Basic TG/TS/IS Information
by Lynn Conway
Copyright @ 2000-2006, Lynn Conway.
All Rights Reserved.
Part II:




עברית (Hebrew)





Photo of Lynn, July 2006.

 [Click for larger view]

We learned in Lynn's story that she was born and raised as a boy, and later in life was changed into a girl by female sex hormone treatments and major surgical procedures. Because of this past, Lynn is sometimes called a "transsexual" woman. Why did this happen to Lynn, and what is transsexualism anyway?
In Part I, we first answered some basic questions about gender and transgenderism. We learned about the nature of gender identity, about where it comes from and about what events occur in nature that interfere with correct assignments of gender. We also learned about transgenderism and transgender (social) transitions.
Here in Part II, we provide detailed information about MtF transsexualism, including historical, cross-cultural and prevalence information. We also describe current methods and technology for complete MtF transsexual transition, and provide links to more information about TS (social and physical) transition.
Then, later in Part III, we discuss the lives of women after MtF transsexual transition. Many short term practical issues face these women, and they also must manage longer term issues such as living in stealth vs being open about their pasts, adjusting or severing post-transition relations with family, relatives and former friends, dealing with a variety of legal issues, obtaining compassionate health care, finding good employment and managing their careers, adjusting to their new sexuality, finding and maintaining love relationships, and achieving full social assimilation as a woman.
Knowledge in this area is under rapid development. The taboo on this area has also been broken, so that we can openly discuss these important issues without fear, shame or embarrassment. Much more is known about transsexualism and methods for transsexual transition than just a few short years ago, and those new understandings are very much worth sharing and building upon. Far more people suffer from transsexualism than previously suspected. The key to improving the quality of their lives is better knowledge and more widespread understanding of all this emerging knowledge.

Part I: Gender Basics & Trangenderism

Part II: Transsexualism (MtF)

Part IIa: (TS continued)

Part III: Life as a Woman After TS Transition 
 TS Womens' Resources
 TS Women's Successes (es)
 Facial Feminization Surgery (FFS) (es)
 TG/TS/IS Info Links
 Successful TransMen (es)
 Sex Reassignment Surgery (SRS) (es)

Part II - Contents:
 Historical and cross-cultural evidence of transsexualism
 What causes transsexualism?
 Do we really need to know the cause in order to treat the condition?
 How frequently does transsexualism occur?
 The important implications of "The Numbers"
 How is MtF transsexualism medically treated?
 What is transsexual transition?
 Transitioning "On the Job", and how FFS can insure employment continuity:
 At what ages to TS women transition? And what does it cost?
 Continued - in Part IIa:
 Transitioning Early in Life
 The great obstacle to transition: The challenge of confronting and coping with fear
 Fear is often heightened by GLBT activism which portrays all TG's & TS's as "victims"
 WARNING: Be sure to visualize the real risks of transition and factors that affect success
 Assessing risks, making decisions, and taking actions during transition
 How can family, friends, teachers and co-workers help a transsexual woman in transition?
 With better understanding, how might transsexualism be treated someday?
 TS Success Stories: Websites of Successful Post-op TS Women
Transsexuals are the most intensely afflicted of transgender people. They strongly feel that they are, or ought to be, the physical gender opposite to that in which they were born and raised. The body they were born with does not at all match their own inner gender feelings and image of who they are or want to be, nor are they comfortable with the gender role that society expects them to play based on that body. Most are painfully aware of their gender incongruity from very early childhood. While transgender transitioners feel compelled to correct their social gender, transsexual transitioners feel compelled to also correct their physical gender.
If you've seen the movie Boys Don't Cry, then maybe you can visualize the deep feelings and passions that drive a transsexual teenager (in that case a female to male (FtM) transsexual) into crossing over the gender divide, the joys they feel when accepted and finding love on the other side, and the terror and humiliations that await them if their status is ever discovered.

The movie Different for Girls also conveys some of the nature and depth of early transsexual feelings, especially in its powerful and poignant opening "shower scene". Here a young male-to-female (MtF) teen is seen experiencing transsexual girly body feelings, with her genitals tucked away and hidden from herself . While in this reverie, she feels some of the joys of being a sensual woman, at least for a little while.
Suddenly, she is set upon and violently attacked by a group of boys
who've witnessed her behavior:

Fortunately, she is rescued by another boy who confronts the group,
puts his jacket around her and comforts her:

This scene from Different for Girls captures ever so much of the inner experience of being a young trans girl, from experiencing the joys of a blossoming female sensuality, to experiencing the dangers of being attacked for exhibiting those feelings.
You can see in her responses in this unfolding situation, in the lonely terror and vulnerability in her eyes, and in her emotional release into the arms of her rescuer, that she is inherently a girl inside - even though she exists at the time in a boy's body. The movie well portrays the inherent femaleness of this young trans girl, as opposed to the more exaggerated effeminacy frequently seen in young gay boys.
For more about this scene, see Victoria Jefferies page "Boys - personal reflection", which is located in her wonderful website for young trans girls, "From Within". Many thanks to Vicky for capturing these still-images from the movie! (Note that Vicky had a somewhat similar shower experience when she was a young teen.) Vicky's overall website conveys in many powerful ways what it feels like to be young and trans, and is highly recommended reading.
The behavior of experiencing female sensuality while hiding their genitals is a very common behavior in young trans girls. As they grow older and begin to be masculinized by testosterone, the time may come they when no longer can conceal from themselves and others the effects of the awful transformation being forced upon their overall bodies. From this point onwards they may experience intense emotional distress and anxiety.
Thus many transsexual people feel almost claustrophobically trapped and destined to live out their lives "imprisoned in the wrong body", unless they can correct the situation with sex hormones, sex reassignment surgery (SRS) and complete physical transition. They long to live out their lives in the correct gender not just socially, but also in their private, intimate lives too - in the right body for their inner gender feelings. 
They feel as you might if you suddenly found yourself physically changed into the opposite gender and forced into that gender role, while still having all the body feelings and social identifications of your old gender. It is a profoundly disorienting experience to have a body that is totally wrongly-sexed. Everyone is challenged in their efforts to find love in this life. Can you imagine how frightening and challenging that is if you were wrongly sexed?
For an excellent overview of both MtF and FtM transsexualism, see: True Selves: Understanding Transsexualism - for Families, Friends, Coworkers and Helping Professionals, M. L. Brown and C. A. Rounsley, Jossey-Bass Publ., 1996.]. For a discussion of the now internationally standardized protocols for medically and surgically treating transsexualism, see the "HBIGDA Standards of Care, Version Six" of the Harry Benjamin International Gender Dysphoria Association.
[ *Note: In this webpage we focus on male to female [MtF] conditions, since those are within Lynn's direct experience. However, there is a completely symmetrical set of female to male [FtM] gender conditions that are almost as common as MtF conditions. For more information about FtM transgenderism and transsexualism, see the websites of FtM International and The American Boyz. The article "Girls will be Boys", by T. Eve Greenaway discusses the sudden emergence of FtM transgenderism out of the shadows and into the open in many U.S. colleges and universities. For in-depth background on FtM transgenderism and transsexualism, see the recent book by Jason Cromwell, Transmen & FtMs. See also Lynn's webpage listing weblinks and photos of Successful TransMen (es). ]
Historical and cross-cultural evidence of transsexualism
Transsexualism is not a "modern discovery". Instead it is a not-uncommon, naturally-occurring variation in human gendering that has been observed and documented since antiquity.
In many cultures, including native tribes in North America, transsexuals have long had the choice to cross-dress and live their lives as women, including taking husbands. The surgical alteration of genitalia to relieve intense cross-gender feelings was also not "invented in the twentieth century". In some cultures, including many ancient ones, many transsexuals have voluntarily undergone surgeries to modify their bodies in such a way as to "change their sex".
The surgical methods and the effects of castration were everywhere for the ancients to see. Its use in the domestication of animals quickly taught ancient people that removal of a human male's testicles at a young enough age would prevent his masculinization too. Such a person would forever be childlike - or "girly". These surgeries were also often forcibly done upon captive adult male slaves in order to "domesticate them" as "eunuchs". Performing such surgeries on normal post-pubertal males does not change their gender feelings or gender identity, although is lessens their sexual drives somewhat and sharply reduces their ability to develop male musculature.
The accumulated knowledge about the effects of castration was further extended to help MtF transsexual girls: Untold millions of them over thousands of years have voluntarily sought and undergone surgeries vastly riskier and more dramatic in effect than mere castration. In these surgeries the girls are completely emasculated by total removal of the testes, penis and scrotum. In addition, the external pubic area is often roughly shaped to look like a girl's vulva. No one knows precisely how it started, but such transsexual surgeries were well known by the time of ancient Greece and Rome. These transformations were usually traditionalized in "religious rituals" that provided the resulting "women" with an explanation for what they had done, and thus a "cover story" for finding a place in society.
By undergoing these surgeries, young MtF transsexual girls (if they survived) not only avoided becoming men, but also gained genitalia that looked somewhat like those of a woman. Although lacking vaginas and lacking the powerfully feminizing effects of female sex hormones, young transsexuals in the past could nevertheless live life better as women after undergoing such surgery. By retaining their pretty girly features and soft sensual skin from childhood, and by avoiding becoming hairy all over and having craggy facial features, some of them could attract and enjoy male lovers as women. In some societies they could even hope to find a husband to love them and care for them.
Many skeletal remains of surgically modified transsexual women from ancient times have been uncovered by archeologists, who usually refer to them in confused terms as "eunuchs" and "transvestites", as in the BBC story "Dig reveals Roman transvestite" about a skeleton found recently in England. Here's an excerpt and a photo from that BBC story:
Excerpt from a recent BBC news story:
"Archaeologists in North Yorkshire have discovered the skeleton of a cross-dressing eunuch dating back to the 4th Century AD. The find was made during excavations of a Roman settlement in Catterick, first started in 1958.
The skeleton - found dressed in women's clothes and jewelry - is believed to have once been a castrated priest who worshiped the eastern goddess Cybele. - - - The young man was found buried in a grave at Bainesse, a farm near Catterick, and once an outlying settlement of the Roman town.
He wore a jet necklace, a jet bracelet, a shale armlet and a bronze expanding anklet - - - In life he would have been regarded as a transvestite and was probably a gallus, one of the followers of the goddess Cybele who castrated themselves in her honour."
It is so sad when archeologists naively obscure and inherently ridicule this girl's gender identity by calling her a "cross-dressing eunuch". Such comments reveal their lack of understanding of human nature in the large, and their lack of appreciation for how sophisticated some ancient civilizations were when accommodating gender variations. Those who are knowledgeable about transgenderism and transsexualism will recognize that this person is not a "eunuch" (a male-gendered boy or man who has been castrated - in ancient times usually as a slave), nor is she a "transvestite" (an intact male-gendered man who is cross-dressing for male erotic satisfactions).
Instead this person was very likely an intensely transsexual girl who desperately sought and willingly underwent a voluntary emasculation surgery at a young age, probably her early teens, and then lived as a female "priestess" afterwards. The evidence that she underwent her primitive sex change early in life is staring right out at us in the photo above: The girl has no male brow-ridge on her forehead above and between her eyes (take a close look at the photo above). Given her rounded female facial structure and slight build, she may have been a very beautiful woman. Her elaborate burial upon her death in her early twenties suggests that she was very much beloved, and perhaps left behind a grieving lover or patron.
These ancient practices continue in some parts of the world even today. In India and Bangladesh very large numbers of desperate young transsexuals run away from home to join the "Hijra" caste. To become Hijra, these teens voluntarily undergo fully emasculating surgeries under primitive conditions just as they would have in ancient times, with only opium as an anesthetic. Most undergo the surgery in their teens shortly after the onset of puberty, with results as seen in the photo of a young Hijra woman on Lynn's SRS webpage. By being castrated just early enough they can avoid the development of male secondary sex characteristics (except for the breaking and lowering of the voice), and their bodies can remain permanently soft, childlike and girly. These "sex changes" and their effects are shrouded in mystery and religious symbolism.
The possibility of being able to undergo such sex-changing transformations is widely known about in India, and exerts an incredibly powerful and mystical calling to all young transsexual girls there. About one in every four hundred such teenagers runs away from home in modern India and becomes Hijra, and there are now approximately one million of them in the country.
Contrary to popular myth, total emasculation after puberty does not necessarily "de-sex" the young person. Castration after puberty leaves the young Hijra with her newfound feelings of sexual arousal and her newfound orgasmic capabilities. While the psychological impact of such surgery would cripple the libido of a normal male, the effect on a young transsexual girl is just the opposite: The surgery is liberating, and enables a fuller expression of her sensuality and libidinous feelings. Just as in the case of modern post-operative transsexual women, many Hijra can have strong feelings of sexual arousal in the inner remnants of their genitalia (even though they lack the external nerve tissue preserved by modern SRS). Although Hijra lack vaginas, many greatly enjoy (to orgasm) penetrative (anal) sexual activities with men. Because of their complete emasculation, Hijra genitalia and pelvic regions look very "girly". Many men in India greatly enjoy lovemaking with Hijra, and thus the girls can find some small measure of intimate contact, passion and love in this life.
Most Hijra live out their lives as women with other Hijra in "family groups", earning an existence by performing in traditional ceremonies at weddings and childbirths. Many work as prostitutes and beggars in this lowest of traditional Indian castes. Some Hijra today are fortunate to have access to female hormones, and can feminize their bodies by growing breasts and developing natural female body contours. The combination of emasculation as teenagers combined with use of estrogen enables some Hijra now to become very beautiful - even though, sadly, they do not have female genitalia (vaginas) and are not socially accepted as women.
The Hijra community and its traditions, including their very basic form of "sex change" from male towards female, has a recorded history of over 4000 years in India.  This widespread practice in India enables transsexual kids to escape the angst and fate of masculinization as teenagers, and provides a safe though very lowly place in society for them. The agonizing extremes to which these transsexual youngsters will go in order to "approximately have a female gender", with full knowledge that they will never see their families again and will face social degradation for the rest of their lives, is a testament to the reality and extremity of the gender conflict that they face within themselves.
Today in India the Hijra are thought of as a "third gender", and are often called "eunuchs" because of the British use of that term for them. This use of the word eunuch is a total misnomer and is very unfortunate, because that English word has long been used to signify castrated adult males who identify as males. The word conjures up images of loss and neutering, rather than of feminization and the resolution of gender confliction. Thus the word does not convey the transsexual nature of the Hijra, and tends to further marginalize them as social outcasts.
That indeed was their fate during the period of colonial British oppression in India. Before British rule many Hijra lived fairly secure lives working as domestic "girls" in the homes of wealthy people and by performing during numerous ritual ceremonies. However, many traditional Hijra social roles were eliminated by homophobic British colonials unable to visualize the deep meaning of Hijra traditions. Many Indians themselves then came to view the Hijra as "perverted" street people, by buying into the "modern and advanced" British colonial attitudes towards this gender minority.
In the face of caste stigmatization, the Hijra are secretive about their surgical initiations and practices. Some say that they were abducted and emasculated against their will, making it seem to "not be their fault". Although they view their emasculation surgery as a "sex change", the Hijra are also realistic in their recognition that they are not really women. However, they wear female clothing, take feminine names and use female pronouns. They embrace their ambiguous status as preferable to being men, for them. The practice is very widespread in India and Bangladesh (see Prevalence section, below). For more information see the Kinnar (Hijra) website at
Although shrouded in caste secrecy and mystery for centuries, the underlying condition that compels most of the young teenagers who become Hijra is clearly transsexualism. Says Dhanam, the leader of a Hijra family in India (i.e., a Hijra 'Guru'):
"We are born with a gender identity crisis. It is not an imitated or learnt one,
but a natural instinct that urges us to be women.'' - Dhanam
Important note: In 2002 Lynn began to communicate with a number of Hijra women in India, and strongly suggested that they try wherever possible to eliminate the use of the word "eunuch" to refer to them. Lynn suggests that they substitute the word "transgender" or "transsexual" for "eunuch" whenever they are using English. If the Hijra can gradually bring about this change in English terminology in India, they would more correctly be seen as transgender and transsexual women instead of as some kind of weird "crossdressing-castrated men". Such a change in viewpoint about their nature could help make a much stronger case for the "transgender rights" of Hijra in India.
Even in the modern western world some truly desperate young transsexual girls who cannot find help from the medical system will "commit Hijra" upon themselves. By fully emasculating themselves and then falling upon the medical system for "patching up", they can achieve a "low-cost SRS early in life". A number of girls in the U.S. have performed these complete emasculations on themselves, and then feminized themselves with estrogen to quickly become very passable and pretty as girls (unfortunately, the loss of penile and scrotal skin makes later SRS much more difficult). These desperate acts were more common decades ago when TS girls in the U.S. had great difficulty obtaining medical help. An even more common practice has been for TS girls to resort to basic self-castration (removal of their own testicles) in order to avoid masculinization.
The Hijra are, in many ways, a long-traditionalized cultural equivalent in India of the "street trannies" seen on the nightime streets in many major U.S. cities, and indeed (as "travestis") in cities all around the world (for example, see the recent survey of transsexuals in Malaysia). None of these societies is aware that many of these people are transsexuals who at heart desperately need to be women, and who, without identification papers, social position or families, usually have no employment options other than prostitution.
Here in the U.S., the street trannies are usually thought of by polite society as "sexual deviants who have lost their minds". They are very frequently misclassified as "gay" males, when in fact they often self-identify as girls and their customers are mostly straight guys (not gay men) who enjoy lovemaking with "she-males". Thus both the Hijra of India and the hormonally feminized street trannies in the U.S. are mostly transsexuals. Both groups are misunderstood and mis-identified by society, and treated as male social outcasts. Instead, they are people who are just doing the best they can to be, and to live as, women.
Photo of Pokaraji, a pretty young Hijra girl in Calcutta, from the remarkable book
Hijra-The Third Gender in India
by Takeshi Ishikawa
Here are photos of two other Hijra women from Takeshi Ishikawa's book. As you can see, some Hijra are very beautiful. Sonamu (on the left) grew up as a street child in Bombay India, and then became a Hijra in her teens. She was so beautiful that she became rather famous in Bombay.



