# Are Transsexuals Mentally Ill?
**URL:** https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759
**Category:** Cecil's Columns/Staff Reports
**Created:** [August 17, 2012, 9:13am UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759 "2012-08-17T09:13:00Z")
**Posts on this page:** 20
**Page:** 2
### Author:  [@bup](https://boards.straightdope.com/u/bup)
#### Post date: [August 17, 2012, 2:54pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/21 "2012-08-17T14:54:40Z")
> [@Una\_Persson](#):
>
> I disagreed with Cecil’s conclusions in this column. He and I had very many conversations over how to interpret the problem of high drop-out rates. I believe there is a preponderance of evidence, despite the dropout rates, to err on the side of “hormones/SRS are good and proper treatment.” Later on I intend to post some of my citations to support my position.
Well, admittedly it’s a tough issue. I respect Cecil and staff’s addressing the issue, and being willing to go where the truth leads them, not where prevailing social beliefs say.
The more evidence you present, the better.
---
### Author:  [@Learjeff](https://boards.straightdope.com/u/Learjeff)
#### Post date: [August 17, 2012, 3:23pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/22 "2012-08-17T15:23:57Z")
> [@adaher](#):
>
> For me the issue isn’t body modification. It’s believing something that is just not true.
>
> Sex is a defined biological characteristic. You are male or you are female, or you have a birth defect that leaves you with something else. If you are male, however, you are male. If you are male and you think you are female, you unquestionably have a mental disorder.
This is a mistake. It’s like saying a car is either blue or green. But a car can have a green body and blue doors.
Sexual development is _extremely_ complicated, especially concerning brain development. It’s quite possible to have male genitalia but, during brain development, for female characteristics to be emphasized.
So, it’s not as simple as “believing something that’s not true.” It’s being internally inconsistent (which is definitely a disorder). Of course, people with disorders can live happy, healthy, fulfilling lives, either by adjusting or by treatment.
> [@](#):
>
> I dislike transsexuals who view it as my obligation to act in accordance with their incorrect worldview.
I bet you’d feel quite differently if you had experienced this internal conflict. I hope you don’t feel contempt for transsexuals who wish to be treated according to their mental roles.
Again: this is not a case of “the mind conflicting with reality”. It’s a case of an internal conflict between mind and body. To call one right and the other wrong is meaningless, objectively. But IMHO we should give the mind precedence, not the body.
> [@Blake](#):
>
> but I have always thought that if I woke up tomorrow and found out that, as a result of a well studied biological process, I was in a woman’s body I would come to accept it. I would be freaked out to hell initially of course, and the doctors may have to explain to me what has happened and that there is no way to change it a lot of times before I would believe it.
I’d still look at good-looking men and women very differently. No question of where my eyes would be drawn, and who I’d want to chat up. Would I want to be treated like a man? I really can’t say … but I wouldn’t be surprised to find myself dressing and acting like a man.
There’s an implicit assumption in many posts above that the mind state is more plastic than the body state, that the genitalia is CORRECT and the mind is arbitrary. I don’t believe that; I think that most men’s minds are biologically different than most women’s minds, and in most cases, it’s biology making someone “feel” like a man or a woman. If this is true, it’s easier to “fix” the body than the mind. Furthermore, our mental state is a far bigger factor in our identity than our body state. How many of us want to change who we are? In any case, if we could “fix” either mind or body, it should be the person’s choice which to fix.
Regarding drivers’ licenses etc., it does seem odd to me that it’s based on preference rather than observable criteria. As mentioned above, we can’t choose our height. (We can, for hair and eye color … but can we say we’re blond even if the hair in the picture is raven black?) It’s a goofy world we live in!
BTW, there are people with brain disorders that make it feel like a part of their body is not theirs. (cf., Ramachandran’s book, The Tell-Tale Brain) Many of them want the offending limb removed. Ramachandran provides good arguments that this isn’t a simple matter of someone being “nuts”, but of brain miswiring during fetal development.
> [@](#):
>
> Someone wandering into the mens toilets in women’s clothes, maybe with makeup, fake boobs etc is going to get a lot of funny looks and may feel uncomfortable.
> Depending on their specific appearance they may get funny looks in the womens toilet too, but they’ve got to go somewhere.
Right. We can’t have a bathroom for every possibility. Perhaps we should have just one bathroom for all. Meanwhile, we have F and M, and people with ambiguities just have to work that out for themselves. The rest of us should show reasonable tolerance.
> [@adaher](#):
>
> Actually causing females to feel threatened by a male is a case where women’s rights and transgendered rights come into conflict.
True, but transgender isn’t the only possible cause for this. I’m sure there are people with female bodies who can scare the crap out of the other women in the women’s room! (Of course, in the men’s room, we men never admit to any sort of fear, unless firearms are involved. Or maybe gays.)
> [@Mijin](#):
>
> Yeah they’re so in your face with it. The number of times I’ve had a transsexual get me in a headlock and refuse to let go before I acknowledge that they are biologically the other gender, it’s appalling.
Hah! Yeah, me too! I wish they’d quit that!
I only knew one transsexual very well. He was originally a very robust, barrel-chested manly man, fierce handshake, very likeable. Then Mike became Michelle. Michelle overdid trying to be feminine, and it was a bit pathetic, especially given her masculine visage. But that was her choice, and I honored it, and she was no less friendly, intelligent, and likeable.
> [@Blank](#):
>
> it is must also be fine for them to treat you in a manner consistent with reality
Absolutely! And the reality is that someone who feels like a woman is in the body of a man (or vice versa). They should be treated accordingly, but according to which side? I say, honor their choices.
There’s a difference between transsexuals and people who think they’re dragons. We don’t actually have any cases where the mind of a human developed into the mind of a dragon.
