Information and Guidelines for Transsexuals

PREFACE

The following text was digitized from a pamphlet from the (former) Erickson Educational Foundation called "Guidelines for Transsexuals". It was printed in 1974, but the information is still very valuable.

[The original version of this file was scanned in by Jennifer King, and was called TS-GUIDE.TXT. This version has been "cleaned up" in an effort to eliminate errors which her OCR software created during the original scan, and has been edited in an effort to reduce overall file size, focus more directly on the male-to-female transsexual, and update certain information. It has been renamed TS-INFO.TXT in order to aviod confusion. Any significant changes to the original file created by Ms. King appear in brackets.]

INTRODUCTION

The earliest printed records of human behavior clearly indicate that transsexualism existed long before it found a name. But until modern medicine recognized, defined and developed therapies for this condition, the transsexual was left to cope with his (Masculine pronouns are used throughout, unless the genetic female is referred to specifically, for the sake of clarity) difficulties by more or less unsatisfactory, and often tragic, means of his own devising. The individual whose firm conviction that the sex which his body expresses contradicts the sex to which he feels himself to belong need no longer resign himself to this predicament. Skilled professional help is now available to him, help that is given with understanding and free from false moral judgments.

The course of sex reassignment is a complex one, involving many physical, social and emotional readjustments. It is a sensitive, ongoing process, of which surgery, while it is the culmination, is but one of many essential elements of transformation. Once your physician makes a diagnosis of transsexualism, he will require, and you should require of yourself, that the way toward surgery be careful) prepared, in order to eliminate possible practical problems and embarrassments, and the more serious possibility of belated doubts, which might otherwise arise after surgery has been performed. Ever after the successful completion of surgery, certain physical and emotional precautions must be taken, to ensure your continuing health and well-being.

The foregoing reminders were not set down to discourage you from seeking help, but with the object of promoting a realistic approach to therapy. Most instances of difficulties in post-surgical adjustment to sex reassignment may be attributed to careless or insufficient preparation. On the other hand, physicians report marked success in the vast majority of cases where preparation has been intelligent and thorough.

This pamphlet is designed to inform you as to how you may help yourself, and obtain the best possible help from others, in building a new life.

SELF HELP: THE TRIAL PERIOD

No part of your preparation for sex reassignment is more important than the first-hand experience of dressing, working, living in the desired gender role for a continuous and considerable period of time prior to surgery. Most gender identity clinics, and many physicians in private practice, require from six months to two years of cross-gender experience before recommending a patient for surgery. This may seem an excessively long period to you before you begin, but experience has shown that no other test is so effective in preventing the tragedy of a wrong decision for surgery, the results of which are irreversible. On the other hand. there is no better means of laying the groundwork for every aspect of your new life, and strengthening your confidence for it, than this preparatory period.

It will be helpful to review two typical cases in which people who considered themselves transsexuals decided against surgery as a direct result of their cross-gender experience.

A married man who occasionally wore women's clothes when he accompanied his wife to nightclubs, and who found intercourse more pleasurable when he dressed in feminine lingerie, began a trial period in which he lived alone and wore feminine clothing consistently. One evening he picked up a man and brought him home. Far from finding sexual relations more satisfying, as he had expected, the experience was very distressing to him. Later he found himself missing his wife, who was sympathetic to his intermittent desire to cross-dress, and the life they shared together. Finally, he returned home with relief, thankful that he had not taken prematurely a decision that could not be reversed. Physicians would recognize that this man was not a transsexual, but a transvestite, whose final decision reflected a realistic adjustment to that condition.

Another man, who lived with a male lover, decided to prepare himself for transsexual surgery. He was of slender build and, with his delicate features and tasteful grooming, presented the appearance of an attractive young woman when "dressed." It was necessary for him to leave his high-salaried professional job, and he found employment as a secretary in the same field, with considerable loss of income and of the mental stimulation he previously enjoyed in his work. This man was accepted completely as a woman, socially, in his office, and on the street, where he attracted many admiring glances from men. Yet he decided that surgery was not for him. Why?

As Bill tells it, "This is definitely a man's world, whatever they say about Women's Lib. I just couldn't get used to that condescending manner most men have toward women. If I offered an opinion to any of the bosses at work, even on a subject I knew a lot more about than they did, they either ignored me or let me know that I was out of line. At a party, when the men were talking about something that interested me, it was the same thing. And if I saw a man there who attracted me, he backed away if I took the initiative.

"And of course living on so much less than I was used to and counting pennies was hard to take. And all because 1 wore skirts! When I went to see Dr. X, I wanted the operation right away, and I couldn't understand why he insisted I give it a trial first. Now, am I glad he did! Surgery would have been a terrible mistake for me." Bill has found himself a new job at his original status, and accepts his homosexual nature and relationships more fully than he ever did before.

Apart from winnowing out those who would not benefit from sex reassignment, the trial period serves several positive functions for those who would. No matter how powerful your personal conviction that you are trapped in the body of the wrong sex, nothing can reinforce your confidence in this conviction as effectively as the experience of being treated as a member of the gender of choice-all day, every day, by everyone you meet. Continuous daily practice in the new role, socially and at work, is essential for the development of the habit patterns and the inner assurance that will evoke this gratifying response from friends and associates.