Important note:  In September 2003, the Peoples’ Union for Civil Liberties, Karnataka (PUCL-K) published a truly remarkable report on human rights violations against the transgender community in India.  In the spring of 2004, I was fortunate to obtain a copy of the report, and I wish to alert you to it via this webpage.


The 117 page PUCL report provides extensive background on the social, cultural and political context of Hijras. It then documents violence against the Hijra, and discusses the institutional basis of this violence. It documents recent Hijra efforts to organize and protest the discrimination that they face, and makes important recommendations on how to improve the plight of transgender people in India. The report is an excellent source of up-to-date cross-cultural information about the Hijra, and I highly recommend it to you. See the following webpage for more information, including links for downloading the report in PDF format: Report.html



What causes transsexualism?
Many causes for transsexualism have been proposed over the years. As discussed above, it's long been known from many intersex cases that the genes do not determine gender identity. The recent follow-ups on intersex infant surgeries also show that "genitals and upbringing" do not determine gender identity. Instead, current scientific results strongly suggest neurobiological origins for transsexualism: Something appears to happen during the in-utero development of the central nervous system (CNS) so that the transsexual child is left with innate, strongly perceived cross-gender body feelings and self-perceptions. We still don't know for sure what causes it, and more research needs to be done. But the neurobiological direction for these scientific explorations seems clear.
For example, recent research suggests that MtF transsexualism may result from a female differentiation in a genetic male of the BSTc portion of the hypothalamus, during interactions between the developing brain and fetal sex hormones; this brain region is essential to sexual feelings and behavior. The first such research was reported in 1995: See NATURE, 378: 60-70, 1995 (this paper is also web accessible at ). Extensions of this earlier work were reported in May 2000 (see following abstract and link to the full paper) :

The Journal of Clinical Endocrinology & Metabolism, May 2000, p. 2034-2041
Copyright 2000, The Endocrine Society Vol. 85, No. 5

Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus
Frank P. M. Kruijver, Jiang-Ning Zhou, Chris W. Pool, Michel A. Hofman,
Louis J. G. Gooren, and Dick F. Swaab
Graduate School Neurosciences Amsterdam (F.P.M.K., J.-N.Z., C.W.P., M.A.H., D.F.S.), Netherlands Institute for Brain Research, 1105 AZ Amsterdam ZO, The Netherlands; Department of Endocrinology (L.J.G.G.),
Free University Hospital, 1007 MB Amsterdam, The Netherlands; and Anhui Geriatric Institute (J.-N.Z.), The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230032 China
Address all correspondence and requests for reprints to: Frank P. M. Kruijver, M.D., or Prof. Dick F. Swaab, M.D., Ph.D., Graduate School Neurosciences Amsterdam, Netherlands Institute for Brain Research, Meibergdreef 33, 1105 AZ Amsterdam ZO, The Netherlands. E-mail:
Transsexuals experience themselves as being of the opposite sex, despite having the biological characteristics of one sex. A crucial question resulting from a previous brain study in male-to-female transsexuals was whether the reported difference according to gender identity in the central part of the bed nucleus of the stria terminalis (BSTc) was based on a neuronal difference in the BSTc itself or just a reflection of a difference in vasoactive intestinal polypeptide innervation from the amygdala, which was used as a marker. Therefore, we determined in 42 subjects the number of somatostatin-expressing neurons in the BSTc in relation to sex, sexual orientation, gender identity, and past or present hormonal status. Regardless of sexual orientation, men had almost twice as many somatostatin neurons as women (P < 0.006). The number of neurons in the BSTc of male-to-female transsexuals was similar to that of the females (P =3D 0.83). In contrast, the neuron number of a female-to-male transsexual was found to be in the male range. Hormone treatment or sex hormone level variations in adulthood did not seem to have influenced BSTc neuron numbers. The present findings of somatostatin neuronal sex differences in the BSTc and its sex reversal in the transsexual brain clearly support the paradigm that in transsexuals sexual differentiation of the brain and genitals may go into opposite directions and point to a neurobiological basis of gender identity disorder.
However, without even having ANY scientific evidence to back them up, many psychiatrists and psychologists over the past four decades have simply assumed that transsexualism is a "mental illness". By DEFINING this socially unpopular condition to be a mental illness, psychiatrists have shaped much of the medical establishment's and society's view of transsexuals as "psychopathological sexual deviants". However, those viewpoints are gradually fading away as the old generation of traditional "behaviorist" psychiatrists passes on, and as the underlying neurobiological bases for many basic human behaviors have begun to be understood.
For a more complete discussion of the older "mental illness" concepts of transsexualism, and a comparison with more recently emerging scientific evidence for neurobiological causes, see Lynn's page on
Do we really need to know the cause in order to treat the condition?
Why is there so much fixation on "causes"? The answer is simple: Transsexualism has been such a socially unpopular condition in the past that the issue of "what causes it" is always raised in discussions about what to do about it. In the past many behaviorist psychologists and psychiatrists have inherently blamed transsexuals for causing their own "sexually deviant mental illness", giving those psychiatrists a claim to responsibility for the "treatment and cure of transsexuals" and giving society a rationale for discrimination, marginalization and ghettoization of transsexuals.
However, as we've seen, transsexualism is most likely a neurological condition of as yet unknown origin and not a "mental illness". There are many other intense neurological conditions such as pain, depression and bipolar disorders for which we do not know the underlying causes but suspect biological causes. We know that these other conditions are real because we see people in distress, and we treat those people medically and with compassion to relieve their suffering.
Why should it be any different with transsexualism?
We now know how to relieve the suffering of transsexual people, having many options for practical counseling, social transition and hormonal/surgical gender reassignment. Why not accept those treatments as valid, since they truly relieve suffering and enhance the quality of life, even if we aren't sure what causes the underlying condition? And why stigmatize people just because they have sought medical treatment for this condition?
How frequently does transsexualism occur?
'Prevalence' is the number of cases present in a given population at a given time. If there are 100 cases of some condition in a city of 100,000, then the prevalence there at that time is 1 in 1000 (1:1000). Fortunately, we can make good estimates of the prevalence of transsexualism without being a research scientist. Any good journalist could easily triangulate on good ball-park estimates.
Medical authority figures often quote a prevalence of 1 in 30,000 for MtF transsexualism and 1 in 100,000 for FtM transsexualism. You'll see these numbers over and over again, as in recent news stories in the Washington Post and the New York Times. But don't these figures seem odd to you? They portray transsexualism as being incredibly rare. However, many people nowadays know a transsexual person or know of one in their school, company or small community. Where do these "extreme rarity" figures keep coming from?
These figures are from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The numbers are often sent to the media by the two "elite psychiatric centers" that have long promulgated and dominated thinking regarding "psychiatric theories of transsexualism", namely the Clarke Institute in Toronto, Canada and the Johns Hopkins School of Medicine in Baltimore, MD.
However, the figures are from decades-old data when modern sex reassignment surgery (SRS) first became available, and only include the numbers who bravely stepped forward and asked for SRS at a time when discrimination was incredibly intense. Common sense says there were many more who suffered in silence than came forward openly. But how many?
Let's do some "numerical detective work". We can triangulate the prevalence of MtF transsexualism in the U.S. by estimating how many transsexuals here have already had SRS. We can then divide that number by the population of adult males in the U.S. (up to about age 60, since those older had little access to the surgery in the past).
Before 1960, only a tiny handful of SRS operations were done on U. S. citizens. Georges Burou, M. D. of Casablanca, Morocco, then began doing a large series of operations in the 1960's using a vastly improved new "penile-inversion" technique. Harry Benjamin, M.D., a U.S. physician who had done pioneering research and clinical treatments of transsexualism, began referring many U.S. transsexuals to Dr. Burou and to several other surgeons who used Burou's new technique. (Lynn later learned from Dr. Benjamin that in 1968 she had been among the first 600 to 700 transsexual women from the U.S. to have had SRS).
Harry Benjamin, M.D.
The great medical pioneer and compassionate physician
[photo taken by Lynn Conway in 1973]
The U. S. numbers grew in the 1970's as gender-identity programs at Johns Hopkins and Stanford University triggered an easing of restrictions on SRS in U.S. hospitals, and several U.S. surgeons began performing SRS. In 1973 Lynn learned from Dr. Benjamin that 2500 SRS operations had been done on U. S. transsexual women by that date.
Beginning with that data, the table below shows Lynn Conway's estimate of SRS operations done by major SRS surgeons both here and abroad on U. S. citizens in recent decades, extrapolated to include those done by many secondary surgeons (each performing smaller numbers per year). A range of values is given, from conservative to most likely numbers.
At present about 800-1000 MtF SRS operations are now performed in the U. S. each year, and that many or more are performed on U.S. citizens abroad (for example in countries like Thailand, where the quality of SRS is excellent and the cost is much lower). The top three U. S. surgeons (Eugene Schrang, Toby Meltzer and Stanley Biber) together now perform a total of 400 to 500 SRS operations each year. Stanley Biber alone has done over 4,500 SRS operations since he began doing the surgeries in 1969; for many years Dr. Biber did two SRS's per day, three days per week!
"Lynn Conway's Numbers": Estimates of MtF SRS operations among U. S. residents:




1990 - 2002




Adding up these numbers we find that there are at least 30,000 to 40,000 post-op transsexual women in the U. S. Of course some surgeries done by U.S. surgeons are on foreigners (perhaps 15%?), and some who've undergone SRS have passed away. However, the majority of post-op transsexuals had SRS within the past 15 years, and a high percentage of them are still living. TS's in the smaller group who underwent SRS in the 60's to mid-80's were mostly young - in their twenties and early thirties, and thus most of those women are still alive too. Even accounting for mortalities, Lynn estimates that the number of post-ops in the US is greater than 32,000.
To determine the prevalence of MtF SRS, we simply divide 32,000 by 80,000,000, which is the number of U. S. males between 18 - 60 (the age range from which most current post-ops originated):
32,000/80,000,000 = 1/2500.
We discover to our amazement that at least one out of every 2500 persons born male in the U. S. has ALREADY undergone SRS to become female! This 1:2,500 estimate is vastly higher than the 1:30,000 estimate so oft-quoted by the medical community. The DSM-IV number is clearly way off, and by at least a factor of 12! However, on closer examination we will find the error is far worse than even that!
But remember: The DSM-IV "estimate" is for the prevalence of transsexualism, not the prevalence of SRS. Recent newspapers articles always make that interpretation, and refer to the 1:30,000 figure as a "the number of transsexuals".
Lynn estimates at least 3 to 5 times as many people suffer intense MtF transsexualism as those who have already undergone SRS. The reasons are obvious: Many transsexual people are unaware of the options and treatments for resolving the condition, and suffer in silence thinking there is no hope. Many are terrified to "come out" and seek help for fear of social stigmatization. Many more are incapable of paying the high medical costs for transition. Thus there must be on the order of 100,000 to 200,000 UNTREATED cases of intense transsexualism in the U.S.
Thus the number of treated and untreated cases must be ~ 130,000 to 240,000. If the number were 160,000, which is nearer the lower end of this range, then the prevalence of intense transsexualism is ~ 160,000/80,000,000 = 1:500. This value is only a rough LOWER BOUND on the prevalence, and the intrinsic value could easily be much higher.
[*See also the NEW PAGE containing Donna Patricia Kelly's recent estimate of TS prevalence in the UK. Donna uses Lynn's methodology of calculation, and her results for the UK turn out to be very consistent with Lynn's results for the US.]
These studies begin to triangulate on a likely prevalence of intense MtF transsexualism in the range of 1:500 to 1:250. This is roughly 100 times the number (1:30,000) published by the APA in the DSM-IV-TR! Therefore, the DSM-IV prevalence numbers are wrong by more than two orders of magnitude*.
By comparison, consider the prevalence of other conditions having profound impacts on people's lives: The approximate prevalence of muscular dystrophy is 1:5000, multiple sclerosis (MS) is 1:1000, cleft lip/palate is 1:1000, cerebral palsy is 1:500, blindness is 1:350, deafness is 1:250, self-reported epilepsy is 1:200, schizophrenia is about 1:100, and rheumatoid arthritis is about 1:100. All of these conditions are high on our society's radar screen and there is massive public empathy for those who suffer from them. There are large research funds available for studying and treating these conditions, and patients have welcome access to any existing medical treatments that might relieve such conditions.
Contrast that to intense transsexualism, which has an equally profound impact upon a person's life. This socially unpopular condition is totally off our society's radar screen and access to effective treatment is out of reach for the vast majority of sufferers. Meanwhile, the medical establishment is totally unaware of the prevalence and tragic impact of the condition.
 For further discussion of the prevalence of transsexualism, and a discussion of how and why the psychiatric community estimates are so erroneous, see Lynn's page on
The important implications of "The Numbers"
With 1500-2000 people in the U.S. now undergoing MtF SRS each year (and at least half that many undergoing FtM surgeries), transsexualism is common enough that large schools and companies encounter a transitioning case from time to time. Everyone knows this. The media is full of stories of transition. Universities in particular have seen many recent transitions among faculty members who have tenure and who can "get away with" open transition without losing their jobs. The numbers are now large enough to warrant formal rethinking of school and company policies so that such transitions can proceed smoothly and successfully.
As awareness spreads that TG and TS conditions are not all that rare and that many young people have successfully transitioned, it is becoming more likely that TG and TS kids will self-identify, come out to themselves, and on average seek help much earlier in life than in the past. It is also more likely that they'll find help, because more psychologists and family counselors are now adding gender counseling to their professional services, and because so much information is now available via the web.
However, the old myth of the "extreme rarity of transsexualism" has led to some severe social consequences, including the conflation of TG/TS conditions with "being gay" and the long-standing invisibility of the many "street trannies" who don't register on society's radar screen, as discussed in Part I. Only as society realizes that TG/TS conditions are not all that rare will these conditions be taken more seriously.
Numbers count! They really do matter! Well-triangulated ballpark numbers provide far better social measuring sticks than reliance on the uninformed, non-common-sense, self-serving propaganda of a biased professional group (the psychiatrists) that a has a vested interest in "low numbers" and "non-permissiveness" towards transsexualism. Physicists, engineers, epidemiologists and politicians know that getting "good numbers" really matters, and can affect major scientific, engineering, social and political decisions in the real world. It's about time that psychiatrists were confronted with the reality of the widespread nature of TG and TS conditions.