Bottom line: it’s not just a MENTAL ILLNESS. It’s an internal conflict disorder. Genitals are one sex, brain is another. Which is right?
Finally, what do we do about hermaphrodites? I say we let them decide, and treat them accordingly, rather than treating them as some “3rd sex”.
---
### Author:  [@Una\_Persson](https://boards.straightdope.com/u/Una_Persson)
#### Post date: [August 17, 2012, 3:34pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/23 "2012-08-17T15:34:24Z")
> [@Blake](#):
>
> Wouldn’t good manners dictate that they \*not \*make others feel uncomfortable by breaking social mores if it can be avoided?
By that token interracial marriage would never have been made legal, because it sure as heck made a majority of the populace in many States, perhaps the entire nation, uncomfortable with breaking the social mores.
I wager there are a hundred other examples. Women wearing trousers and cutting their hair short in the 1920’s? How about women voting? Black children who want to go to school with white children?
OK, you can argue that being black or being female is unquestionably a physical thing, not a mental one. How about hippies with long hair in the 1960’s? Jews who want to be treated like Christians when hiring time comes? And of course the elephant in the room, all those lesbians, gays, and bisexuals out there - why should society accommodate them one iota more than a transsexual? After all, isn’t it “crazy” for a woman to sexually love another woman?
All of these things broke social mores. Social mores change. They will keep changing, and some day, probably long after I’m dead, transsexuals will be welcomed as sisters and brothers in society.
Overall, you appear to be starting from the assumption that transsexuals are so incredibly and unstably mentally ill that to perform the minimum, insignificant accommodation of using the proper pronouns and giving them the right to work, love, and live in society is some burden for all the sensitive cisgendered people out there. Surely that’s not your intention…?
---
### Author:  [@Mijin](https://boards.straightdope.com/u/Mijin)
#### Post date: [August 17, 2012, 3:51pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/24 "2012-08-17T15:51:07Z")
> [@Blake](#):
>
> Nobody mentioned offended sensibilities, but hey, if you need to find some snarky way to imply that I’m a prude for refusing to agree with statements of fact about the world that are at odds with reality, go for it.
>
> When a poster has to resort to this sort of _ad hominem_, his position has become pretty damn weak,
Yikes overreact much?
I only (briefly) mentioned sensibilities because I don’t get why some people are apparently so angry about someone wanting to call themselves male or female.
If my neighbour wears a red t-shirt and wants to call it blue, so what, I don’t give a crap.
And that’s an example of something demonstrably false whereas the gender identity thing is different. There does appear to be an instinctive gender identity, it’s not simply a conscious choice, so there is a concrete meaning to saying that inside you’re female or whatever.
> [@](#):
>
> I think we all agree that people have the right to make \*requests \*of this type.
>
> Where the disagreements starts is that some will immediately label me a bigot if I respond to the request with “No, your beliefs are at odds with reality and I have no intention of acting as if they are real.”
You’re shifting this to make it as though transsexuals are requiring you to do some action. I’ve seen no example of this.
If a transsexual really did want you to force you to make some public acknowledgement, I’d be on your side. But I’ve never seen it.
> [@](#):
>
> Yep, your position is so weak that you have to resort to this sort of garbage in response to perfectly cogent arguments.
Your argument is repeatedly trying to shift this on to transsexuals as though you’re being persecuted. That they are “pretty damn rude” for forcing their beliefs on you. Other than having to call someone with broad shoulders and an Adam’s apple “brenda” exactly what have they forced you to do?
> [@](#):
>
> So you believe that most transsexuals with XY chromosomes and a penis and testicles accept that they are men?
> Cite! Because the link adaher posted earlier, the [story here](http://transpacificgirl.wordpress.com/2011/06/28/i-am-woman/) and thousands of other stories all say differently.
Physiologically, yes, of course. Your cite says exactly that.
That’s why people go through hormone therapies, operations etc. They are aware that their body’s gender and their gender identity are at odds. It’s weird that I even need to say this.
---
### Author:  [@TriPolar](https://boards.straightdope.com/u/TriPolar)
#### Post date: [August 17, 2012, 4:14pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/25 "2012-08-17T16:14:38Z")
I find it hard to believe that a lot of people who undergo surgical changes to their body to indulge their fantasies aren’t mentally ill. But that isn’t a good description of everyone who does it. Some of them must be perfectly sane and realize they are making cosmetic changes that don’t change their chromosomes. We allow people to have all sorts of other body modifications for stupid reasons but don’t call them mentally ill. Like most questions concerning sexuality, things don’t reduce to one or two correct answers.
---
### Author:  [@Una\_Persson](https://boards.straightdope.com/u/Una_Persson)
#### Post date: [August 17, 2012, 5:17pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/26 "2012-08-17T17:17:21Z")
OK.
The following is my opinion, backed up with a lot of studies. I helped Cecil with research on this, and that requires doing a lot of legwork. You have to when you work for the Big Guy.
In defense of Cecil’s column, one point Cecil makes which is very important is that in most of these studies, the follow-up rate is very poor. Transsexuals are a difficult population to track on a long-term basis **after** they undergo SRS. This really is unfortunate, but it also corresponds to my personal experience working with the trans community for more than a decade. Once a transsexual transitions, they usually do not want to do anything other than lead the rest of their life and be left alone. They often break off contact with physicians, excepting for continuing hormone use, and they often do not continue psychological counseling because, IME, their gender dysphoria is addressed so well they no longer have grief from it. They had a misalignment, they fixed the problem, time to move on with life and put the old behind you.
