When Carol McCord's patients first seek her out, it is usually because they want to make a drastic change in their lives. For them, the road ahead is potentially rocky — filled with difficult decisions, awkward moments and possible conflict with those closest to them. The patients are transgender, and the help they seek often relates to their wish to transition from one sex to the other, explains McCord, a psychotherapist with The Kinsey Institute Sexual Health Clinic, based in Bloomington, Ind. We talked to her recently about what transgender is, the challenges transgender people face and the medical interventions that are available to them.

Q:		What does the term "transgender" mean?
A:		It is an interesting term and one that is in flux: It is becoming more inclusive over time. So people will hear the term used in different ways by people with different levels of experience. But the term transgender was specifically coined to describe someone who is a member of the cross-dressing community who lives a gender role that is opposite the gender role society would assign to them based on their anatomical, genetic or chromosomal makeup. So, for example, it may refer to a man living as a woman.

---

Q:		How does that differ from transsexual, transvestite or gay?
A:		In clinical terms, transsexual is a further extreme of transgender. A transsexual is someone who makes the choice to have either hormonal or surgical intervention to change their gender. So the term transgender is the broader term, which includes all of the interpersonal and societal ramifications, while transsexual relates specifically to the genitals. Transvestite is in a totally different category. Transvestites are people who don't actually live their lives as if they are a different gender or feel they are a different gender. When we think of transvestite, most of us are actually thinking of a fetishistic transvestite, which is most often a man dressing in women's clothing, usually for sexual pleasure. So a transvestite is usually a man who gets turned on by being in contact with women's clothing.

---

Q:		Are transgender people usually males who feel they are female?
A:		There are both male to female — what we refer to as m to f — and female to male (f to m) transgender individuals. I see a lot of transgender clients in my clinic, both male to female and female to male. It may seem to many people like there are more male to female transgender individuals, but you have to keep in mind that in our society females have the ability to dress with far fewer constraints than males do. So if I'm talking to you as a female and I'm wearing a skirt today and trousers tomorrow, that would not be odd. However, if I'm male and I'm wearing trousers today and a skirt tomorrow, that would be odd. So one of the things that happens is that the stereotypes of these definitions get identified in people's minds based on a lot of things people might not even think about. Historically, in fact, there have been many more female to males. And today a woman dressing as a male is so unremarkable that it isn't the hallmark of anything. So when we think of cross-dressing today, almost exclusively we're thinking about males as opposed to females and that has to do not so much with reality as perception. In reality, when we talk about transgender people living the other gender, there are both males who live as females and females who live as males.

---

Q:		What about sexual orientation? Are transgender people usually homosexual or heterosexual?
A:		There is a lot of controversy about this right now because a new book has just come out that is very controversial. But my answer is that sexual orientation is distinct from gender. So some people who are transgendered identify as heterosexual and some identify as homosexual.

---

Q:		You mentioned that the term "transgender" is in flux. How has the term transgender changed in recent years?
A:		Typically, in the past, people used to think of a transgender individual as someone being trapped in the wrong body. And, indeed, for quite a number of people that is the case. But younger people today are having the opportunity to explore their gender identity and gender experience, and they are more willing to try out other identities and roles. So, for example, I have one client who was born female who uses a male name but says "I am a trans-boy: I will never be a straight guy; people will see me as very feminine because I am, so I'd be seen as a gay guy except that I am attracted to women." So there are further expansions to the term transgender than there used to be. More people are saying "I feel kind of gender different." Another term they often use in this community is "queer." They use it to mean "I don't conform to the gender rules that society wants me to." Young people like the term because it is nice and ambiguous and they don't have to identify exactly how they feel. My view as a sex therapist is that this is a good thing because it is easier for people to explore their gender roles earlier in life. When people with gender dysphoria — or gender discomfort — come in later in life dealing with it, more often they have gone through life trying to conform to their genitals and the expectations that people have regarding their gender. Often they get to the point where they say, "I can't do it anymore — I'm so miserable," and they have to make a change at a point in their lives when their life is already established. That is a tremendous upheaval in their lives; it's much easier if people can explore these things early on. So the good news is that society is opening up a little with these things and younger people are more likely to try out different things earlier in life and figure out where they fit at a time that is more in sync with normal life stages. Then they can go on with the rest of their lives in the same way that people who already have this under their belts do.