How is MtF transsexualism medically treated?
Whether it is hard-wiring in the brain, or structures deeper in the CNS or some other mechanism that causes innate gender identity, one thing is for sure: Gender identity cannot be altered by psychological or psychiatric treatments under the old "mental illness" model. Countless TG and TS people have been subjected over the decades to psychiatric "treatments", including shock therapy and institutionalization, and there are no confirmed cases of any "cures" that way.
However, dramatic modern medical and surgical advances have made it possible for the gender-identity conflicts of intense transsexuals to be fully corrected. By undertaking female hormone therapy and undergoing sex reassignment surgery (SRS) to change the genital sex, the body-sex can be altered to match the neurological sex, thus solving the MtF transsexual's gender incongruity. These treatments are usually conducted under the guidelines defined in the "HBIGDA Standards of Care, Version Six" of the Harry Benjamin International Gender Dysphoria Association.

In the past, many trans women were forced to see psychiatrists, who served as strict "gatekeepers" to all aspects of transition. They claimed that their permission was required for hormones, for social transition and for SRS, and it often was granted only after years of "therapy".  Unfortunately, by thinking of transsexualism as a mental illness, and having little knowledge of the many practical aspects of transition, such psychiatrists proved to be very poor gender counselors. Today it is much more common for transitioners to obtain help and advice from well-informed, specialized gender counselors who can actually help them succeed in transition.

Prior to SRS, the transitioner completes a period of hormonal feminization and social transition to living full-time as a woman. After some time has passed (usually a year or so) and the person is still sure of their feelings about complete transition, they then undergo SRS. In this surgery the external male genitalia are removed and portions of those genital tissues are used in the construction of female genitalia, including a sexually functional vagina and a sensate clitoris. The basic SRS operation is often followed by later "labiaplasty" surgery to refine the external appearance of the new female genitalia by shaping normal-appearing inner and outer vulvar labia. The appearance and function of the reconstructed genitalia are virtually indistinguishable from those of women who were born with typical female genitalia. A thorough discussion of the historical development and surgical details of MtF SRS is contained in Lynn's SRS webpage. Many post-operative MtF transsexual women continue to enjoy strong genital arousals and can enjoy vaginal sexual intercourse just as any women does. Many post-op TS women are orgasmic; some are highly so (see discussion of arousal and orgasm in post-op women in Lynn's SRS webpage).
Unfortunately, most people are unaware of the nature of sex reassignment surgery, and mistakenly believe that it involves only the removal of the male genitalia, as in the cases of the Hijra of India. Such ignorance fosters many superstitions and prejudices about post-op MtF transsexuals, especially concerning their sexuality and sexual behaviors (many ignorant people assume that post-op women are limited to anal intercourse, not understanding that these women really do have a vagina). However, there are now many web resources covering all aspects of SRS, and such ignorance is becoming less common in the general population.
Ongoing treatment with female sex hormones (especially after SRS) greatly alters body sensations, emotional feelings and secondary sex characteristics, including stimulating growth of breasts, softening of the skin, redistribution of fatty tissues, and so forth. Over time the effect can be a startling and rather complete physical transformation from being a boy into being a woman. Released from the misgendering trap, the new woman can find emotional healing and self-acceptance, and can go on to live a real and joyful life.
 For more detailed information about these physical gender transformations, including diagrams and photographs, see Lynn's webpage on
What is transsexual transition?
TS transition is a term used by transsexual people for the period of time when one is undergoing a "change of social and physical gender". For the young street tranny, transition usually means TG transition, i.e., the taking of female hormones to feminize her body and then beginning to live openly as a girl.  Sadly, because of employment difficulties, in many cases such girls may be able to only aspire to living life as a transgender woman, without SRS.  For other TS transitioners who have better financial opportunities, such as middle-class college students and well-employed adults, transition means the same thing - but with the added goal of achieving a full change of physical gender through sex reassignment surgery (SRS) and then going on to a full social assimilation as a woman.
In an era when transsexual women are still highly stigmatized in many communities, the infrastructure that supports TS transitions is very analogous to the "Underground Railroad" in the U.S. which helped African-American slaves escape from the South. As discussed in the NPS website and National Geographic website, "the Underground Railroad was neither 'underground' nor a 'railroad,' but was a loose network of aid and assistance to fugitives from bondage. Perhaps as many as one hundred thousand enslaved persons may have escaped in the years between the American Revolution and the Civil War."
In much the same way, a modern network of care providers including specialized gender counselors, electrologists, endocrinologists, surgeons, attorneys and many others, quietly and rather secretly provide aid and assistance to those seeking escape from the bondage of their birth-sex. In this case, most escapees hope to assimilate after their escape from bondage, so that their origins are concealed and they can be "fully free". This degree of escape is very analogous to that of an escaped slave from the South before the Civil War who was lucky enough to "pass for white" in the North and then be fully welcomed into the majority white society.
Sadly, there is a psychic price to pay for "passing in stealth" for the TS woman - as there was for the escaped slave who passed for white - namely the loss of contact with past friends and family, and the constant fear of being outed and losing everything in one's new life. However, for some this may be a very small price to pay for freedom from bondage and the opportunity for a full human life.
A complete transsexual transition from male to female (including SRS) usually takes at least two or three years, and often longer. The process begins with guidance and counseling, peer support, and then the initiation of hormonal feminization. The effects of estrogen, taken in large pre-operative doses, are subtle but quite profound as the skin softens, breast begin to develop, and fatty tissues gradually redistribute into a more female pattern.
Electrolysis is also begun to remove facial hair and conspicuous body hair. Electrolysis is a very painful, expensive, time-consuming process in which little needles are inserted into the hair follicles and then heated to kill them. It often takes 100 to 200 hours of electrolysis to remove just the male facial hair. The process causes many logistical and time-management problems for transitioners, because the facial hair must be allowed to grow out for a day in order to treat it - and the treated areas are often red and irritated for a day or two afterwards. However, unless all dark facial hair is removed, the new woman has no chance of "passing", because those hairs show beneath the skin even when fully shaved and covered with foundation.
Until facial electrolysis is completed, transitioners usually resort to using special concealment makeup such as Covermark or Dermablend. These makeup systems are designed for people who have serious skin discolorations such as birthmarks. They will temporarily conceal well-shaved dark hairs without looking "too thick", and have long been used by gay drag performers and other "female impersonators" to feminize their facial appearances. However, most transitioners try to get far into their facial electrolysis before attempting their social transition into RLE, in order to minimize the impact of electrolysis on their work schedules, minimize their dependence on cosmetic concealment, and improve their chances at passing well.
Before and during RLE, many transitioners also undergo surgeries that further feminize their facial and body appearance, especially by reducing masculinized facial bony structures (protruding brow-bulges, jaw bones and chins). Some of these medical procedures, such as facial feminization surgery, are often extremely painful, and the TS girls must steel themselves to this very traumatic aspect of gender transition.
However, there is far more involved than just these medical and surgical treatments. The MtF transitioner must completely and permanently change their social gender. In addition to learning how to dress and make up and be pretty as a woman, she must also readjust a phenomenal range of mannerisms and gestures, and learn a whole new set of social protocols. Once she starts this journey and her appearance begins to change in noticeable ways, many people will be afraid to associate with her, or even be seen with her, until she gets far enough along to "pass".
In most cases, she must finally leave her past life behind - often breaking all ties with friends and family as she moves on into her new life - much as did early immigrants from foreign lands, and indeed much as did escapees from the bondage of slavery in the South in the 1800's.
Only just so much assistance can be gained from gender counselors, medical service providers and peer support groups. Thus most of the responsibility for planning and implementing this complex journey rests with the transsexual woman herself.
Therefore, a transsexual gender transition is a very major, socially disrupting, emotionally traumatic undertaking, and is indeed one of the most difficult things someone can do. Traveling this path can be a very lonely journey, because all the physical, emotional and social challenges along the way must usually be faced alone, without much help from family and friends. However, escape from a body and the daily entrapment of a gender role that feels totally alien to you is very much like escape from bondage. Any TS girl who can see a path to full gender transition, no matter how painful or difficult that path is, will usually make her run for freedom.
Fortunately, there are now many websites containing valuable information about these many dimensions of TS gender transition. These excellent guides reveal the underground railroad of services and care-providers who can help the transitioner at various stages of her journey. The very best of these websites is Andrea James' "TS Roadmap". Andrea is a beautiful, successful post-op woman. Her site contains a wealth of knowledge, and is now the "Bible" of male-to-female transition.
The most complete guide to MtF TS transition on the web is Andrea James' "TS Roadmap". Anyone contemplating transition should carefully study Andrea's site, and use it as the basis for their transition plan
Andrea James