Cecil is responsible for the Straight Dope, and as such he needs harder evidence to draw the conclusion that hormones/SRS are beneficial for transsexuals. Long-term changes due to hormones, the social crises which arise during most (if not all) real-life presentation transitions, and SRS, are all so serious life-changing measures that my understanding is that he feels we need better studies before we can conclusively say it works. There is no smoking gun which says they do not work and do not improve the lives of transsexuals, but lack of a negative is not proof of a positive.
I however am a heavily biased researcher on this subject. I admit that the follow-up rate on most of the studies is poor, nonetheless I feel that the lack of much negative evidence to speak of, coupled with what positive evidence there is, is more than enough to err on the side of hormones and SRS being a success.
In addition, I have direct personal experience working with transsexual counselors and transsexuals, and I have never met anyone who regretted their surgery or hormone treatment (although I have met a couple who did have unsatisfactory surgical results). One counselor I know has helped more than 300 individuals fully transition and to the best of her knowledge, not a single one regretted hormones, surgery, or the entire process.
But that’s anecdote, and although I argued this point to Cecil, Cecil can’t go on anecdote – “anecdote does not equal data.”
But here’s my opinion, alright?
I reviewed more than 30 studies and found one common theme – SRS has a high rate of success for improving the lives of transsexuals. Regrets after SRS are uncommon, and the vast majority of transsexuals are happy with the results of their transition. Study 1 found that sexual experience improved for 83.3% after SRS, and was rated as poor or very poor (but not necessarily worse) by 11.2%. The number of transsexuals who had a partner increased from 52.6% to 73.7% after SRS. Some 26.3% reported improved family relations, and none reported worse. Note that this study only examined 19 transsexuals, a very small sample size.
Study 2 looked at 55 transsexuals to evaluate physical and mental health after SRS, and again found promising results. It found only one person was dissatisfied with their surgical results, and none of the patients regretted the surgery. More than 75% reported improved sex lives, and the overall expectations of the transsexuals was met on physical, emotional, and social levels with rates of 81.5%, 94.4%, and 90.7%, respectively. Study 18, examining the quality of life of F2M patients found that hormone treatment significantly improved their quality of life, and breast removal surgery improved matters further.
Study 17, which compared transsexual adolescents who underwent SRS with those who didn’t found that SRS appeared to improve mental attitudes in many, but not all areas; however, none of the SRS patients regretted their decision. It was noted that the population was very well-selected, and it was the opinion of the authors that many of the non-SRS patients simply were not suited to deal with SRS, and depending upon how you choose to weigh that, that either skews the study, or else emphasizes that with proper screening, SRS success rates can be quite high indeed.
Study 3 was a meta study covering more than 2,000 transsexuals and found that 80% of post-SRS transsexuals reported a significant improvement in their quality of life, examining several hundred transsexuals who underwent SRS found that 91% of transmen and 83% of transwomen were satisfied with their decision. When regret after SRS occurs it is typically short-term regret, related to post-operative pain, job loss, departure of a partner, or family disputes. Serious, long-term regrets are rare, typically under 2%, and is typically due to misdiagnosis of a psychosis, lack of a real-life trial, poor family support, or poor surgical results. (Study 4 backs up two of these points) Age is also a factor, with younger transsexuals having a more positive outcome. (see Study 5)
Study 6, an academic dissertation, says that for all transsexuals studied therein there appears to be a steady improvement in their quality of life as the level of treatment increases. This study of 95 Munich transsexuals found overall that psychotherapy alone yielded satisfactory results for the patient 76% of the time, hormone treatment 81% of the time, and SRS 84% of the time. When the study focused on psychological factors, transsexuals showed a strong and steadily increasing trend at different levels of treatment, from psychotherapy through SRS. In terms of physical factors, a similar but much slower trend was seen, save for the case of transmen, who had more success with hormone therapy than SRS. Transmen tend to be more satisfied by the social results of their transition, and this is possibly due to it being much easier for a woman to be masculine in modern society (this is backed up by Study 3 and Review Study 7) – a woman can wear blue jeans and flannel shirts, and eschew jewelry and makeup, drink beer and watch NASCAR, and no one bats an eye. Whereas a man suddenly showing up at the office in a dress and pearls is likely to witness their co-workers metaphorically gathering pitchforks and lighting torches.
In terms of overall health, transsexuals have some other problems which complicate matters. Study 8 is a very long-term follow-up of 1,331 transsexuals (1,177 having had SRS) with an average time on hormones of 18.5 years, and found transwomen had a 51% higher mortality rate than the general population, primarily due to suicide, drug use, and AIDS. Transmen did not have a significantly higher than average mortality rate. Completed and attempted suicides are serious concerns for transsexuals, and although numerous studies showed SRS greatly reduced the risk of suicide, post-SRS suicide rates were still much higher than the general population.(See Studies 9 and 10) Two studies suggest high suicide attempt rates before SRS, 19-33% (Study 3 and Study 11). Review Study 7, a study of 141 Dutch transsexuals who underwent SRS showed a majority had a successful outcome, although suicide attempts were still abnormally high, with 1 in 7 transwomen and 1 in 36 transmen attempting such. The large meta-study 3 found rates of just over 1% post-SRS - compared to the general rate of 11.5 in 100,000 (Study 11) the situation is very sobering. However, Study 8 noted that before SRS, transsexual subjects have much higher rates of attempted suicides and drug use, most likely due to the psychological burden of living with gender dysphoria and social ostracism.
Some bones are made of the findings in a study by the National Center for Transgender Equality (Study 16), where there is a quote which says “Those who have medically transitioned (45%) and surgically transitioned (43%) have higher rates of attempted suicide than those who have not (34% and 39% respectively).” This is often taken out of context to mean that SRS is harmful. Here’s the problem, though. The survey did not ask _when_ the suicide attempts occurred. “Our questionnaire did not ask at what age the respondents made suicide attempts and therefore it is difficult to draw conclusions about the risk of suicide over their life spans.” The actual survey is back on page 183, and I read it and found that ONLY question 54 asks about suicide, and it just asks “Have you ever attempted suicide?”. It does NOT ask “did you attempt before or after treatment.” All the study tells us is that someone who feels strong enough to undergo SRS really has difficulty with their gender dysphoria.