As certain as you may be of your inner identity, and even if man of your behavior patterns already conform to it, there are likely to be a number of subtle ways of expressing gender--for example, choice of words, and loudness or pitch of laughter--that only observation ani practice can perfect. Furthermore, some of the social adjustment that made problems for Bill may at first trouble you to some degree until you find a way to live with them. It is essential, then, that the cross-gender trial period be long enough to allow you to overcome awkwardness, establish new behavior patterns, and approach unfamiliar situations with an unforced inner confidence. When you have achieved this, the moment will have arrived for surgery to confirm the changes which you have so well prepared.

PREPARING YOURSELF

Younger transsexuals generally have an easier time than older transsexuals in easing into the new role, since their peers tend to be more accepting and to hold more generous and flexible concepts of gender identity. ln addition, people in a more advanced age group usually have more at stake, emotionally and economically, in making the change. They may have to disentangle themselves from marital commitments, and sometimes they will have to forfeit an advanced career, with the highest income and the professional status to which they have become accustomed. It is also true that our masculine and feminine habits become more ingrained with time.

Moreover, transsexuals, such as teachers, whose jobs require them to work under the public eye, may even have over-compensated (i.e., exaggerated their manner and dress to conform with their officially recorded sex) as a form of protective camouflage. This is not to say that modes of behavior cannot be altered later in life. It simply means that the older transsexual may have to work a little harder in assuming the new role than may his younger counterpart.

It is advisable to postpone your testing of the new identity until the hormones administered by your physician produce adequate physical changes. Like an actor preparing for a new role, hold your rehearsals in private, consulting your mirror and perhaps using a tape recorder, and then try several dress rehearsals before holding your first public performance. A close friend or friends, visiting with you for an evening at home, might be your first audience. For your next effort, you might arrange to spend a weekend away from home with a friend, going out with him in cross-dress only in the evening. When you feel more fully prepared and confident--and this is a moment only you will recognize--take a walk in daylight in a public place. You will know that your performance is successful if no one you pass turns to take a second doubtful look as you go by.

It has been observed that some male-to-female transsexuals tend to over-do in makeup and dress. It is always advisable, when you are uncertain, to understate rather than exaggerate your appearance, which might otherwise attract undue attention. If you are now fairly sure of yourself, but still have some doubts, you may decide to take a course in grooming. ln some states, funds are available for this purpose to those who are unable to pay, though the Department of Vocational Rehabilitation. This, too, may be accomplished during the trial period.

A charm or model school can offer good guidance in helping you to polish your mannerisms and in providing tips on behavior in various social situations. (Beauty schools usually limit their instruction to hairdressing and makeup techniques; they will not be as useful for your purposes.) ln enrolling in such a school, use your judgment about confiding in the director. As with people in any walk of life, some may be unsympathetic and reject your application, while others will be more cooperative, and perhaps arrange for you to be instructed privately.

Above all, realize that most people will take you at face value without speculating about your sexual status, especially if you are not apologetic in your manner. You can reinforce this awareness by taking note of how many hairy, muscular women and how many beardless, somewhat feminine-appearing men are unquestioningly accepted as members of their genetic sex by the people around them. Few individuals physically approximate the masculine or feminine ideals of the magazine ads and television commercials. The key to being accepted by others is your own self-acceptance. Remember that the confidence with which you approach them will be the determining factor in their response to you.

In a later section, we will discuss the physical changes achieve through hormone therapy, which you will be receiving during the preoperative period. You will find these changes highly beneficial in reinforcing your confidence and your acceptance by others.

ADDITIONAL TIPS

Hormones will effect some important physical changes during the preoperative period, but there are some other steps you will want to take to improve your appearance in the new role before surgery.

The penis may be concealed by bending it backward toward the anus and securing it with surgical or masking tape over gauze, covered with a kotex pad. A girdle is then worn to secure it in place. If there is discomfort, your physician can prescribe an anesthetizing cream to be used locally.

Avoid the use of public restrooms whenever possible. When this is not feasible, always urinate in a seated position in a locked cubicle. If you stand, your head may be seen over the top of the door, or it may be noticed that your feet are pointed toward instead of away from the commode.

POSITIVE ATTITUDES

Other people can be of assistance to you in many ways during your transition to the new role, particularly if their help is intelligently sought and gracefully received. Experienced physicians will provide the essential medical care. An understanding friend, relative or employer, even if you know only one such person, can offer invaluable moral or practical support. Some physicians and social workers who specialize in treating transsexuals schedule regular group meetings in which their patients meet to discuss their mutual problems and benefit from shared experiences. But it is a mistake for anyone to depend solely upon others for help in surmounting his problems. indeed, if it becomes apparent that we are not meeting our friends at least half way, by showing initiative and courage on our own behalf, their inclination to be of help may quickly diminish.