Important inner changes


As transition proceeds, hormonal feminization causes not only visible physical changes, but also enhances subtle yet profound psychic changes. Under the influence of estrogen (especially after SRS), it becomes easier to shift one’s basic "inner vibes" from any vestiges of “vigilant masculinity" (especially a non-smiling "tight" face and avoidance of eye contact) to that of "warm femaleness" (with its projection of non-threatening vulnerability, especially via a warm, open-eyed smile). Here are some tips from Lynn about this important "inner psychic transition":


"While in the male role, social pressures reinforce a tendency to always "keep an eye out" and "keep some distance" between yourself and others. To guys it sometimes seems as if a "fight could break out at any moment" and they must always be on guard.  It is very important during gender transition to phase out any remnants of such feelings.  Relaxing and letting oneself feel vulnerable and open, and then smiling warmly, will help this inner transformation proceed.


Perhaps for the first time you’ll fully open up to your inner female feelings, now enhanced by estrogen.  You’ll begin to experience a profound shift in inner emotional setting towards wonderfully soft warmth and vulnerability, and openness towards warm emotional contact with others. As this happens, you will “vibe” differently not only inside yourself but to others too. The warm social feedback you then receive as a woman will then reinforce your new internal feelings.”


Other people unconsciously read gender "vibes" just as they unconsciously read masculine facial features, and even very pretty transitioners may not seem female if they still "vibe" as males. Thus it's important to project one’s inner feelings as early as possible during transition.  Otherwise, negative social feedback from others can stall progress towards self-acceptance and self-realization - enclosing the transitioner in a vicious circle of resentment and rejection.


Fortunately, the hormonal changes during transition tend to reinforce these inner emotional changes. But this can be scary too. At the beginning of transition, persons are often quite fragile. Many become much more emotional than before, with emotions and tears coming much more easily, and they need to be reassured that this is a normal response.   Often they are a lot more open, talkative and interactive too.  Sometimes for the first time in their lives transitioners are accepting and asserting themselves, and not hiding their true self or their pain at having to play a false role in the past. This is a profound experience for the transitioner. These changes can be so pronounced that friends, family and loved ones may become “lost” (confused by it) for a while.


It can take time for a transitioner to completely get rid of the mask she had to wear and the pressures she suffered under, sometimes for decades. Even though most transsexual women never really corresponded to the stereotypes of masculine behavior society tried to impose on them, most were subjected to extreme pressure to conform to those stereotypes. Their burden was often most painful during childhood, when they were less able to resist pressure, and when they felt totally alone and betrayed and tormented by those whose duty it was to protect them.  Such experiences can have devastating consequences and cause lingering sadness in some cases. However, a carefully chosen, really helping, respectful, welcoming and loving therapist, one who places him/herself as a guide and as an ally (instead of a gatekeeper) can help a lot with issues like this, as with many other aspects of the transitioner’s journey. 


In the end, it is by discovering and fully manifesting their true inner selves, and leaving behind unwanted vestiges of their pasts, that most MtF transitioners' identities as women become obvious to everyone.


Voice training:
Another very difficult step for many TS transitioners is adjustment of a deep masculine voice to that of a female. Here are some tips from Lynn:
"I gradually raised my voice while I transitioned until the fundamental tone was up to around 180 Hz. Then I worked on making it "breathy" or "smoky" and kind-of-sexy in sound, patterning somewhat on the voices of old-time actresses June Allison and Lauren Bacall. I got in the habit of occasionally checking my fundamental frequency by hitting the piano keys F (175 Hz) and G (192 Hz) below middle-C to make sure I stayed above 180 Hz. I recommend that you do this too once your voice is raised.

In this range of frequencies the voice can pass as either male or female depending upon whether it is soft and breathy and uses female intonations, or hard and monotone (male). Thus you can work on getting your frequency up into this range and keeping it there, even when still presenting as male. The adjustment to female is then made by using intonation and a "breathy" form of voice.
Once you've permanently transitioned, try to raise your fundamental frequency further towards middle-C (262 Hz). If you can raise your voice closer to middle-C, it will be within a female-only range and will be a great asset to you.

Whatever you do with your voice, the key test of success is whether you can always pass as female with strangers on the telephone (i.e, whether you are always called "ma'am" by those who can't see you and only hear your voice). If that always happens, then your voice is OK. If not, then you MUST keep working on it!"
When Lynn transitioned decades ago, we TS women had to struggle on our own to develop our voices by trial and error, judging from sometimes harsh feedback from strangers whether we were doing OK or not. Nowadays there are excellent instructional materials available to help you develop your new voice. Transitioners can now benefit greatly by studying and participating in the exercises at the TS Voice website. I also strongly recommend that transitioners purchase and carefully study Andrea James' and Calpernia Addams excellent new video training course entitled "Finding Your Female Voice" (available in VHS and DVD).
Finding Your Female Voice
The breakthrough program for vocal feminization
Your hostess, Andrea!
Following the success of that video training course, Andrea and Calpernia have gone on to produce a two-DVD training course (also available on VHS) entitled Becoming You: The Fast Track To Your Female Face.
This new course for TS women covers make-up and presentation, including sections dealing with scalp hair loss and hairline issues, managing hair removal, sections on clothing, shoes, jewelry and accessories and on dealing with the emotions and social situations surrounding the process of transitioning. Here are some quotes from Andreas and Calpernia about their new course:
"Most makeup instruction available in the TG community is designed for the women who "dress up" for kicks. That's cool, but we are focusing on being accepted as female in day-to-day life. This is designed for women like you, who wish to have a smooth transition into living full-time in mainstream society. - - - While the tone of this video is upbeat and fun, I know this isn't just fun and games for you. You're making a serious commitment to transition. You want to be accepted as female in work and social settings, not just at home in front of a mirror or in a dark bar on weekends."
This is a truly outstanding new training course. It covers many essential skills that are very difficult to efficiently and thoroughly learn by any other means, and it also contains lots of positive thoughts and encouragement along the way. I highly recommend that all transitioners purchase and carefully study this wonderful course:
Becoming You:
The Fast Track To Your Female Face

An accelerated course in makeup and skin care
from Deep Stealth Productions
Your hostess, Calpernia!
Real Life Experience (RLE).
As a key step in the formal treatment protocol, the transsexual woman enters what is often called a "Real Life Experience" (RLE). The woman usually enters RLE only after having worked very hard during her pre-transitional period to learn how to feminize her voice, facial appearance and presentation, and after being on hormones and electrolysis long enough to feminize her features.
RLE is a time when, under the guidance of her gender counselor, she "socially transitions" into living and working full-time in her new gender role for at least one year.  RLE is a time when all her social skills, grooming, dressing and personality presentation are enhanced and refined, and confidence and self-esteem are developed in her new social role. It is also a time for handling many of the difficult family, relationship, employment, bureaucratic and legal aspects of the gender change. Finally, it is a time for deep introspection, during which she must make the ultimate decision of whether or not to undergo SRS (be sure to read the WARNING section below!).
Illustration from cover of

Supplement 154 of the 1993 Scandinavian Journal of Urology and Nephrology.