Many express concern over the long-term impacts of taking large doses of hormones, but the risks appear to be low. Study 9, one of the largest studies conducted to date on the subject, consisting of 816 transwomen and 293 transmen over more than 10,000 patient-years showed the overall mortality rates were not significantly different than the general population. A 20-fold increase in blood clots was seen for transwomen, but almost all cases were due to oral ethinyl estradiol intake, which is no longer advised for patients at risk (endocrinologists I’ve interviewed who specialize in transsexual patients say they stopped prescribing ethinyl estradiol a long time ago). Study 12, a recent 10-year study of 95 transsexuals showed no evidence of significant health effects from hormones, and Study 13, a larger 20-year survey showed no significant differences in mortality, but for transwomen who had taken ethinyl estradiol, again there was a significant increase in blood clots. Study 14 claims that despite fears of breast, pituitary, and prostate cancer, transsexual hormone-related tumors are rare. A more recent study, which (caveat) I have not fully reviewed, claims that the risk of deep vein thrombus for transwomen is even less than previously thought, on the order of about a 7% relative risk increase.
It’s important to remember that psychotherapy, hormones, and SRS are not cures, they’re treatments. Gender dysphoria can continue long after SRS, and transsexuals face a world where they are subjected to employment discrimination, loss of family and friends as a support group, and troubled romantic and sexual relationships. Study 11 contains a non-scientific survey of 6,500 transgendered persons which reported 97% experienced workplace harassment or mistreatment, and Study 15, another survey, found 60% of transsexuals had directly experienced violence or harassment as a result of their status, with a sobering 1 in 7 being raped or sexually assaulted, and 1 in 10 being assaulted with a weapon.
I don’t want to cast this as a rebuttal to Cecil, as he and I work closely together on this issue and many others, and I support the validity of his conclusions for erring on the side of caution, even though I would most certainly have chosen to optimistically err on the side of success. This is just my personal opinion on how an optimistic viewpoint could be backed by many of the available facts.
1. Lobato, Maria Ines Ines et al. “Follow-Up of Sex Reassignment Surgery in Transsexuals: A Brazilian Cohort” _Arch Sex Behav_ 35 (2006): 711–715.
2. Cuypere, Griet De et al. “Sexual and Physical Health After Sex Reassignment Surgery” _Archives of Sexual Behavior_ 34.6 (December, 2005): 679–690.
3. Michel, A. et al. “The transsexual: what about the future?” _Eur. Psychiatry_ 17 (2002): 353-362.
4. Landen, M. et al. “Factors predictive of regret in sex reassignment” _Acta Psychiatr Scand_ 971 (1998): 284-289.
5. Murad, Mohammad Hassan et al. “Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes” _Clinical Endocrinology_ 72 (2010): 214–231.
6. Bazarra-Castro, Maria Angeles (2009). Etiological Aspects, Therapy Regimes, Side Effects and Treatment Satisfaction of Transsexual Patients. Dissertation. Aus dem Max Planck Institut für Psychiatrie, Klinisches Institut, München. Director: Prof. Dr. Dr. Florian Holsboer.
7. Snaith, P., Tarsh, M.J., and Reid, R. “Sex reassignment surgery. A study of 141 Dutch transsexuals” _British Journal of Psychiatry_ 68 (1993): 681-685.
8. Asscheman, Henk et al. “A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones” _European Journal of Endocrinology_ 164 (2011): 635–642.
9. Kesteren, Paul J.M. van and Asscheman, Henk. “Mortality and Morbidity in Transsexual Subjects Treated with Cross-sex Hormones” _Clinical Endocrinology_ 47 (1997): 337-342.
10. Murad, Mohammad Hassan et al. “Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes” _Clinical Endocrinology_ 72 (2010): 214–231.
11. Haas, Ann P. et al. “Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and Transgender Populations: Review and Recommendations” _Journal of Homosexuality_ 58 (2011): 10–51.
12. Bazarra-Castro, Maria Angeles et al. “Comorbidities in Transsexual Patients under Hormonal Treatment Compared to Age- And Gender-Matched Primary Care Comparison Groups” _Reproductive Sys Sexual Disord_ 1.1 (2012).
13. Gooren, Louis J. et al. “Long-Term Treatment of Transsexuals with Cross-Sex Hormones: Extensive Personal Experience” _J Clin Endocrinol Metab_ 93.1 (January, 2008): 19–25.
14. Mueller, Andreas and Gooren, Louis “Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones” _European Journal of Endocrinology_ 159 (2008): 197–202.
15. Kidd, Jeremy D. and Witten, Tarynn M. “Transgender and Transsexual Identities: The Next Strange Fruit—Hate Crimes, Violence and Genocide Against the Global Trans-Communities” _Journal of Hate Studies_ 6 (2008): 31-63.
16. Grant, Jaime M., Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. _Injustice at Every Turn: A Report of the National Transgender Discrimination Survey._ Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
17. Smith, Yolanda L.S. et al. “Adolescents With Gender Identity Disorder Who Were Accepted or Rejected for Sex Reassignment Surgery: A Prospective Follow-up Study” _J. Am. Acad. Child Adolesc. Psychiatry_ 40:4 (April, 2001): 472-481.
18. Newfield, Emily et al. “Female-to-Male Transgender Quality of Life” _Quality of Life Research_ 15.9 (Nov., 2006): 1447-1457.