---

Q:		Is being transgender a lifestyle "choice," or is there a genetic reason people are transgender?
A:		We don't know, but the expectation is that, yes, there is something different in people who are transgender. People tend to think of gender as binary: In most species, there are males and females. But the reality is that we know there are a lot of situations where that is not the case. Some people are born with a set of hormones that would make them male but have hormone insensitivity, so they live their lives as women. Some are chromosomally a male but have no penis and undescended testes, so their genitals appear to make them female. That is not what happens to transgender people, but the point is that gender is not as binary as most of us think of it as being. Our hunch is that transgender experiences are probably in part related to those kinds of differences. So, for instance, my brain might respond differently to female hormones than a transgender person's brain does, and we just haven't gotten our science fine-tuned enough to understand it. On the other hand, part of it is lifestyle. People can choose to live their lives as they feel — they may say "I'm too unhappy to live with the gender I was assigned, so I'm going to take the risks that are involved in living the way I feel." To that extent, it is a choice. But in terms of where the feelings come from, that is not something people choose without having some internal motivation. They have more opportunity for ridicule and harassment than almost anyone else in our society. The group that we are least accommodating of are people who cross gender boundaries — people lose jobs, their families, basically their entire support network. So it is not something anyone would take on lightly.

---

Q:		What kind of medical help is there for people who are transgender?
A:		First, there are different levels of transition for people who choose to transition. Some people just choose to cross dress, while many people choose to do more than that — either by taking hormones to help make their body change somewhat toward the gender that they want or by choosing to have surgery. There is the expectation in many people's minds that everyone who is transgender chooses to have surgery. This is not true — first, because it is astronomically expensive, and secondly, because it is major surgery and there is the opportunity for something to go wrong. Even if surgery goes well, there may be problems, such as loss of sexual feeling or urinary incontinence. For those transitioning from female to male, you can fashion a penis, but to have one that functions with an erection is not possible at this point without some sort of implant. Likewise, you can't allow someone born with testicles to have a functioning uterus and ovaries or the ability to give birth. So there are severe limitations to surgery. More often people choose to live with some amount of medical intervention, but not as much intervention as is possible. The way it is set up right now, if they want medical intervention, they have to go through a counseling process and have to be assessed to make sure there are no major psychological problems, that they are of sound mind to make the decision and that this is what they want to do. So, often the help that we give them is not really help, it's more of a passing through particular barriers or jumping through hoops to be approved to go on for more medical care. The other thing that we can offer is support for dealing with the crises that can come up when they are going through the transition — telling your wife you want a divorce because you're becoming a woman, for example. These kinds of things are hard to do, as you can imagine. There are also support groups out there as well as the web, which has been wonderful because people can connect with others in similar situations. They can find support no matter where they live.

---

Q:		What are some of the challenges people face when transitioning?
A:		It is pretty major. Getting your name changed legally is a set of court documents and costs a small amount of money and takes some time. Getting a new driver's license is more paperwork and requires going through more bureaucracy. Probably the biggest piece is dealing with people's responses and not knowing how hostile or shocked they will be. I have clients of all ages and in all stages of life. I have one client who is a college student and who started college as a male but plans to arrive at school next year as a female. She has been having electrolysis and working on her makeup and clothing, and she has even contacted a sperm bank to save sperm so that later in life she can have a child that is biologically hers. I have another client who has male pattern baldness and is very embarrassed about it. So he gets Propecia (a hair-loss treatment) from one pharmacy and then goes to another pharmacy to get his hormone-therapy prescription filled. So these are some of the things that you might never think of that people go through. You have to be willing to cope with it, and you never know how hostile the reaction will be. In addition, in relation to the hormones, when you add estrogen into a body that wasn't meant to have it, there can be an increased risk of breast cancer. Likewise, when you add testosterone into a body that wasn't intended to have it in that amount, you get facial and body hair developing, but you can also add an increased risk of cardiovascular problems, especially if you're overweight.

