4, Coronation Street (Hayley) – Granada, I want to be a man – Channel 4, My Millennium (Emma) – Channel 4 etc.
Goodwin v The United Kingdom 2002
Harry Benjamin Standards of Care (version 6) 2001
A, D and G v North West Lancs Health Authority 1998
Money – `Ablatio Penis’ Normal Male Infant Reassigned as a Girl – Archives of Sexual Behaviour 1975
Diamond & Kipnes (1998), BBC Horizon – The Boy they turned into a Girl (1999)
Green – Biological Markers of Transsexual Origins
Martin – Occupations of Trans People 1995
Next Generation On-Line 1999
Whittle (GIRES workplace survey) 2002
Contact information for Depend, Emma Martin, FTM Network, Gender Trust, GIRES and Mermaids was also given in the article
Citation: December, 2002 Vol 13, no. 10 an article published on the Internet by CPJ – Counselling and Psychotherapy Journal