---
### Author:  [@tim314](https://boards.straightdope.com/u/tim314)
#### Post date: [August 17, 2012, 5:55pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/27 "2012-08-17T17:55:30Z")
> [@adaher](#):
>
> For me the issue isn’t body modification. It’s believing something that is just not true.
>
> Sex is a defined biological characteristic. You are male or you are female, or you have a birth defect that leaves you with something else. If you are male, however, you are male. If you are male and you think you are female, you unquestionably have a mental disorder.
I think you’re oversimplifying. Yes, we can look at your genitalia or your chromosomes and say “You are male” in a well-defined way. But there are many other biochemical differences between males and females, including differences that affect the brain.
So a transgender person might very well be correct in thinking that they have a brain that is in some way biochemically more typical for a woman, even if their body is physically male. When someone says “My body is wrong”, of course what they mean is that there’s a mismatch between their body and their brain. But our brain contains the essence of our identity; it’s not surprising that this mismatch would be perceived as their body not matching who they “really are”, and I certainly can’t blame them for wanting to change their body over wanting to change their mind.
Besides, they’ve got to go with what works, and if sex-reassignment surgery is more likely to produce a positive outcome (in terms of happiness) than therapy or mind-altering drugs, then that makes a lot of sense. It may be that, even if someone would be just as happy to correct the mind/body mismatch by changing the mind, we just don’t have the ability to do that effectively.
At any rate, I won’t be convinced that this is analogous to a person thinking they shouldn’t have a left arm, unless there’s such a thing as a “biochemically one-armed brain”. Males and females have different hormone levels (some of which are known to affect the brain), and many other well documented differences. I don’t know if that’s true for things like missing an arm, and at the very least I doubt it’s true to the same degree.
---
### Author:  [@John\_W.Kennedy](https://boards.straightdope.com/u/John_W.Kennedy)
#### Post date: [August 17, 2012, 7:13pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/28 "2012-08-17T19:13:26Z")
Seems to me I’ve seen quite a few reports of transsexuals who turned out to be hermaphrodites “corrected” in infancy, sometimes without anyone but the doctor knowing.
---
### Author:  [@Chipacabra](https://boards.straightdope.com/u/Chipacabra)
#### Post date: [August 17, 2012, 7:20pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/29 "2012-08-17T19:20:22Z")
> [@John\_W.Kennedy](#):
>
> Seems to me I’ve seen quite a few reports of transsexuals who turned out to be hermaphrodites “corrected” in infancy, sometimes without anyone but the doctor knowing.
It’s not a huge proportion of transexual people, but it definitely happens enough to throw a wrench in the idea that biological sex is absolutely binary.
---
### Author:  [@CJJ](https://boards.straightdope.com/u/CJJ)
#### Post date: [August 17, 2012, 7:28pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/30 "2012-08-17T19:28:31Z")
I just wanted to say that the original question, Cecil’s article, and this follow-up thread have been one of the most fascinating discussions I’ve seen on this site in a long time–and as we all know that’s a high bar to cross.
This goes way beyond “fighting ignorance”; in my case at least, it’s more like “improving thought”–and I still haven’t come to a satisfactory conclusion. Thx.
---
### Author:  [@Learjeff](https://boards.straightdope.com/u/Learjeff)
#### Post date: [August 17, 2012, 7:34pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/31 "2012-08-17T19:34:37Z")
> [@tim314](#):
>
> At any rate, I won’t be convinced that this is analogous to a person thinking they shouldn’t have a left arm, unless there’s such a thing as a “biochemically one-armed brain”.
You might find the work of [url=[V. S. Ramachandran - Wikipedia](http://en.wikipedia.org/wiki/Vilayanur_S._Ramachandran)] S Ramachandran
[/quote]
enlightening. See the section on Apotemnophilia, or read his very interesting book, “The Tell-Tale Brain.” Oversimplified, he has evidence that in addition to areas of the brain dedicated to sensations from body areas, and dedicated to motions of body areas, we also have brain areas dedicated to our concept or internal image of body areas. In cases where the sensory and motor areas exist but the “image” doesn’t, people feel like those parts “aren’t theirs”. Note that these are people who behave very oddly regarding the missing part, but are otherwise quite normal.
However, I don’t think that contradicts any of your points above, which I agree with.
**Una** , Thanks, very interesting. It doesn’t contradict his post, but shows that he’s setting the bar fairly high for what he considers evidence.
---
### Author:  [@tim314](https://boards.straightdope.com/u/tim314)
#### Post date: [August 17, 2012, 7:45pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/32 "2012-08-17T19:45:25Z")
> [@Learjeff](#):
>
> You might find the work of [S Ramachandran](http://en.wikipedia.org/wiki/Vilayanur_S._Ramachandran) enlightening. See the section on Apotemnophilia, or read his very interesting book, “The Tell-Tale Brain.” Oversimplified, he has evidence that in addition to areas of the brain dedicated to sensations from body areas, and dedicated to motions of body areas, we also have brain areas dedicated to our concept or internal image of body areas. In cases where the sensory and motor areas exist but the “image” doesn’t, people feel like those parts “aren’t theirs”. Note that these are people who behave very oddly regarding the missing part, but are otherwise quite normal.
Thank you for the link and book recommendation. That does sound interesting.
---
### Author:  [@Irishman](https://boards.straightdope.com/u/Irishman)
#### Post date: [August 17, 2012, 8:16pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/33 "2012-08-17T20:16:14Z")
To me, I am much less concerned with whether we consider them mentally ill or not, and much more concerned with how do we deal with it. But I understand how defining the condition helps us pick a course of action.