"Why me?" is the question so often asked by people in trouble. Perhaps it is a question which at first one cannot avoid asking. But nothing is more certain than that no one holds the key to the inequities; of human fortunes-why some of us suffer material want while other; are over-endowed with the world's goods, why some have a greater share of physical beauty and others less. We must all ultimately acknowledge the futility of such questions, accept our circumstances, and go on energetically from there, doing the best we can with what we have. Whatever our religious beliefs, or lack of them, the Book of Job is a storehouse of practical wisdom on which we all may draw. For as long as Job persisted in lamenting his fate, his troubles, which at first seemed so great they could grow no worse, grew greater still. When at last he came to the end of lamentation, and accepted himself an his circumstances, he found in himself the strength to rebuild a life that had seemed ruined beyond repair.

Although other people can help us, as we can help them, each one of us must learn to look inward, to discover his own resource: and to depend primarily upon them. Those of us who enjoy a faith in God, or in a reality that transcends the personal, may find strength in this belief; but even this orientation may not be one of utter dependency. Every religious philosophy embodies the awareness that "God helps those who help themselves."

How we regard ourselves suggests to others, if only subconsciously what their attitude toward us will be. If the transsexual persists i thinking of himself as essentially crippled, in a physical or an emotional sense, it is probable that this feeling will infect other in their reactions to him. If, on the other hand, he more realistically regards himself as an individual with problems which can be remedied, and actively applies himself to obtaining the help which is available to him, this constructive self-acceptance will stimulate in other people a enthusiastic response that will reinforce his own efforts. Negative thought patterns can be as damaging as negative actions to the person who indulges in them. Learn to divert yourself from the self- destructive mental repetition of your problems by turning your attention to some constructive activity the moment you become aware that your thoughts are taking a negative turn. Arrange to meet a friend or pick up a good book. Learn some simple handicraft with which you can quickly occupy yourself at difficult moments. Take on some volunteer service, assisting at a hospital or a senior citizens' home, or working with underprivileged children. There can be unusual gratification in using your own misfortune to help you grow in compassion toward others who may be even less fortunate than you. Another advantage of doing volunteer work is the possibility of making useful job contacts among the people with whom you work.

Make a virtue of the common necessity of working at a job to discharge your medical and living expenses. During the hours in which you apply yourself to your work, you will generally be too busy to drift into negative thoughts. Remember that no matter how humble the work you do, it produces a product or serves a need, and the salary you earn each day carries you closer to your goal.

In summary: Your personal program should be one of constructive thought reinforced with constructive action.

PREPARING OTHERS

One important way in which you can smooth the path for yourself is to carefully prepare those with whom you are closely associated for the changes to come in your life. Except in the case of those friends and relatives you are fairly certain will be inclined to support your decision, it would be wise to postpone discussions until you are well along in the trial period and you and your physician are in agreement that you have made the right choice.

It cannot be too strongly stressed that it is in your own best interests to approach others with the utmost tact and forethought when the time comes to talk over your plans. Professionals who have worked with transsexuals can cite numerous instances in which families and employers have been shocked and alienated on seeing a familiar person abruptly appear before them in unfamiliar guise, when, at least in some cases, a sensitively prepared discussion before they appeared in cross-dress would have kept a family united, or saved a job.

There are families who, when carefully approached, surprised their son or daughter by being far more sympathetic and helpful than could have been anticipated. Similarly, it is not uncommon for a transsexual to be accepted in his old job after surgery (if the job is not considered inappropriate to his new sex), or assisted by his boss in finding new employment, after a frank private conversation about his plans. Many schools will readmit a student, correcting his records so that they care only his new name and sex, or help him to gain admission to another school with no loss of scholastic credit, upon tactful application to the appropriate officials.

If you are married, and especially if there are children, the situation is in some ways more sensitive. You are then concerned with the person or persons with whom your life has been most intimately related. Reactions will vary, according to the quality of the relationship with spouse and children. A husband or wife probably will not be taken completely by surprise, but he or she may need some professional assistance in reorienting his life. You will no doubt choose to obtain a divorce, and the surgeon will require this before undertaking surgery.

Where children are concerned, one should proceed with delicacy and care. It may be advisable to postpone a full discussion of the facts of your situation, if the children are adolescent or of pre-school age. A child in grade school, by which time gender identity is well established, is less likely to be disturbed. However, you will want consider the likelihood that he will discuss the matter with his peer who may react adversely or make your private concerns common knowledge in the community.

The child's age and maturity should be carefully weighed before deciding whether or how fully to take him into your confidence, and one or two meetings with a professional counselor may greatly assist you to fulfill this parental responsibility with intelligence as well as love. When you separate from your spouse, and if the children remain with him/her, remember that they will continue to need assurance through your letters, phone calls and visits, of your continuing interest in their activities and their welfare.

To sum up, it stands to reason that you will be seeing your own best interests by considering the feelings of others, and not, through thoughtlessness or a self-defeating defiance, risking severed relations with those people who may be of real help to you if they are approached with tact and care.