[Note the old-fashioned notions of requiring "psychiatry" and "permission"

before going on hormones or transitioning (changing identity).

Unfortunately this is still the case in some countries.]


If the woman wants to go forward to SRS after successful completion of at least one year of RLE, and if she is otherwise in good health and good spirits, her gender counselor will provide her with the needed documents so that she can go on for the surgery. However, even after her sex reassignment surgery there are still many, many things she must do to complete a full transition, and settle fully into the new gender role.
Although the procedures and trans-community customs for the social changes, real life experience (RLE) and medical treatments are well established, transition is often an awkward and frightening time for the emerging woman. She must face many challenges in relating to others, maintaining employment, and maintaining self-esteem and confidence in the face of public ridicule, family rejection and social stigmatization. There is always the risk of "transition failure", where someone loses their employment, is unable to make steady progress through all the complex medical and social procedures, and eventually becomes socially marginalized back into the world of the inner-city streets (see, for example, A Tragedy's Tragic End). Transition failures often have terrible consequences, and the TS transitioner needs to plan and work carefully to avoid such a failure.
On the other hand, tens of thousands of transsexual women have completed successful transitions and are living full lives as women now. Many of these women have gone on to have wonderful love-lives and romances after their transitions. Many have found life-long partners and many have successfully married (as in many stories in the "TS Women's Successes" page). In the end, being able to find a life-partner (whether male or female), and enter into a loving, sensual, fulfilling relationship while at the same time feeling fully gender-congruent in one's own body - that is the ultimate reward for all the pain, cost and sacrifices of TS transition.
Transitioning "On the Job"; How FFS can insure employment continuity:
Fortunately, with increasing awareness and acceptance of transsexual transitions a number of leading companies have established policies and guidelines that protect and support "on-the-job" (OTJ) or transitions. Many corporations now have (in addition to sex and sexual orientation) some form of gender protection as part of their EEO policies, including American Airlines, Apple, Avaya, Eastman Kodak, Lucent, Verizon, and Xerox. Notable among these companies is Lucent, which has very well-defined guidelines for such transitions. In these and many other companies the TS woman does not have to lose her job or transfer in stealth - she can transition while maintaining her present position. See also the Washington Post article "More Transsexuals Start New Life, Keep Old Job".
In an important recent trend, many TS women schedule facial feminization surgery (FFS) just BEFORE their social transition at work, in order to remove vestiges of facial-bone masculinization caused by testosterone. This is an excellent way to insure a really smooth OTJ transition, because it makes it ever so much easier for co-workers to actually "see them as females". Continuity of employment and for continuing a good career often more than compensate for the cost of this surgery. Sally is a good example of this approach: She transitioned OTJ just after her FFS, and has advanced really well in her company since then.
For example, consider the case of Sally, as seen in the following three photos. The first photo (on the left) shows her when she was still a boy, and a very handsome boy at that. The second photo shows her after two years of hormones and electrolysis. Many transsexual women would feel very wonderful having made a transition from the first to the second photo, and by contrast many might think they "look really good now".
However, although her facial features are softened and somewhat feminine in the second photo, you'll notice that she still has a "tranny appearance". The protruding brow ridge, the tall chin and the widely flared jawbone that made her handsome as a boy now spoil her looks as a woman. The third photo shows her after having FFS performed by Doug Ousterhout, M.D. We now sense the problems in the second photo and why she "wasn't pretty" there. The FFS transformation, while subtle, is really profound. She is now a strikingly beautiful woman, even without any makeup on. This is an excellent outcome. Now not all results will be this striking. However, the results are very often life-changing in their impact on passability and self-esteem.
Photos of Sally
Pretransition; after two years on hormones and electrolysis; after FFS with Dr. Ousterhout

Well, what on earth is going on here? What made Sally's appearance change so much? The answer is seen in PROFILE views. Although we almost never look at ourselves in profile, that's the direction other people often see us from. And it is our facial profile that most determines facial beauty and gendering at intermediate angles towards face-on. Thus it is a male-type profile that most frequently gives away "tranny features" and keeps a TS woman from looking pretty.
The following profile photos of Sally show the truly astounding changes made by FFS. Her appearance in profile before FFS was very unflattering for a woman, even though she looked "OK" face on. After FFS her protruding brow ridge is gone, and is replaced with a rounded female contour. Her nose has been reshaped and contoured into her reshaped forehead. Her chin height and chin angle have been radically modified. The width and flare of her jawbone have been greatly reduced. And her hairline has been brought forward significantly:
Profile views of Sally before and after FFS:


Sally finally has facial features similar to those she might have had if she'd gone through her initial puberty as a girl: on estrogen and without testosterone. The final results are wonderful and are truly life-changing, as seen in the following photo. These results also indicate how important it is for our society to help transsexual girls earlier in life - so they could avoid developing heavily masculinized facial features which require such costly and painful surgery to correct.
Sally - now a beautiful woman

It is no wonder that Sally had a smooth OTJ transition after her FFS. As you can imagine, success in maintaining a good job and in continuing to advance in a good career can have a huge impact in a transitioner's life, and thus careful planning on how to do this can be critical for overall success in transition. Warm acceptance at work can then be followed by an ever-increasing spiraling outward into new social relationships, and out into a fuller life in one's new identity.

Facial Feminization Surgery with Dr. Ousterhout (38 min)

facial feminization surgery with dr ousterhout

Join transition authority Andrea James and famed Facial Feminization Surgery pioneer Dr. Douglas Ousterhout for an illustrated conversation about his procedures at the California Pacific Medical Center. It's just like being there!

If you're considering Facial Feminization Surgery, shopping for surgeons or just informing yourself on the procedures, this seminar is for you.

Characteristics that no current surgery or treatment can transform:

The above cases and photos illustrate how spectacular and life-changing facial feminization surgery can be.  However, there are some things that cannot currently be corrected. For example, no medical procedure can transform a very tall and broad-shouldered person into a petite and slender one. 


Trans women who are taller and have broader shoulders than the majority of women need to find ways of accommodating to and even exploiting their physicality in various ways. Becoming at ease with our bodies is very important, not only for a successful transition, but also for happiness in life beyond transition.

If tall trans women look around them, they will discover many other tall women who can serve as very positive role models. They prove that a woman can have a fulfilling and happy life independent of her height. Finding these role models will reveal that being tall and perhaps a bit athletic can be very positive and attractive features for a woman, especially if she keeps herself quite trim and in good shape.


There is also an extensive infrastructure of websites and retail outlets that cater to tall women, and that can help a tall woman look her best.  Tall women can thus enjoy shopping and fashion as much as any other woman, and have the opportunity to find superb clothes that are high quality and are as business-like, or as elegant, or as "practical" and sporting, or as full of fantasy and as feminine as they want.