I am very much in agreement with **tim314** when he says:
> [@](#):
>
> So a transgender person might very well be correct in thinking that they have a brain that is in some way biochemically more typical for a woman, even if their body is physically male. When someone says “My body is wrong”, of course what they mean is that there’s a mismatch between their body and their brain. But our brain contains the essence of our identity; it’s not surprising that this mismatch would be perceived as their body not matching who they “really are”, and I certainly can’t blame them for wanting to change their body over wanting to change their mind.
We are still trying to define what it means to have an identity, much less where gender identity comes from. Suppose there is some biological arrangement or switch or whatever that can show sexual identity, the way chromosomes tie to physical sex. At that point, it becomes much more clear to see how a person’s sexual identity is at odds with the physical one.
And I think it is inherent in the concept of identity that we choose our mental one over our physical one. After all, the “me” I experience is the internal one, only mostly linked to the exterior one of this body. But “me” is the “me” inside. So why should this be different if I were somehow teleported to a woman’s body? And wouldn’t I be rightfully upset that everyone now sees and treats me as a woman, when I’m still a “man” inside?
> [@adaher](#):
>
> For me the issue isn’t body modification. It’s believing something that is just not true.
>
> Sex is a defined biological characteristic. You are male or you are female, or you have a birth defect that leaves you with something else. If you are male, however, you are male. If you are male and you think you are female, you unquestionably have a mental disorder.
You seem certain that sexual identity is not a real concept, that there is no biological basis for it. But the sexual makeup of our bodies is defined not simply by our genetic code - the Xs and Ys of our chromosomes - but also by a string of hormone activations that are triggered during our development, including fetal development. And those hormone triggers can be thrown out of sequence or otherwise activated in mismatch to the chromosomes. Not only for odd chromosome mixes (XXY, etc), but even within nominal XX or XY sets. So why are you certain that transsexuals are not the result of some odd mismatch in hormonal triggers defining the mental state differently, flipping one switch male and the other female, as it were?
And if that’s the case, then it is not a clear case of the person being something at odds with reality. It’s a case with their specifics not matching the standard case of all M or all F, but getting a mismatched set of states. So they are not ad odds with reality, the are merely choosing from their two options which best represents how they feel over how they look, because feeling is more important than looking.
> [@](#):
>
> Not only that, but isn’t the very concept sexist? Genders don’t have defined roles anymore. How would one know if they should be one or the other in the absence of such roles?
It’s not strictly true that there are not gender defined roles. Sure, job markets are much more egalitarian, but society still does have some social hangups. For example, those roles about who can wear pink frilly dresses and who can play football (the kind with pads and tackling, not the kind where you only use your feet).
But regardless of that, your question is staggeringly ill-informed. Gender identity is less about “I like to wear dresses” or “I want to play with trucks and guns”, and far more about “I don’t feel right”. It’s easiest to see through the physical choices demonstrated, like choice in clothing and activities, but the internal experience is where the real issue is.
> [@](#):
>
> “We were getting dressed, and he wanted to wear a dress. He wanted to be pretty like his sister,” said Stephanie. “He was saying, ‘I want a dress. I’m a girl, Mommy, I’m a girl.’ And I’d say, ‘No, honey, you’re a boy. You have a penis, you’re a boy. Allie’s a girl.’”
>
> No, RICHARD, you are a boy who likes dresses and pink. There’s nothing wrong with that. So stop trying to cut off your own penis!
:rolleyes: What makes you qualified to tell Richard what he/she actually experiences inside his/her head?
> [@Blake](#):
>
> That is easily established for members by simply doing a search on the quote. Here is the post in question.
You mangled that link.
[http://boards.straightdope.com/sdmb/showthread.php?p=15258563](http://boards.straightdope.com/sdmb/showthread.php?p=15258563)
> [@](#):
>
> But yeah, the main point is obviously true. When the ideas in your head don’t match consensus reality, the problem is with your head, not in reality: you have a mental problem. The difference between someone who thinks they are another sex and someone who thinks they are a space man is practically non-existent.
As far as I am aware, there are not a string of hormonal triggers that activate during development that define whether you are a space man (or a dragon or Napoleon). So that is one solid distinction for transgenders.
> [@adaher](#):
>
> Now personally I think everyone should just be who they want to be, but much as my right to swing my arm ends at another person’s face, your right to pursue a different identity ends where it requires another person to accept something that is false. We have 100% freedom to view ourselves as we wish, but by the same token everyone else has the freedom to view you as you actually are.
And how are they, actually? They have a physical male body, but a female identity. Sure, it’s easier to see the body, and thus it primes our reactions, but their experience is less how they look and more how they feel.
And the reaction to transgenders seems to be saying that they shouldn’t pursue actions to change their physical body to meet their mental one, so that your observation is more in line with their experience. If you want to view people as they actually are, then why all the hangups over SRS? Why do transgenders getting hormones and SRS still get treated as freaks for not complying with “reality”? They’re doing their best to shape reality to a consistent set, not a mismatch between outward and inward.
> [@adaher](#):
>
> Society should accept that boys and girls will do whatever they want. What society cannot accomodate is boys wanting to use female facilities even though they have a penis.
Why not? You state that as a fact, but it’s just an assertion.
The whole problem appears to be discomfort at what someone else is doing. You are experiencing personal discomfort at what that individual over there is doing, how they are protraying themselves. You wish they wouldn’t intrude their behaviors that you find odd into your space.
The thing is, this discomfort is not an inherent thing of nature, forever bound to men in a dress or women with facial hair. It is, rather, the reaction that comes from lack of familiarity. The lack of social familiarity leaves you without a defined category of where to put them and how to react to them. It is exactly the social discomfort that comes from dealing with other races outside your common experience, or dealing with dwarfs, or dealing with people with severe burn scars, etc. Those things are unusual enough to stand out and leave you not knowing how to fit them into your social patterns. With transgenders, it is slightly worse, because they trigger your desire to fit them in one category but that category is at odds with they way they wish to be perceived. Thus that disconnect is the source of social discomfort.