MAKING IT OFFICIAL

When the probability of sex reassignment surgery is imminent, you will want to begin to establish a new public identity. There are a number of legal and administrative processes which you should use to your advantage and to prevent harassment, both during the preoperative period and after surgery. Throughout this section it is frequently suggested that you may find it convenient and helpful to enlist the services of an attorney. While it is true that in some delicate situations (e.g., approaching an unsympathetic former employer for job recommendations in your new name) and sometimes in dealing with bureaucratic officials a skillful lawyer may be more influential than a layman, many of these procedures can be successfully handled on your own. If you find it advisable to consult an attorney and your funds are limited, your local Legal Aid Society may provide assistance for a token fee.

You may not be aware that under the common law, you have a legal right to call yourself by any name you wish, provided there is no intent to defraud or be of prejudice to others. If your name applies to either sex (e.g. Chris, Leslie), it may be advisable to continue to use it. Otherwise, it would be expedient to select a name with the same first initial.

You may use your new name when applying for a library card and museum memberships, when establishing a bank account or applying for credit cards: all useful items of identification. Many of these procedures may be handled through the mails. For example, you may open a new bank account without closing out t@e account under your original name, and conduct the transaction by mail. Then, at a later date, you may write a check to your new account from the old one, withdrawing all funds and thus closing the account. In opening a checking account, a friend or your attorney can provide a credit reference.

During the transition period, when mail may be arriving in the names of both sexes, it might be advisable to rent a Post Office box in order to avoid embarrassment. Once your new name is firmly established, you can revert to receiving mail in the usual way.

There are several safeguards you may take to avoid running afoul of the law. The first precaution is to favor conservative over flamboyant dress, so that you will not attract undue notice. Second, you may obtain from your physician a letter to the effect that he is treating you for a transsexual condition, and that you are cross-dressing on his recommendation. Many county and state Departments of Health, when presented with this letter, will provide you with their own letter of authorization. ln many localities, this official document has proved useful.

It is advisable to provide yourself with whatever record change and documents are available to you; this will enhance your sense of comfort and security in the new gender role. The letter from your treating physician and a court order for a legal change of name al the most helpful of those obtainable preoperatively, as the new birth certificate will be after surgery is completed. The methods for securing these official documents, which can be useful in helping you to acquire still other documents, will be discussed in detail below. Whether you are applying for new documents of identity or requesting correction of those you already hold, you can help yourself by being neither over-aggressive nor apologetic. Remember that you are within your rights in making use of these procedures, and that an attitude of quiet self-confidence will get the best results.

BIRTH CERTIFICATE

A new (or failing that, an amended) birth certificate, registering the new name and sex of a postoperative transsexual, can be a convenience in several situations, as, for example, in claiming social security benefits. One instance in which it is essential is in making application for a passport. The degree of success your application for a new birth certificate will have depends entirely upon the policies or laws of the state in which you were born, and since these vary from state to state, legal advice will be most helpful to you in this instance. Several states have established new rulings in this matter, and there are now bills pending in other state legislatures. To date, only Arizona, Illinois and Louisiana have state laws which regulate birth certificate changes specifically for transsexuals; but they can be obtained in other states through administrative channels.

To give you some idea of the varying degrees of cooperation states which grant new certificates, we will use the policies of Illinois, Louisiana and New York as examples.

The state of Illinois is at present the only state which issues a printed form specifically designed for use by transsexuals requesting a new certificate. Payment of the fee provides the additional, automatic advantage of a legal change of name, without resort to the court system. The old record is sealed and the information on it is never divulged. An entirely new certificate (with new name and sex designation and free from all notations indicating that a previous certificate exists) is then issued.

ln the state of Louisiana, medical affidavits attesting to your post- operative status must be filed in a suit with the judicial district court, and a new certificate is then granted.

Other states follow the procedure of amending the original certificate; that is, it now bears the original name and sex and the new name and sex. This is obviously a less satisfactory practice as far as privacy is concerned. But even in states which follow this policy, it has been circumvented in some cases on request of a lawyer. The state office, in these cases, retains the original, amended certificate, and a new one is issued with only a code number to indicate that an earlier certificate exists in the state records.

New York state, which formerly followed the procedure above, has revised its policies favorably. On receipt of an affidavit attesting to performance of sex reassignment surgery, the state now issues an entirely new certificate reflecting the change of name and sex and omitting the code number. The city of New York will issue a new certificate, with changed name and omitting gender, on receipt of a copy of the court decree of name change, and an affidavit which indicates positive psychological status and proof that sex reassignment surgery has been performed.

In most states which grant new or amended birth certificates, the following procedure is standard. You or your attorney submits, either to the State Board of Health, which then handles the rest of the process, or directly to the Registrar of Vital Statistics in the state in which you were born, a letter from your physician requesting the change and attesting to your postoperative status. This letter should also specify that, because of surgical procedures which he has performed, you are no longer a functional female (i.e. cannot bear children) or a functional male (i.e. cannot impregnate a woman), as the case may be. The unique advantage of securing a new birth certificate is that it is the only official document to date which is accepted as proof of a change in gender.

