The Mixed-up World of Gender Identity Disorders

Actor Jonathan Chen cross-dressed one night on a trip to the Core Pacific City Mall. A law school graduate who was ridiculed by elder family members on account of his cross-dressing jumped to his death from a building in women's clothes. Tony Chen, a famous English teacher, formed the Tender Men's Association in the hope that people would rediscover the bright side of feminine men. A sixth-grade boy cross-dressed seductively and worked as a "betel nut beauty" (a seller of betel nuts who sits in a glass booth by the roadside and shows a lot of leg as a sales tactic). Police arrested a street hooker and discovered that she was a he. . . . Recently, there has been a lot of news about transgenders. While appealing to people's appetite for titillation, these news items also tell of the endless torture to body and soul of those who suffer from gender dysphoria (or gender identity disorder).

In the past, men played both the male and female parts in traditional theater, and there were quite a number of famous actresses who were actually men. The picture shows a member of Hung-ting Artists drag show putting on make-up.

In the wrong body

What is gender identity disorder? Has God played a joke on its sufferers by trapping their souls in the wrong bodies?

Fang Rong-hwang, director of plastic and reconstructive surgery at Taipei Veterans General Hospital, is known as the "father of Taiwanese transsexuals." He explains that there are many forms of gender dysphoria, including homosexuality, bisexuality, gender schizophrenia, transvestism and transsexuality. As for "sissies" or "tomboys," these are terms that merely describe social stereotypes and have nothing to do with gender identity disorder.

Transsexuals are often regarded as homosexuals, but in fact transsexuality and homosexuality are two different conditions. Transsexuals, unlike homosexuals, cannot identify with their assigned gender. They are disgusted by their sexual organs and wish to change their bodies through surgery to match their minds. For example, in a lesbian couple one partner may play the more male-or "butch"-role. Yet playing this role within the relationship does not mean that she has any problem with identifying herself as a woman. A female-to-male transsexual, on the other hand, may have a female lover before she has a sex change operation. But since her adopted gender is male, she does not identify herself as being homosexual. Rather, she considers herself as being a heterosexual man.

The most intense form of gender dysphoria is called transsexuality. People who are primary transsexuals harbor lifelong desires to change their sex. They often fall into deep depressions and feel suicidal. The public has very little understanding of them and often groups cross-dressers and transsexuals in the same category as "perverts." Transsexuals are likely to have been laughed at since early childhood, and when they express their love to the person they admire, they are typically spurned in a panic. Even many of their own parents refuse to accept them for who they are and regard them as the "black sheep of the family."

Lin Kuo-hua, a male-to-female transsexual who is now nearly 40 years old, has always considered herself to be female. In a health education class in junior high school, she learned of the physiological characteristics that define males and female. Alarmed at the prospect of never being a girl, Lin Kuo-hua bought some anesthetic and twice tried to remove her testicles. She thought that by so doing she could refuse to be a man. Heart-rending stories of people hurting themselves or even committing suicide are seen time and again in the medical records of transsexuality over the last 100 years. Among patients who underwent sex change operations at Veterans General Hospital, over 80% attempted suicide in the years before their operations. It's a figure that shows the agonies and frustrations of transsexuals.

Thailand is transsexual heaven, and shows featuring transvestites are one of its tourist attractions. Nevertheless, respect for the transsexuals is still lacking.

A cosmic joke?

There are two psychiatric classes for transsexuals: primary and secondary. Primary transsexuals are those who have considered themselves to be trapped in the body of the wrong sex and desired to change their physiological gender for as long as they can remember. Intersexuals (also known as hermaphrodites) are people who were born with two sets of sexual organs. They have chromosomal abnormalities or hormonal imbalances and are not transsexuals. People who adopt a persona of the opposite sex for a special reason, such as Mulan (who took her father's place in the army) or the transvestites who change their sex to make a living, cannot be counted as true transsexuals.

Real primary transsexuals, regardless of what kinds of rejection or discrimination they face, almost never regret gender reassignment afterwards. This is not the case for secondary transsexuals. These are often people who decide to have a sex change only after they are fully grown, usually because they are upset by something. "When secondary transsexuals rush into an operation because of some strong motivating factor other than self-identification, they often regret it," explains Feng Yung, director of the Department of Psychiatry at Far Eastern Memorial Hospital, who has treated nearly 500 transsexual people. A-chi, a male-to-female transsexual who now wishes to change back into a male, went to Thailand for a sex change operation because his homosexual lover fell in love with a woman. A-chi wanted to become a woman to win him back. But it didn't work, and now he wants to reverse the surgery.

When you examine the memories of primary transsexuals, you discover that they have all identified themselves as members of the opposite sex for as long as they can remember, even in their dreams. For them, it is a condition, not a choice.

As for what causes transsexuality, no one can say for certain-just as no one can say for sure what causes homosexuality.