---

Q:		And explaining it to your friends and family must be extremely difficult, right?
A:		Probably the hardest thing for transgender individuals is dealing with the people in their day-to-day lives. It's very hard. Parents have an awfully hard time moving from having a son to having a daughter and from daughter to son. Children have a hard time, too, as do siblings and grandparents. A number of people end up really distancing themselves from their family. Sometimes some members can deal with it and others can't. Coming out to your employer is a pretty awkward thing, too. I see people who really have lost everything — financial, family support, their job. So the number of and the kinds of problems people encounter in transitioning is huge, and it is very hard. Even the little things are difficult, like getting people to refer to you as he if they have known you as a she. Or finding clothes and shoes that fit you. I have one client who was big as a male, and when she transitioned to a female, she found it hard to find clothes and shoes that were big enough. I have another client who had a very heavy 5 o'clock shadow and who, before she was in transition, covered it with makeup. She got caught in a rainstorm and by the time she got home from work she looked pretty bedraggled. And it felt bad to her. It doesn't feel good for anyone, but when your makeup is running and your beard is showing through, it is really hard. It is not an easy thing to go through. The clients I have who have done the best are female to male clients who have partners who were with them when they were female. They've already broken the gender stereotypes, so they tend to do well. It really runs the gamut, though. I've seen people who have had fairly easy transitions, and I've seen people who have lost everything.

---

Q:		What guidance do you give those people who are considering living their life as the opposite sex? What types of questions do you ask them to make sure they are ready for this new lifestyle?
A:		I'm not one who believes that we need to identify this as a problem. Usually people who are considering this are willing to make adjustments because the adjustments are exactly what they need to feel better. So I think it is pretty arrogant for the medical community to think we have to make sure they are ready. But some of the things that I might ask them are: How are things going at work? How are they going at home? How do you feel? How does it feel when people are rude or harassing? My experience is that, especially with the advent of the Internet, most people have already addressed these questions and gotten answers to their questions from communities on the Internet. But, generally, I want to make sure they have the support they need to come out.

---

Q:		As you mention, family members can have a hard time accepting this change. What advice would you give parents of teens who are considering living as transgender individuals?
A:		First, it makes sense that dealing with this type of issue with your child would be a difficult thing. Gender is such a significant part of what and how we understand another person — any other person — to be, and everything about our child we experience more intensely than with others. So the first thing I say to parents is to be gentle with themselves. Next, I remind them that their process of coming to grips with this issue is separate from their child's — and usually a few paces behind. I recommend learning about transgenderism in general — it helps to know that others have gone through this. I also suggest they find a support group of other parents, through an organization like PFLAG. Even the parents of a gay, lesbian or bisexual child can be of help, in terms of nonjudgmental acceptance of a child who breaks societal gender norms. A therapist experienced with this issue can also provide support through this process. There are several specific things I would share with parents, too. One is that in general it is easier on a person to be dealing with such issues earlier in life rather than later. When a person goes through childhood, adolescence and some part of adulthood feeling unhappy and uncomfortable, that has a lasting effect. Even worse are the effects of trying to fit in when one has to hide who one is to do so. It is a part of the development of our ability to have relationships that are genuine, to be genuine in our dealings with others as we come to know ourselves. When one is trying to hide one's self from others, that works against this process. And it also takes up a significant amount of cognitive and emotional energy. This is also not a decision that many people are likely to come to lightly. It is a path that is clearly difficult — which is not lost on those considering it — and it is usually embraced by someone when it is the only answer that they can see to ease the discomfort they feel. This is difficult, because it is very hard to recognize the level of pain and discomfort that someone else is experiencing — especially when they may have worked actively for a long time to hide it. It is useful for parents to try to parse out their concerns and separate those that have to do with their child's well-being from those that have to do with their own personal discomfort. While this process is something a transgendered person does to alleviate their discomfort, it often causes us discomfort. Then again, it is OK and even useful to get support for their process of dealing with it.

---