States which to our knowledge have issued new or amended certificates are as follows: Arizona, Arkansas, Colorado, Florida, Hawaii, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Pennsylvania, the Commonwealth of Puerto Rico, Rhode Island, Texas, Virginia, West Virginia, and Wisconsin.

LEGAL PETITION FOR CHANGE OF NAME

As previously noted, a change of name by court decree may not be necessary in most cases. In general, because of the costs and the possible loss of privacy, it might be wise to avoid litigation. ln some situations however, as for example in claiming a legacy, a prior change of name and a court decree may be a convenience, if not a necessity. This is handled by petition of your attorney to the local court having jurisdiction over such matters.

The physician of a postoperative transsexual should write to the attorney, stating that sex reassignment surgery has been performed and recommending the change of name to reflect your changed anatomical sex, alleging that this is vital to your health and well being. This is the essential document in your attorney's presentation to the court. If the court then determines that there is no evidence or intent to defraud, your petition should be granted.

It should be noted that the court's decree in granting a change of name is not accepted as legal proof of a change of sex. However possession of court order for a change of name has been known assist the process of changing sex status, as well as name, on the birth certificate. This is more easily achieved by the postoperative transsexual because of the medical documents he presents, but preoperative transsexuals, on presenting the court decree of name change, also have been successful in having sex status altered on birth certificates.

In one instance known to us, a preoperative transsexual had his petition for a change of name granted by the courts giving as his reason simply his desire to do so. Without requesting it, the court forwarded a certified copy of the decision to the Bureau of Vital Statistics, and a representative of that office then wrote to the individual concerned, asking for a written request "specifying what changes are desired in the original certificate." The requests for change of name and sex were both granted.

ln another case, the judge awarding a name change to a postoperative transsexual incorporated into his decision a recognition of the change of sex. The state in which he presided had no legal provisions for this action, but since this meant that neither was there a prohibition, he couched his statement in these terms: "lt seems under such circumstances reasonable and proper that the petitioner be entitled to have her name changed from Charles Brown, a name commonly used by males, to Charlotte Brown, a name proper to females." The judge then further ordered that a copy of his decision be furnished to the Bureau of Vital Statistics, advising them of the change of sex as well as the change of name, for purposes of issuing a new birth certificate.

When changing your name, it is advisable, for obvious reasons, to retain the last name unchanged.

SOCIAL SECURITY CARD

When you are ready to work under the new name and sex status, the procedure recommended by the Social Security Administration should be carefully followed so that you will incur no loss of the benefits to which you are entitled. The Administration has advised us that a legal opinion will be required in the case of any individual applying for widow's or other benefits if his sex is other than that on his original Social Security Card, even though the name on the records has been changed.

The first step is to obtain and fill out a green card, available at all local offices of the Administration, with the heading "Request for Change in the Social Security Records." If you live in a small town, it may be preferable for you ar your attorney to make a written request for the form to the District Director, to ensure privacy. The card may be filed with the local or district office prior to surgery. If you do so after surgery, accompany the card with a letter from your surgeon stating that transsexual surgery has altered your sex status.

ln either case, it may be advisable to submit the green card to your attorney who will then prepare an affidavit, to be signed by your physician, which will state that he is preparing you for surgery or that surgery has been performed and is irreversible, and that, in either case, he recommends a change in your records in the interest of your health and well-being. The attorney will then submit the card and affidavit to the Social Security Administration. Legal assistance may provide a possible safeguard against delay or withholding of benefits. Should the card alone be submitted, with only your own statement requesting the change for personal and medical reasons, there is a risk that benefits may be denied until a legal opinion is available.

DRIVER'S LICENSE

Recently EEF made a survey of the policies of the Bureaus of Motor Vehicles in the various states with regard to change of s status on driver's licenses for pre- and postoperative transsexuals. Of those Bureaus that replied, thirty-four stated that they would issue new license with the new sex designation for postoperative transsexual The majority of these require a notarized letter from the treating physician, attesting to the fact that the applicant has undergone sex reassignment surgery. The states are as follows: California, Colorado, District of Columbia, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa Illinois, Kansas, Louisiana, Maine, Maryland, Michigan, Minnesota Missouri, Montana, Nebraska, New Hampshire, New Jersey, New York, Ohio, Oklahoma, Oregon, Rhode Island, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin. The states of Pennsylvania and South Dakota carry no sex designation on driver's licenses.

With respect to changing sex designations on licenses of preoperative transsexuals, several states made no reply, and twelve those listed above answered in the negative. Nebraska, New Hampshire and Oklahoma require a birth certificate for verification of status. Since a new birth certificate showing the new sex status can not be obtained prior to surgery, their policies are, in effect, negative.

Those states which will grant a change of sex status on licenses for preoperative transsexuals require either a court order of name change, a physician's letter, or both. They are: Colorado, District Columbia, Delaware, Florida, Idaho, Maine, Maryland, Michigan, Rhode Island, South Dakota, Utah, Virginia, and Vermont. New York will change the name but not the sex status on licenses of preoperative transsexuals.

ln the state of Pennsylvania, where licenses do not include sex status, preoperative transsexuals have been issued new licenses showing the first name's initials only, on presentation of a doctor's letter. Since our survey was made, it is possible that some of the states have adopted more generous policies. It would be advisable to check with your state Bureau of Motor Vehicles. The District of Columbia, Illinois. and Louisiana also require a court or designating a legal grant of change of name. Michigan requires a birth certificate, showing the new name and sex.