But what if we approached this from a different direction? Instead of freaking out about it, we as a society learned to categorize them as “transsexuals” and then accept them for the way they wish to be perceived? What if we innundated our culture with this message of acceptance, the way we are trying to shift culture to accept homosexuality, the way we are doing so with interracial relationships and marriage? What if everyone got their “Mommy what is that thing?” out of the way as children, the way many of us do with race and other things? It’s no different than seeing a man with a beard for the first time, or someone in a wheelchair, or those funky piercings all over the face and face tattoos. “That’s just people being different.”
> [@Blake](#):
>
> Firstly, transgenders _don’t_ say “Treat like a man/woman”. They say “I \*am \*a man/woman”. And they (or the ones I have met or heard of) become offended and irate if anyone says “Sure I’ll treat you like a woman, but you’re really a man with his penis amputated.”
But why do you have to perceive them that way? Why can’t you perceive them as a woman that was accidentally born with a penis?
> [@](#):
>
> The point being that people don’t treat people “as women” they treat them as a type of woman. But transgenders, especially younger ones, very often don’t fit into any type for obvious reasons. As such it’s impossible to actually treat them “as women”. All anyone can do is treat them as a type of woman which they are not, rather than treating them as a transsexual man.
And how should you treat a transsexual man? Why not treat them as a type of woman, a woman who was born in a male body?
> [@](#):
>
> Thirdly, you are asking people to go out of their way to reinforce your divergent view of reality. You aren’t asking people to treat you as a transsexual male, which you are and what they will naturally treat you as. You are asking them to constantly check the behaviour they are comfortable with and that conforms with reality in order to reinforce your fantasy that is at odds with reality. That is pretty damn rude.
And how should one treat a transsexual male? Like a man who wants to wear a dress and talk funny? Or like a woman who has an adam’s apple and maybe looks a little too masculine for you to be attracted to her?
> [@Broomstick](#):
>
> Assuming for the sake of this discussion that transsexality is a mental illness, for me the question then becomes how can we best alleviate this person’s suffering?
>
> Can we cure this mental illness? No.
>
> Can we dispense some medication that will put this mental illness into remission? No.
>
> Then the question becomes “does sexual reassignment treatment result in happier/more functional mentally ill human beings?” Note I said _treatment_, not _surgery_. While the surgical treatments tend to attract a lot of attention a lot of transsexuals stop at hormone treatments or something else.
I certainly agree we need to look at the treatment and measure it’s effectiveness. I don’t think, for those purposes, we should lump all kinds of modalities together. What kind of therapy is effective? What kind of SRTs are effective? Is surgery necessary? How well does it work?
And just to throw a monkey wrench into the topic, what about cases like the East German athlete from the 80’s? A female athelete that part of the East German Olympic training regimine was subjected to high doses of anabolic steroids during childhood and puberty, and she became an Olympic winner in IIRC shot put. Of course, she had all sorts of identity issues, and later went on to complete transformation to male. Various other women given similar treatment but to lesser degrees remained female, but have had a host of health issues since then. That case appears to be less a case of internal hormonal signals during development creating sexual identity, and more a case of the injected hormones causing enough changes that the person’s psychological state was affected.
---
### Author:  [@DocCathode](https://boards.straightdope.com/u/DocCathode)
#### Post date: [August 17, 2012, 8:52pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/34 "2012-08-17T20:52:06Z")
First
A number of you are using “sex” and “gender” as synonyms. They are not the same. Sex is biological. Gender is social.
[http://jcem.endojournals.org/content/85/5/2034.long](http://jcem.endojournals.org/content/85/5/2034.long)
TLDR version- The human brain is sexually dimorphous. Transsexuals have a brain that is much closer to the sex they ‘feel inside’. The differences in their brains are not caused by hormone therapy. Gay men and lesbians showed no such differences.
---
### Author:  [@namatad](https://boards.straightdope.com/u/namatad)
#### Post date: [August 17, 2012, 8:55pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/35 "2012-08-17T20:55:55Z")
> [@](#):
>
> For example, one study found that of 727 subjects who had undergone male-to-female SRS, 539 had a known address, 420 of those had a correct known address, 417 of those were still alive, 355 of those agreed to participate, and 232 of those returned their forms. Of the last group, 86 percent rated their “happiness with result” at 8 or higher on a 10-point scale, and only four percent said 5 or below.
86% of respondents were happy. 200 out of 232. That is a significant percentage.
All surveys have the problem of respondents versus total subjects. Most surveys would kill to get 232 respondents out of 727 subjects!!
In the end, survey researchers would look at a 30% response rate and be happy.
86% report being happy! That is much higher than I would have guessed and even if biased, still probably indicative that most people who get surgery are happy about it.
---
### Author:  [@namatad](https://boards.straightdope.com/u/namatad)
#### Post date: [August 17, 2012, 9:06pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/36 "2012-08-17T21:06:32Z")
> [@Una\_Persson](#):
>
> I disagreed with Cecil’s conclusions in this column. He and I had very many conversations over how to interpret the problem of high drop-out rates. I believe there is a preponderance of evidence, despite the dropout rates, to err on the side of “hormones/SRS are good and proper treatment.” Later on I intend to post some of my citations to support my position.
You would think by now that you would have beaten Cecil with the stat stick enough that he would at least sort of, kind of understand that stats are mystical and strange and worse, counter intuitive at times.
The fact the some studies are showing the low respondent rates might be more accurate than high respondent rates is even crazier.