Furthermore, there are many tall men's and women's clubs and singles groups, where tall girls will feel short by comparison to the men!  There are also many potential partners who enjoy being with a tall, self-reliant woman who, for example, enjoys the out-of-doors and is a good sport when doing active, adventurous things.  By following and exploring a variety of such pathways, a tall girl can find many friends, companions and dating partners, and go on to live a full and happy life.


In the end, living life as a happy and radiant woman has nothing to do with trying to correspond to a stereotype, but is related with one's ability to welcome and cherish the woman within - then living according to one's heart, while bringing kindness and warmth into one's relationships with others.

At what age do TS women transition? And what does it cost?
Traditionally, most TS women have transitioned on their own as adults (after age 18), because of lack of parental and societal support for earlier transition. The overall reassignment procedures of counseling, hormone therapy, electrolysis to remove facial hair, and sex reassignment surgery can be very expensive ($30K to $40K) and are rarely covered by medical insurance. SRS alone costs about $20K in the U.S. (including labiaplasty). Many must spend even more than that for additional major reconstructive surgeries, such as FFS.
Madeleine Williams - before, during and after
her facial feminization surgery by Douglas Ousterhout, M.D. 
Madeleine, now a beautiful woman, transitioned OTJ in a high-tech company just after FFS.
Therefore, most TS women must wait until they are at least in their mid-to-late 20's or early 30's in order to can save up enough money or build enough financial credit to complete their transitions (including SRS). Nevertheless, the cost per patient is low compared to the benefits, especially when amortized over a lifetime: For an amortized cost on the order of $1000 to $3000 per year of adult life, the transsexual can leave all the gender angst and emotional pain behind and move on to a normal life in their correct gender.
Lynn has compiled a webpage listing photos and links to the stories of many successful post-op women, in order to provide clear evidence on the many successes out there. On that page you'll find many examples of women who successfully transitioned at a wide range of ages. By carefully studying their stories, you'll be better able to visualize what is involved in TS transition and how age is a factor in those transitions. Here are just a few examples from Lynn's "TS Women's Successes" webpage:
Examples of successful women who transitioned in their late 20's or early 30's:
Christine McGinn
Emily Hobbie
Antonia San Juan (Spain)
Examples of successful women who transitioned during their 40's:
Frances Bennett
Trish McCurdy
Many women now try to complete their transitions in their 20's and 30's if they possibly can, especially those who have very intense transsexual feelings and are totally positive that they must transition. Some women may need to take longer or transition later, especially if family situations or financial problems interfere with their plans.
However, the extreme difficulties, risks, and fears of transition often hold back many TS people for many years, even if they can afford transition. This is especially true for those who are highly masculinized as middle-aged adults, and who fear that they'll never "pass" as women. Sadly, some lose hope, and commit suicide along the way. A spiraling down into depression, substance abuse and then suicide is a likely trajectory for many unresolved cases of intense transsexualism, which is undoubtedly the hidden explanation behind many otherwise baffling suicides.
As the stigma surrounding transsexualism has lessened in recent years, more and more of the older, long-repressed transsexual people are deciding that they must transition before it is too late for them. Therefore, in recent years we've begun to see the emergence of a rather visible group of "late transitioners". Transitioning in their late 40's, 50's or even later, these women face much greater hurdles than younger transitioners. They also have less time to enjoy the rewards even if they are successful in transition.
Transitioning late in life can be very difficult, because many cannot "start all over again" in stealth at an advanced age. They may simply face too many family, financial and career entanglements to be able to start fresh new lives where they are only known as women. Many may also have difficulties "passing" as women, because of the long-term effects of male hormones on their bodies. They may remain easily identifiable as "transsexuals" unless they undergo many painful and expensive reconstructive surgeries and also work very hard at undoing decades of male habits. In the end it may be difficult for them to fully assimilate as a woman in society. Some insight into these difficulties, as seen from a family member's point of view, can be found in an essay by Stephen Gunther entitled "My transsexual father".


Many of the late transitioners emerge from long-term marriages. Not only do they mourn their early years spent in the wrong body, but they must also be aware that their marriage is likely to break up. If they have children, they are likely to face struggles around custody and visitation rights, and many are likely to lose all access to their children.


Finding a new partner, regardless of his/her sex, is also likely to be difficult for later transitioners. They must face their limits in passing and their lack of experience as a woman. There is some risk that they will not find a new partner and they must be very aware of it.


Those who are attracted to women may fear rejection by lesbian women in their age group, many of whom have been politicized against trans women in the past, and this may hold them back from seeking relationships.  Those who are heterosexual as women may never have experienced the joy of young love with a young man as a young T-girl, which can be a cause of deep regrets. Sadly, these women are often overly and unnecessarily afraid of exploring relationships or dating men, because of life-long fears of "homophobic" violence from men.


However, regardless of their sexual orientation, some of these women will overcome their fears and go on to find partners, often by seeking someone interested in a love-relationship involving deep emotional sharing and intimacy, instead of focusing simply on sexual relationships (as younger couples so often do).  Such partners exist and their own quest for a life-partner may be as long and as uncertain as the one of transsexual women. However, in order to be successful in finding love, the trans woman must have found enough peace, joy and self esteem in herself so as to be able to fully partner in a loving relationship.


Despite facing many of these handicaps, many transsexual people finally decide late in life that they must transition, and some are able to do so very successfully. Several of the women listed on Lynn's "TS Women's Successes" webpage transitioned during their 50's, and have done very well afterwards, including Deirdre McCloskey, Leandra Vicci, and Jamie Kaufman.
Examples of successful women who transitioned during their 50's:
Deirdre McCloskey, Ph.D. 
Leandra Vicci
 Jamie Kaufman
Although many late transitioners are much better off after their transitions, there are many others who are not. Late transitioners often have problems with very unrealistic expectations, difficulties in objective self-assessment and effective self-improvement. They may also find it very difficult to disentangle themselves from marriages, families, careers and responsibilities. Thus they can end up with a feeling of "losing everything" during transition, while gaining little from their new lives as women. Others, especially long-term crossdressers (who often do not have the gender identities of women), may have transitioned for the wrong reasons, which can lead to even more serious difficulties in adjustment to life afterwards (see WARNING).

Because circumstances force many late transitioners to be "out", older and marginally-passable transitioners have become a common media image of modern transsexualism. The larger numbers of early and mid-life transitioners who have quietly and successfully transitioned and are living in stealth, and who are well assimilated as women, are simply "invisible" to the media, to the public and even to other transitioners.

Quite a few transgender support groups now consist mostly of intensive crossdressers, some of whom undertake TG transitions late in life even though unsure about their chances of success. The dreary images of some of these cases, who often linger in support groups long after their transitions, can be frightening to young transitioners who may worry whether they will "end up like that". 


Such worries are usually unfounded, because by seeking and finding help from appropriate support services at younger ages, most young TS girls can transition and go on to live full and happy lives and assimilate well into society. 


Note that it is important for young transitioners to find friends and support groups where their concerns are considered important and where early transitions are the norm.  After all, young transitioners are at a time in life where their concerns are deeply different from those of late transitioners. They are looking for their place in life, are learning what it means to be in love with someone, and are trying to become autonomous and more distant from their families, and so on. 


It is also essential that they find a group where, regardless of their sexual orientation, the intensity of their desires, sensations, and attractions as young women are not only welcomed and respected, but fully validated. They must know that they have all the chances to have a fulfilling emotional, sensual and romantic life, as would any other woman. They need to be reassured that their body feelings and longings for love and passion are completely "natural and OK", and that after transition their lives can be really sweet - including having boyfriends and getting married just like any other girl, if they would like to do that.

For all these reasons and more, it is important that young persons (and their families) become aware that early transition can enable them to live almost their whole life in an appropriate body and role, and that they must try very hard to not lose this opportunity.

In the next section, we'll go on to a discussion of options and methods for transitioning early in life.  (See also Andrea James' page Transitioning Early in Life).



  Continue to next Section:
Part IIa: Transsexualism (cont.) 


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