If you plan to move to another state following the sex reassignment operation, you may find it simpler to wait until you have lived in the new residence for the required period of time and then apply for a driver's license under your new name and sex.

PASSPORT

If you plan to travel to a foreign country for the sex reassignment operation and apply for a passport, your passport photograph must conform with the sex designated on your birth certificate, which is the sex you are required to write on the passport application. However, some clothing and hair styles are appropriate for either sex. ln cases where the first name may apply to either sex (e.g. Evelyn, Beverly), or where boys have given names usually associated with girls, no problems should arise, since the passport does not specify sex. Your dress while traveling should also accord with the identity implied by the name and photograph on your passport. To do otherwise involves the risk of adverse remarks from officials, and perhaps legal proceedings.

If surgery is performed in the United States, the Passport Office of the Department of State in Washington now requires that you submit proof of legal change of name and sex, in the form of an amended or recertified birth certificate, before they will accept a new photograph and issue a new passport.

No passport is needed to enter Mexico, but you are required to present either a voter's registration card or a birth certificate as proof of citizenship. If you have a passport, this is also acceptable documentary evidence of your citizenship.

IN CASE OF ARREST

If you are taken into custody for cross-dressing or another complaint related to transsexualism, Remember that you are not obliged to supply any information other than your name, address, date of birth, and social security number. Other questions need not be answer without the presence of an attorney, and you would be well-advised to volunteer no further information. Even seemingly innocent remarks may later be used against you. Be sure that the data you supply (name, address, etc.) is not inaccurate. Giving false information is grounds for prosecution on the charge of obstructing an officer.

The arresting officer must inform you of your constitutional rights to remain silent during interrogation. Information obtained without the issuance of a warning cannot legally be used against you.

Do not wait until the time of trial before requesting legal aid. You are entitled to call an attorney even before preliminary questioning (i.e., name, address, etc.) begins, and it is recommended that you do so. Once the intake process is under way, the authorities have the right to check your record and you may find it helpful to consult with an attorney before supplying any information. He can also provide substantial assistance during the pre-trial hearing in the District Attorney's office, when he may be successful in having the case dismissed or the charges against you reduced.

A lawyer also will be helpful if you have been subjected to police brutality during the arrest or while in custody. We know of several such actions which have been successfully filed, and damages collected, on the attorney's petition for a trial judgment.

EMPLOYMENT AND EDUCATION

Medical costs for sex reassignment therapy are considerable (this includes: hormone therapy (pre- and postoperatively), physical and psychiatric examinations and tests, surgery, and related therapies such as electrolysis.) Unless you have substantial private means, it will be necessary continue earning prior to surgery, and you will want to give care thought to your vocational plans after surgery is completed. ln some cases, where your employer is sympathetic and the work you do appropriate to your new gender role, this will not present a problem since you may continue to work in the same job or field of work, Others however, may find it essential to plan for vocational training in a new field. If financial assistance is needed for this, there are funds available from public sources to which you may apply on your physician's recommendation.

Your employer may agree to discharge you from your job, so that you can qualify to collect unemployment insurance. If you judge that it will be necessary to resign your job should your plans become known, be certain to draw all sick leave or sabbatical benefits that have accrued to you, applying them toward the period of cross-gender testing, when you may be short of funds.

If you are a licensed member of a trade or profession, you may apply directly to the appropriate state agency to have your name corrected on the licensing documents. However, since the officials concerned may not be well-informed about transsexualism, it may be advisable to make your request through a skilled legal intermediary. Petitions for correction of work licenses usually are routinely granted by trade associations and the accrediting boards of most professions. School boards, however, tend to regard returning postoperative transsexual teachers with honest if misinformed concern about endangerment of the morals of their students. They are more likely to alter the license and reassign the transsexual teacher to duties in another school, if they are approached by a skilled attorney.

An attorney can be helpful, too, in presenting your request for job recommendations to former employers, if you anticipate any difficulty in obtaining them in your new name. Most employers, if approached in this way, will be cooperative. If you fail to get their cooperation, an alternative, if you wish to stay in the same line of work, is to apply for jobs subordinate to the one you formerly held, with the confidence that your skills will soon earn you promotion. Another possibility would be to explain your situation honestly to a prospective employer, if you judge that he may be sympathetic.

If you have no trade or profession, these problems will not arise. You may find it easiest to begin with some unskilled occupation for which recommendations are not needed, or for which a personal recommendation will do: for example, factory work, waiting table, or babysitting. Most taxicab companies will hire both men and women drivers who have passed the test for a chauffeur's license. It would not be advisable to apply for a job with a large company, most of which require complete physical examinations of new employees.

