Born in the wrong body
By Cheow Xin Yi and Esther Fung - Mar 9, 2007, The Straits Times Mandy (not her real name) had known she was 'different' since she was young. Back then, the primary schoolboy did not know how to articulate the problem, but he had always felt like a she.
'I always wanted to hang out with the girls, but then I realised I wasn't a girl,' she told Mind Your Body.
'It was very bitter initially because you feel that life has dealt you a wrong hand.'
What she - now more or less a socially accepted female in her 20s - had experienced throughout childhood was the classic example of a girl trapped in a guy's body.
While that is the conventional description for transsexuals, psychiatric doctors usually diagnose them as sufferers of GID or Gender Identity Disorder.
According to the World Professional Association For Transgender Health, a leading international health body on transgender issues, transsexuals identify strongly with the other gender and are persistently uncomfortable in their assigned one at birth.
GID is the new term for transsexualism, which was first coined in the 1950s, said psychiatrist Tsoi Wing Foo, who is the co-author of Cries From Within, Singapore's only medical book on transsexuals to date.
'It was recently changed to gender because it is not a sexual disorder,' he said. While causes of GID have been debated inconclusively along the lines of nature versus nurture for the past 50 years, a 2003 study provided the strongest evidence that it has got to do with the hard wiring in the brain before birth.
Previously, it was thought that gender was solely determined by the male and female hormones testosterone and oestrogen.
But scientists from the University of California, Los Angeles (UCLA) identified 54 genes that influence the differences between male and female brains.
ROLE OF GENES
The findings imply that due to genetic reasons, people can 'feel' male or female, even though their sexual organs indicate otherwise.
Dr Eric Vilain, assistant professor of human genetics and urology at the David Geffen School of Medicine at UCLA told Reuters that his team believes 'that one's genes, hormones and environment exert a combined influence on sexual brain development'.
This indicates that transsexuals, who possess normal hormonal levels, have legitimate claims to seek treatment.
The most established method of treating the disorder is to go for Sex Reassignment Surgery (SRS). Prior to that, patients must already be on hormones.
Male-to-female patients must start taking the female hormone oestrogen or hormones that suppress their male hormones (anti-androgens). While on oestrogen, they start to develop breasts and softer skin. Some also report feeling calmer and less aggressive than before.
For female-to-male patients, it usually starts with the termination of their menstruation. Gradually, their voice will break and they will become hairier.
'It's like going through menopause first and then starting puberty all over again,' said Kelvin, a female-to-male transsexual who has been on testosterone for the past year.
In Singapore, it is standard practice for transsexuals to consult at least two psychiatrists and be diagnosed to have GID before any prescription.
Diagnosis is based on their history and what they tell the doctor about their behaviour, said Dr Tsoi, who was medical superintendent at the Institute of Medical Health in the 1970s. He later moved to the National University of Singapore as head of its department of psychological medicine before entering private practice in 1994.
'Many of them come to see me already convinced that they want to change their gender,' said Dr Tsoi. But that is not the only criterion in the assessment.
'The final test is whether they can live comfortably as a member of the opposite gender,' he added, which also means seeing if they have been comfortable with cross-dressing and taking hormones.
But not everyone goes for psychiatric counselling. Psychiatrist Brian Yeo said he knew of cases that had gone for hormonal treatment without seeking psychiatric help.
'The numbers we see in private practice are just the tip of the iceberg,' he said.
No one knows how many transsexuals there are in Singapore exactly, but Dr Tsoi, who has seen about 2,000 transsexuals in the last 40 years, estimates that there are 30 cases in Singapore each year.
ROUGH ROAD AHEAD
Some transsexuals admit that they consult a psychiatrist for the sole purpose of getting a letter of exemption from reservist training or certifying them fit for SRS.
But doctors say it is important to ensure that the patient is rational and properly counselled in preparation for the rough road of transitioning.
Mandy, for one, is self-diagnosed. She started to take feminising hormones prescribed by a general practitioner four years ago after national service.
But she is wary of the dangers of taking hormones, especially after suffering from jaundice, a side effect of taking oestrogen pills.
The liver takes some time to process the hormones from the body and if a patient takes an unregulated dosage, she might suffer adverse side effects.