---
### Author:  [@Martin\_Hyde](https://boards.straightdope.com/u/Martin_Hyde)
#### Post date: [August 17, 2012, 11:02pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/37 "2012-08-17T23:02:01Z")
> [@DocCathode](#):
>
> First
>
> A number of you are using “sex” and “gender” as synonyms. They are not the same. Sex is biological. Gender is social.
>
> [http://jcem.endojournals.org/content/85/5/2034.long](http://jcem.endojournals.org/content/85/5/2034.long)
>
> TLDR version- The human brain is sexually dimorphous. Transsexuals have a brain that is much closer to the sex they ‘feel inside’. The differences in their brains are not caused by hormone therapy. Gay men and lesbians showed no such differences.
Here you go again, citing a study that says a _certain part of the brain_ in a **very small sample size** of transsexual men have characteristics **more similar to female brains than male brains** , it does not ever conclude what you want it to.
The research done in that article is good research, but you’ve misrepresented it multiple times on these boards now to satisfy a bias that you have.
The simple fact is, transsexuality or gender identity disorder if you will is a recognized mental illness. No science has ever shown that MtF GID patients have overall brains more similar to females than males, what we’ve instead shown is that in a small sampling of MtF GID patients the central subdivision of the bed nucleus of the stria terminalis (or BSTc as they say) is more akin to a healthy female sample than a healthy male sample. Specifically there were two studies, the first study by Zhou showed a sampling of MtF GID patients undergoing hormone treatment and showed their BSTc was similar in _size_ to that of a healthy female. The second study which you link to and misrepresent here for at least the second time on these forums had a large sampling of around 40 brains and included MtF GID patients who were not undergoing hormone therapy. The second study demonstrated the difference in size of a MtF GID patient’s BSTc was on account of a different count of neurons, and wasn’t the result of something else like a possible side effect of hormone treatment in the group in Zhou’s study.
I also most say, it was quite the surprise to see a quote of mine end up in a question someone asked. I am glad my post from that original thread got someone thinking about things, and I’m also glad “Cecil” looked at the evidence without bias and correctly answered the question to the best consensus of current science.
---
### Author:  [@Una\_Persson](https://boards.straightdope.com/u/Una_Persson)
#### Post date: [August 17, 2012, 11:36pm UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/38 "2012-08-17T23:36:39Z")
> [@Martin\_Hyde](#):
>
> The simple fact is, transsexuality or gender identity disorder if you will is a recognized mental illness.
A psychologist who talked to me about this today commented that just being the DSM does not in itself mean it is a “mental illness.” The DSM includes things which are not mental illnesses, such as brain/cognition/affect disfunctions. These range from head trauma to substance tolerance to reading disorders to relationship issues to mental health issues.
> [@](#):
>
> No science has ever shown that MtF GID patients have overall brains more similar to females than males, what we’ve instead shown is that in a small sampling of MtF GID patients the central subdivision of the bed nucleus of the stria terminalis (or BSTc as they say) is more akin to a healthy female sample than a healthy male sample.
And what is the level of similarity needed? What percentage, or what regions, must be similar in order for an assessment of an M2F brain to yield support for a claim of similarity to an XX brain?
> [@](#):
>
> I also most say, it was quite the surprise to see a quote of mine end up in a question someone asked. I am glad my post from that original thread got someone thinking about things, and I’m also glad “Cecil” looked at the evidence without bias and correctly answered the question to the best consensus of current science.
It’s your _opinion_ he looked at it without bias. My _opinion_ is he was overly pessimistic. I offered 18 citations in a post up above which provide support for my opinion.
---
### Author:  [@AHunter3](https://boards.straightdope.com/u/AHunter3)
#### Post date: [August 18, 2012, 12:34am UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/39 "2012-08-18T00:34:33Z")
Transsexuals may or may not [del]be mentally ill[/del] have a less than fully accurate model of reality inside their heads.
In my experience a rather formidable number of non-transsexual people are pretty badly twisted in the heads when it comes to gender, sex, morphology, and sexuality, and a good portion of what they consider to be inviolably true about gender and sex is less than fully accurate by an even larger margin.
On top of all the other considerations and issues, I’d like to point out that many people’s erotic sensibilities are such that they have an eroticized interest in seeing certain things about either themselves or their partner NOT as they necessarily objectively are but as desire and desirability demand that they be. “I am a person with male bits whose nature and preferences and personality and tastes are more akin to what you’d most often find among people with female bits” may not have the right emotional impact for them and how they need to feel about themselves as “I’m a woman” or even “I’m a seductress” or whatever.
I can’t relate firsthand to being truly at odds with the bodily plumbing itself, it’s just not where my experience lies. I’ll grant that sexual reassignment surgery is several steps more significant a body modification than what most people do to feel attractive and sexy and appropriately configured, but it’s not like no one does body mods. And it’s really NOT like chopping off your legs. It doesn’t create huge disabilities and deficits. There are lesbians who have their breasts removed NOT in order to transition to maleness but “just because”. Does that make THEM sick? How about breast implants?
---
### Author:  [@Powers](https://boards.straightdope.com/u/Powers)
#### Post date: [August 18, 2012, 12:48am UTC](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759/40 "2012-08-18T00:48:57Z")
> [@Blake](#):
>
> But if I want to be called a woman, for some reason everybody, including the police and my employer are obliged to act as though my mental divergence from reality was true.
You are presuming that gender is determined solely by physiological sexual development. That is an unwarranted presumption.
Gender is a mental construct; sex is a physical construct. When the two don’t match, who is to say that the physical one is right and the mental one is wrong?
Powers &8^]
[Previous page](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759.md?page=1)
[Next page](https://boards.straightdope.com/t/are-transsexuals-mentally-ill/631759.md?page=3)