Scientists who hold the view that gender identification is innate believe that transsexuals either have abnormal genes or have brains that have been exposed to hormonal abnormalities in the womb. For example, the Swedish psychologist Mikael Landen discovered that there are three genes present in transsexual males that make them less sensitive to testosterone, the male hormone that stimulates the development of male sex organs. He uses this theory to explain why transsexuality can't be cured, and why there are people with transsexual tendencies in every society.

Scientists who believe that people become transsexuals because of social and psychological reasons point out that in the West, male-to-female transsexuals are twice as common as female-to-males, whereas in Taiwan it is the other way around. Wen Jung-kuang, a psychiatrist at Kaohsiung Veterans General Hospital, explains that because males get preferential treatment in Taiwanese society, females are more inclined to identify themselves as being male. Feng Yung thinks that most transsexuals "were raised that way" and that the condition has a lot to do with their relationships to their parents.

Feng goes on to explain that a child develops his or her sense of gender identity between the ages of 18 months and four years. This is the time for a boy to learn to be a man and a girl to learn to be a woman. If they get it wrong, "and the little sapling has already grown up to become a big tree, it's almost impossible to correct," says Feng. In the West, children are mostly given to their mothers in divorces, as is the case in Hong Kong, which was once a British colony. In Taiwan, however, the children of divorcing parents have been traditionally given to their fathers, giving daughters a good reason to identify with them. Although both Hong Kong and Taiwan are Chinese societies where boys are preferred, in Hong Kong there are just as many male-to-females as female-to-males, whereas in Taiwan there are twice as many of the latter.

After many years of struggle, homosexuals can now finally say that they are proud to be gay. The picture shows the 2002 Taipei Lesbian and Gay Civil Rights Movement activities held this October. People with gender identity disorders, whose numbers are much fewer, are still waiting for societys understanding and respect.

"Raised" that way?

In recent years, the social and educational environment has become more liberal, and parents are more aware about what's going on with their kids. As a result, an increasing number of parents are bringing their kids to see psychiatrists when they discover a son who likes to dress in girls' or women's clothes, walks and talks like his mother and dislikes his own genitals, or a daughter who always wears pants and baseball caps and sometimes even binds her growing breasts.

Tung-tung, a fifth grader, went to see a child psychiatrist at the Kaohsiung Chang-Gung Memorial Hospital with his mother recently. As young as he is, he has gathered a lot of sex change information on the Internet. On his own initiative, he firmly asked the doctor to inject hormones to help him grow breasts. He expressed a wish that the doctor give him a sex change operation as soon as possible. Sitting beside him, his mother's eyes swelled with tears.

Tang Ching-su, a child psychiatrist at Kaohsiung's Chang-Gung Memorial Hospital, has lately seen many children with gender identity disorders. Although cautioning that scientists aren't certain what causes these kinds of problems, in the cases he has come in contact with, there are a lot of boys who live with their mothers, grandmothers or sisters, and thus have no males in their lives to identify with. Take Tung-tung, for instance. His father isn't around, and when he was, he was a bad guy who would beat up Mommy.

Wei-wei, a high school girl, has threatened to commit suicide if her family doesn't let her have a sex change operation. Her father likes to drink and gamble, and as the eldest daughter, Wei-wei has wanted to become a man to protect her mother ever since she was small.

But sometimes childhood environments offer no obvious clues to explain transsexuality. Suffice it to say that there are a lot of arguments about nature vs. nurture. Yet doctors in both camps agree that the key changes have already happened by early childhood and that the patients themselves don't know why. Therefore, family, school and society should be more tolerant of transsexuals and give them more respect.

With its dazzling sets and graceful dances, the famous Hung-ting Artists drag show is famous both in Taiwan and overseas. (courtesy of the Hung-ting Artists)

No cure

Over the last century, many psychiatrists have tried hard to treat transsexuality, and they have almost all failed. In fact, patients who see psychiatrists about their transsexuality mostly go just to obtain assessments from two doctors to qualify for a sex change operation. They show little desire to be treated. To the anxious parents who bring their kids to seek help, the most important question is "Can you change him back?" When the doctor fails to give a positive answer, many parents leave in disappointment and never return.

In fact, the transsexuals aren't the only ones who need help; their anxious, angry or grieving parents also need it. The helplessness, sadness and strong guilty feelings of parents only puts more pressure on the children or makes them want to hide their desires. Tang Ching-su, a psychiatrist for teens at Chang-Gung Memorial Hospital, points out that "the meaning or purpose of treating a transsexual is not to change his behavior, but to observe, understand, accompany and feel for him."

How many transsexuals are there in Taiwan? How many of them have had gender reassignments? Estimates vary, as they do overseas-where some put the number of transsexuals at three per 1000 people and others at only one in 50,000.

The only thing that can be said with any certainty is that since sex change operations became legal in Taiwan in 1986, over 160 people have gone through with the surgery in accordance with the proper procedures. Among these, 55 have been male-to-females, and over 110 have been female-to-males. Nearly ten of them got married. Feng Yung roughly estimates that over 500 transsexuals have sought medical help.

In todays androgynous age, whos to say that it is not right to have a tender heart and handsome features?