Doctors say that it is best if transsexuals see an endocrinologist for a proper assessment on hormone therapy since overdosing is common.
While SRS signifies the complete reunion with their preferred gender for most transsexuals, most in Singapore also do it for a practical reason - changing of legal documents.
Singapore is one of the few countries in Asia to legalise gender change on identity cards, but it will only do so after genital surgery.
For Denise, a late-onset transsexual who started transitioning only in her 30s, the change in her IC is the only way she can start her life anew financially.
A graduate who had a cushy job in information technology, she quit after facing discrimination from her boss and colleagues about her increasingly feminine appearance.
Transition has been a costly and painful journey for her. Besides the money spent on various facial-feminising operations and skin-dermabrasion procedures, she has to pay monthly maintenance to her child and wife, whom she separated from after her decision to transit.
To earn money, she got a job as a temporary clerk through an employment agency where she did not have to divulge her personal details and downplayed her resume. Currently unemployed, she intends to get a better-paying job after SRS when she can live legally as a woman.
She is now awaiting surgery in Thailand.
MANAGING EXPECTATIONS
Still, it is possible to achieve a successful transition, and the majority can fit very well into society after surgery, especially if they have lived as their preferred gender for a while, said Dr Calvin Fones, a psychiatrist who has been counselling transsexuals.
'The surgery is also staged, which means it is done over a period of time. It's not like a fairy godmother turning you into a princess overnight,' he added.
Endocrinologist Alex Fok, who has about 40 transsexuals on follow-up, said much has to do with expectations. 'Female-to-males are more stable in outlook. They become men, adapting to their new gender effortlessly. In contrast, some male-to-female patients try to be more female than the average woman,' he said.
Dr Fok has had to counsel and temper the expectations of some of these patients whose expectations of hormonal treatment are unrealistic.
EMOTIONAL SUPPORT
Even though the late Professor S.S. Ratnam performed Asia's first SRS here in 1971, most transsexuals in Singapore go to Thailand now to have theirs done.
While cost is a major factor (operations are much cheaper in Thailand, although the most expensive can go up to $35,000), most choose Thailand because of the expertise and sheer experience that surgeons there have in operating on transsexual patients.
'If you have a doctor who does one operation a year compared to one who does five to six a week, who would you choose?' asked a post-operative transsexual who had surgery in Bangkok for US$5,000 (S$7,600).
Experts attribute the decline of these operations in Singapore to a phasing-out in the 1980s by the authorities because of the worry that SRS was somehow connected to the Aids virus.
'It is a pity that we were once the leading sex-change centre in the world, training doctors from other countries and now we don't even have a programme to speak of. This may have been a knee-jerk reaction to the Aids situation that was emerging in Singapore in the 1980s. The Ministry of Health should have kept the programme going,' said Dr Woffles Wu, a plastic surgeon who frequently does facial-feminisation operations for transsexual patients.
The Health Ministry told Mind Your Body that it had no objection to such operations being performed although specific guidelines were left to the surgical teams in hospitals that did the procedures.
Professor Arunachalam Ilancheran, a gynaecologist who also heads the Gender Identity Clinic in the National University Hospital (NUH), said he had done fewer than six operations since the clinic reopened in 2001.
A student of Prof Ratnam, he said he performed more than 100 operations in those days.
Referring to doctors, Prof Ilancheran said: 'Now, nobody is interested in the procedure anymore.' He is the only surgeon providing the service in NUH.
While Thailand seems to have filled the gap, gaining an international reputation in the meantime, here in Singapore outspoken transsexual Leona Lo thinks more can be done for the continuum of health care for both pre- and post-op transsexuals.
Surgery or not - and not every transsexual seeks to change - what patients need most is acceptance from the public and family to function optimally.
Dr Lee Cheng, a psychiatrist in IMH who is seeing two post-op transsexuals for depression, says it is important to provide emotional support for patients after any major surgery.
'They may have problems adjusting to the drastic changes after the surgery, and for transsexual patients, they need help with accepting themselves and integrating with their families,' he said.
This article was first published in Mind Your Body, The Straits Times, Mar 7, 2007.
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Contributor's Note
This article was first published in Mind Your Body, The Straits Times, Mar 7, 2007.
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