If you are not financially pressed, doing volunteer work for hospitals, social agencies, charitable organizations or political campaigns can provide good vocational experience and may lead to satisfying job contacts. It also would be practical to attend a secretarial school to study typing, and, if time and money allows, shorthand. There is always a demand for men and women with these skills, and temporary job agencies generally require only that you pass their typing and/or stenography tests, without asking for recommendations from former employers. If you are a preoperative transsexual, when you are ready to apply for more permanent work, try to choose a company that offers a good insurance plan to its employees, preferably through an insurance company that is known to have paid full or partial hospital expenses for sex reassignment surgery. Some of these are: Blue Cross, Blue Shield, Traveler's, Equitable, Aetna an Prudential.

When you are ready, you may decide to return to school for preparation for a more rewarding job. If you already have earned a college degree, or wish to continue your studies, most universities and colleges will be cooperative in changing the name and sex designations on the transcript of a former student. In this instance, too, the assistance of an attorney or social worker can be helpful in insuring a receptive hearing, although direct negotiations with the Dean of Students may be successful, if tactfully undertaken.

The federal government makes grants to state vocational rehabilitation agencies "to help them to serve persons with a physical or mental disability who need help in obtaining and holding an appropriate job, and [the grant] is based on (1) the presence of a physical or mental disability; (2) a substantial handicap to employment; (3) reasonable expectation that on completion of services, the disabled person can be engaged in a gainful occupation.

"Services include evaluation of rehabilitation potential, counseling and guidance, personal and vocational adjustment, training, maintenance, physical restoration, placement, follow-up and other services."

Although transsexualism is not a recognized disability category, several states have provided assistance to transsexuals under the category of psychiatric disability. The degree of help available will depend largely upon the policies of your local Vocational Rehabilitation Office and the individuals who administer them. When you apply for aid, present a letter from your physician addressed to the State Department of Vocational Rehabilitation.

"Physical restoration" will generally include a course in grooming for the male-to-female transsexual and, where the policy is generously interpreted and adequate funds exist, may cover electrolysis and plastic surgery, although the present probability is that they will not.

Where assistance in obtaining employment is provided by a state agency, we are aware of cases in Maryland and Georgia where only the new name is used in contacts with prospective employers. ln California, should the employer inquire of the agency whether or not the individual is a transsexual, the agency answers in the negative. This of course is preferable to the equivocal answer that they are not allowed to give out such information. It may fairly be assumed that such sensitive handling of the transsexual's interests will occur at any state agency where intelligent help is available.

MEDICAL HELP: FINANCING MEDICAL CARE

If you, like most people, do not enjoy a large independent income it will be necessary for you to finance at least some part of your expenses for medical care and recuperation with your own earnings a savings, or possibly through a bank loan, if you are able to offer some collateral. Even surgeons who are testing new techniques in transsexual surgery require full payment from their patients. There is no private foundation, including EEF, that offers financial assistance for this purpose to transsexuals. For those who qualify for veterans' benefit, Veterans' Administration Hospitals usually provide postoperative care only. A good health insurance policy can be a major source of assistance. You should take steps as far as possible in advance of surgery to provide yourself with this coverage, since most policies include clauses withholding benefits for the first eleven months for conditions which existed prior to the inception of the contract.

Before taking out a policy, it is advisable to inform yourself as to which companies have been known to provide the fullest medic benefits to transsexuals. EEF has compiled a partial list which we will provide to you on request. If the company is one with which we are unfamiliar, we will write to the main office for information, or your surgeon may do this for you.

Claims for health insurance should never define the prescribed treatment simply as "transsexual surgery," or as "cosmetic surgery." Applications for help under these categories are consistently rejected. Best results have been obtained when the condition (transsexualism) is presented as "a neuroendocrinological or psychohormonal disorder absolutely requiring and responsive to surgical and hormonal treatment. Another effective classification is "gender dysphoria."

Successful claims have been filed for "hermaphroditism" and "exploratory surgery with some tissue removal," although there is that possibility in the latter case that pathology reports may be required for healthy female-to-male transsexuals, where the disorder is not defined as transsexualism, mastectomy is generally disallowed; but benefits are often forthcoming for hysterectomy, which may be indicated by various complaints that are not accessible to medical tests.

Some health insurance policies state that the holder is covered only for "necessary treatment of an injury or disease process." ln such a case, the physician should represent transsexualism as "a distinct, medically definable disease entity, for which treatment is required." in every instance, it is advisable for you and your physician to examine carefully the wording of your policy, for indications as to how he should frame his diagnosis.

Recently, insurance companies have become far more liberal in providing coverage for preoperative evaluation (medical and psychiatric), sex reassignment surgery, related therapies, and hospital costs. While few companies allow benefits for all these phases, there is a distinct and encouraging trend in this direction. ln general, it has been found that coverage is more generously allowed on group than on individual policies, but this is not invariably the case.

CHOOSING A PHYSICIAN

Until quite recently, the gender identity clinics of university hospitals offered the only facilities for complete therapy, including sex reassignment surgery, for the transsexual. Fees at some of these clinics are high, and the number of people applying for help far exceeds the number that can be accommodated. Fortunately, alternative means of treatment are now available. At the present time, many endocrinologists and internists are accepting transsexual patients for hormone therapy, and many surgeons associated with private hospitals now performing sex reassignment operations.