Are there more transsexuals now?

Hospitals in Taiwan set strict guidelines for sex change operations. The "parental consent" requirement, which no other nation in the world imposes, makes many transsexuals seek surgery abroad, particularly in the "transsexual heaven" of Thailand, where operations are relatively inexpensive and there are no parental consent requirements. Just in the past year, Fang Rong-hwang has learned of several dozen people who have come to seek help from doctors in Taiwan after having operations in Thailand. Either the operations have failed, complications have arisen, or the patients have needed sex-change certificates. Log onto the websites of Thai sex-change hospitals and you find beautifully designed Chinese web pages beckoning Taiwanese transsexuals. Packages and perks include airline flights, Chinese receptionists, post-operation condos and sightseeing tours. It is safe to assume that there are many more transsexuals, and people who have actually gone through with surgery, than the official figures would suggest.

Reversing the genders God assigned, sex-change operations have always been full of controversy and myth. Fang Rong-hwang, who has performed over a hundred such surgeries, has struggled with these issues since he was baptized four years ago. Women came from a man's rib, and God created both men and women. Maybe a doctor shouldn't play God. Yet a female-to-male transsexual has thanked Fang for taking the "two rocks" off her chest and making her a man. Every father's day she comes to visit and express her gratitude. Many transsexuals who went abroad to have their operations return home to find that their new vaginas have closed up or their new penises have become inflamed. Even so, they still profess to be happy, because at least they have gotten rid of the unwanted sexual organs that they were born with. At this, Fang can't help but sigh: "That's about as much as we can do for transsexuals."

Fang has come into contact with transsexuals who are laborers and others who are dancing girls-as well as more than a few with graduate-level degrees. Some backed out in the surgery room because of their parents' hesitations. One originally female doctor was accompanied by her girlfriend, and her future mother- and father-in-law both came to cheer her up. In that instance, family and friends have accepted "his" true self.

Who killed Yeh Yung-chih?

One April day two years ago in Pingtung, a junior high school boy named Yeh Yung-chih was found dead in the school lavatory. The back of his head had been hit hard. He had gone to the bathroom ten minutes before recess. The case was unsolved because the murder scene had been badly sabotaged by the school. But why did he go to the bathroom before recess? Yeh had been feminine ever since he was small. He loved to cook, sew and do the laundry. His family ran a beauty parlor, and the customers loved his gentle ways and attention to detail.

But after he entered junior high school, his male classmates became hostile toward him. They ridiculed him incessantly, and in the bathroom would gang up to force him to take off his pants and examine his genitals. After his mother talked to the school, the school let him go to the bathroom before recess to avoid the others. But, tragedy still happened. The story of Yeh clearly shows that even in school "there is uncontrolled sexual stereotyping" says Su Chien-ling, the director of the Taiwan Gender Equity Education Association, who has dedicated herself to gender education.

In our society, those who are not conventionally male or female-including homosexuals, transsexuals, people with gender identity disorders, transvestites, sissies and tomboys-are considered fair game to be mocked or scorned at any time or place. From the time one is born, names, clothes and upbringing continually draw the line between male and female. But making such distinctions actually narrows kids' minds and takes away the chance for them to explore the other half of the world.

"Feminine males are especially hard to accept in Chinese society," says Su Chien-ling. "In a society where men are valued over women, learning from females is, from a male's perspective, like learning from the weak. Hence, the range of acceptable behavior is even smaller for males than females. In the sexual spectrum, there is a wide range of colors. To divide male and female into two extreme categories of masculine and feminine would make us unable to understand and appreciate disadvantaged groups." Su suggests that parents should let the kids happily be themselves instead of treating it as something to grow out of. It's like having a kid who is left handed. Instead of hitting his left hand to discourage its use, it is better to encourage him to use both hands.

Gender diversity

In fact, most kids who visit child psychiatrists do not think that there is anything wrong with them. They feel that they have been forced to come by their parents. Chen Chih-tsai, a child psychiatrist at the Women's and Children's Hospital, reminds parents not to be too anxious. Focusing their child's problems on "gender" would block the view to the core of their problems.

The tragedy of Yeh Yung-chih resulted from the harm and discrimination inflicted by society. "In this society," Chen says, "even the strongest man can meet a fatal attack." Her point is that if parents are afraid their kid will be bullied because he is feminine, instead of asking the kid to dislike and torment himself by toughening up and becoming masculine, it is better to teach him to appreciate himself and to enjoy what he has. At the same time, teach him how to get help and protect himself when needed.

Last October in the United States, a 15-year-old boy with gender identity disorder was suspended from school for wearing high heels, bras and wigs to school, making other students and parents uncomfortable. The boy's psychiatrist said that forcing him to wear boys' clothing would harm his mental health. The judge thought that the school's measures would "stifle his sense of self" and thus allowed him to continue to wear girls' clothing to school.

"Students' exposure to different lifestyles makes them more tolerant as adults." The lesson given to that school and its students by the American judge is in fact a lesson for every one of us.