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Male-to-female (MTF) transsexual refers to biologically born males who identify as female or as a woman and who may seek to undergo or have undergone hormonal and/or surgical intervention(s) to align their external physical sex with their internal female gender identity. Conversely, female-to-male (FTM) transsexual refers to biologically born females who identify as males or as a man and seek to undergo or have undergone hormonal and/or surgical interventions to align their physical characteristics with their male gender identity. According to the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, the prevalence of MTF is approximately 1 in 30,000 whereas the prevalence of FTM is reported to be 1 in 100,000.

Whereas transsexuals may identify as transgender, not all transgendered individuals are transsexual, the distinguishing characteristics being that the individual's gender identity does not align with the gender assigned at birth and that medical intervention(s) may be sought to alter external physical presentation to match internal gender identity. Common interventions for MTF transsexuals include feminizing hormones (e.g., estradiol, antiandrogens, gonadotropin suppressors) that modify secondary sex characteristics, cosmetic surgery (e.g., facial feminization, electrolysis, breast augmentation), and sex reassignment surgery (altering sex genitalia).

Though a number of theories have been proposed in attempts to understand and explain the developmental processes that relate to transsexuality, the etiology remains under debate. Historically, models have conceptualized transsexuality as a psychological disease or disorder that contradicts typical development. A large body of psychological literature exists around the notion that transsexuality can be defined as gender identity disorder or gender dysphoria. The DSM-IV lists five criteria that must be met in order for a diagnosis of gender identity disorder to be applied: (1) there must be evidence of a strong and persistent cross-gender identification, (2) this crossgender identification must not merely be a desire for any perceived cultural advantages of being the other sex, (3) there must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex, (4) the individual must not have a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia), and (5) there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning.

A number of researchers (i.e., Kurt Freund, Gunter Dorner, J. Michael Bailey, Ray Blanchard, Anne Lawrence) have proposed biological explanations for transsexuality, including that it represents a neurological form of intersexuality. In these theories transsexuality is thought to result from prenatal exposure to hormones that alter the brain in ways that affect the formation of gender identity. However, the majority of evidence for such assertions comes from behavioral research conducted with animals that have been exposed to varied hormonal levels during neonatal development. Even within these studies the results are inconsistent at best. Although further research may one day establish a link between prenatal hormonal exposure and transsexuality, in the early twenty-first century, such explanations should be viewed with caution.

Though the majority of transsexual individuals do not begin to live in the social role that represents their internal gender identity or seek medical intervention until they reach adulthood, some may begin to express their desire to live in the opposite gender role in childhood or adolescence. However, it is not uncommon for individuals to acknowledge, retrospectively, feeling that their internal gender identity and external biological sex were discrepant from an early age. Regardless of when an individual begins to identify as transsexual, most suffer from emotional and psychological distress due to the inconsistencies of internal gender identity and external anatomy coupled with social disapproval.

The process of transitioning refers to the period of time when the individual moves from living in one gender role to living in the other. Often this period begins with subtle changes in appearance, such as changes in hair style and clothing, and ends after the individual has fully moved into the desired gender role (with or without hormonal and/or surgical intervention), living full time as that gender. The process of transitioning may include hormonal and/or surgical intervention to bring external physical characteristics in line with gender identity. Transitioning may be a time of significant psychological and emotional distress as the individual seeks acceptance in his or her new role.

Not all transsexuals seek or undergo sex reassignment therapies. Such interventions can be extremely costly and are usually not covered by standard health insurance. For those who do, sex reassignment interventions can include hormone therapies aimed at altering the appearance of the secondary sex characteristics and sex reassignment surgery that alters the primary sex characteristics (e.g., genitalia).

The requirements for hormonal and surgical interventions vary widely. Some physicians require that patients live in their desired gender role for a specific period of time, perhaps up to one year, prior to beginning hormonal treatment. This period is usually referred to as the real-life test (RLT) or real-life experience (RLE). However, this is not always possible for some individuals because they require hormone treatments in order to adequately pass (be perceived as the opposite gender by others) in society. Many MTFs require facial hair removal, facial feminization surgery, and vocal training or surgery in addition to hormonal treatments in order to pass as women. As a result the most recent version of the Standards of Care (SOC) set forth by the World Professional Association for Transgender Health (formerly the Harry Benjamin International Gender Dysphoria Association) suggests that a person may also be approved for hormonal treatment after a period of psychotherapeutic assessment and diagnosis.

Though some physicians are willing to prescribe hormones to patients upon request, many are hesitant to do so without the RLT or proof of psychological treatment because hormonally induced changes can become quickly irreversible, particularly in men. Some transsexual individuals choose to bypass the requirements of the medical community by purchasing their hormones on the black market, often via the Internet. However, substances purchased through the black market may not be safe or effective.

Sex reassignment surgery, also referred to as genital reassignment surgery, is performed to align an individual's external genitals with their internal gender identity. Specific types of genital surgery include vaginoplasty (constructing female genitalia) and phalloplasty (constructing male genitalia). These surgeries can be very risky and do not always result in the desired outcomes. Potential side effects can include problems with urinary and bowel functioning, loss of orgasmic ability, postoperative infections, and persistent genital pain.

Because sex reassignment surgery is permanent and risky, most physicians in North America and Europe require that the individual live as the desired gender for a specified period of time (RLE), usually one year, and undergo psychological evaluation prior to being approved for surgery. However, requirements are often less stringent and less costly in other countries, particularly in Asia; therefore, some individuals bypass requirements by traveling for surgery.

Transsexuality has been observed across cultures and is accepted to varying degrees. The first MTF transsexual to gain notoriety in the United States was Christine Jorgensen (formerly George William Jorgensen, Jr.), a U.S. citizen and World War II veteran who underwent hormonal treatments and sex reassignment surgery in Copenhagen, Denmark in 1952. Whereas Jorgensen is responsible for the early visibility of transsexuality in the United States, transsexuals have played an important role in non-European and non-North American cultures for centuries. For example, in India hijras undergo sex and gender change, adopting feminine styles of appearance and dress. Hijras serve an important role in Indian culture, performing at various ceremonies that celebrate the life cycle (e.g., weddings and the celebration of male births). In Thailand the kathoey are considered an intermediate or third sex/gender category that exists alongside the male/man and female/woman categories of gender. Kathoey are highly visible and many perform in transvestite revues and theaters and participate in beauty contests. Kathoey are often viewed as entertaining and humorous, making them popular among men and women. The Philippines also has a long tradition of transgendered roles that are highly valued. Depending on the region these individuals may be referred to as bakla, bantut, or bayot. Bakla are biological males believed to have a feminine heart. The largely positive social attitudes that surround bakla are primarily based on their ability to transform themselves into glamorous women, often competing in beauty pageants or contests that earn them a great deal of social prestige.

Since the mid-1990s there has been a notable rise in activism among a number of gender variant groups, including transsexuals. The Internet has provided a forum for transsexuals to share experiences and provide support and advice. Further, many European and North American societies in the early twenty-first century have policies and procedures that allow transsexuals to change birth records and other documents to reflect their gender identity. Though many countries are enacting laws to protect transsexuals from discrimination in the workplace and elsewhere, these laws are not always fully enforced.

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Lawrence, Anne. 2004. ''Autogynephilia: A Paraphilic Model of Gender Identity Disorder.'' Journal of Gay and Lesbian Psychotherapy 8(1/2): 69-87.

Meyer, Walter, III; Walter O. Bockting; Peggy Cohen-Kettenis; et al. 2001. ''The Standards of Care for Gender Identity Disorders--Sixth Version.'' International Journal of Transgenderism 5(1).

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