For obvious reasons, it is advisable to choose a physician who has had considerable experience in treating transsexuals. The Erickson Foundation office in Baton Rouge can provide you with a listing of such physicians who are located in your area. Since hormone therapy precedes surgery, your first step should be a visit to an endocrinologist or internist. At the appropriate time, he will refer you to a surgeon who has performed other sex reassignment operations. ln choosing your surgeon, assure yourself as far as possible that he will be interested in vigorously pursuing your insurance claim.

Most surgeons will require that you see a psychiatrist for a consultation meeting prior to surgery. The purpose of this visit is to in any way dissuade you from your decision. It is simply a precautionary measure which your doctor takes to confirm his opinion you will benefit from surgery.

Even though this is not a required part of the prescribed treatment, you may decide independently, as have other transsexuals, that some sessions of supportive counseling with an understanding therapist will be helpful to you during the periods of transition before and immediately following surgery. If you are experiencing any problem with your employer or your family, they may be more receptive learning about your situation from a counselor. This is the kind of service most physicians are too busy to provide. The counselor can help you to gain perspective on your situation and provide support and good advice. He may be the objective friend you can use in your corner in times of stress.

EEF can supply you with a list of psychotherapists in your location who are experienced in working with transsexuals. Transsexuals obtain treatment in hospitals with gender identity clinics usually offered the assistance of social workers who will meet with them privately or in group sessions with other transsexuals.

MEDICAL TREATMENT FOR MINORS

For medical as well as legal reasons, surgeons will not perform the sex reassignment operation upon a minor. However, hormone therapy preparatory to surgery is obtainable in certain instances. It helps to have your parents' authorization for treatment, but this not always required. Some states regard the teenager who is living away from home and providing his own support as an "emancipated" minor, and in these states physicians may cite this doctrine to justify treating a minor at his own request.

Many states recently have lowered the age of majority from twenty-one to eighteen, and some legislatures have enacted statutes specifically enabling minors under eighteen to elect medical care. The tendency even in states with no such laws on the books is the courts to be increasingly liberal in interpreting common-law principles. The urgency and gravity of the case, the age and maturity of the minor, and the doctor's prior knowledge of his medical history are all carefully weighed in such cases.

In the past, physicians have exercised excessive caution in treating minors without parental assent because they feared criminal prosecution. Yet it would appear that there is not a single recorded instance of a doctor's being penalized for treating in confidence a minor over fourteen years of age, when no surgical procedure was involved. With the increasing liberality of the law and the interpretation of the law, the prospect is that the physician's professional judgment and the minor's request for help soon may be the only requirements for treatment of younger patients.

HORMONE THERAPY

Some physicians may adopt practices which differ in degree or kind from those outlined here. This section, and those which follow, are intended to give you a general impression of the most commonly followed course of treatment.

Your physician will prescribe hormones for at least six months before referring you to a surgeon. The physical changes they bring about will enhance your confidence socially, and you will find their calmative effect emotionally beneficial. Should you decide at some point during this trial period not to proceed with surgery, discontinuance of hormones will gradually reverse the physical alterations. What are some of these changes?

You will notice that the skin takes on a softer texture, and that body hair decreases to some extent. There may be some increase of hair growth on the scalp, although this is less common. After a time, muscular development will diminish somewhat, and there will be a more feminine distribution of fatty tissue: for example, more pronounced hips. The breasts will gradually increase to proportions comparable to those of a girl in the late teens. Larger breasts may be achieved through breast implants, at a later date.

With one exception, given below, silicone implants, the internal placement of plastic-like bags containing silicone jelly, is the approved method of augmenting breast size. There are serious health hazards associated with injections of liquid silicone directly into the breast tissue: it is extremely difficult to detect cancer in the area when the breasts have been augmented by this method; and there is the danger that the injected fluid will move to other paris of the body, causing medical complications. The F.D.A. has denied approval to the use of silicone injections, and you are strongly advised against them.

[As of 1991, a new, experimental procedure for breast augmentation that does not require the use of silicone has been introduced. The procedure involves the relocation of a minor muscle and its attached fatty tissue and blood vessels from the abdomen to the breast area. This operation leaves only a small, bikini-line scar on the abdomen--there is no scar on the chest. No artificial implants are used, and the new "breast tissue" is indistinguishable from a natural human breast once surgery is complete. The only other outward change in appearance is a flatter stomach (I understand that the effect is similar to having a "tummy tuck"). As of this writing, this procedure has only been used on female breast cancer patients in cases requiring total removal of breast tissue. It's potential for the transsexual population is unclear.]

Hormone therapy will not feminize your voice, but remember that there are women whose extremely husky voices are considered to both attractive and feminine: Lauren Bacall, Marlene Dietrich, and the late Tallulah Bankhead are notable examples. Speech therapists who work with male-to- female transsexuals concentrate not only raising the pitch and resonance and softening the quality of the voice. They point out that the use of a more feminine vocabulary, more careful articulation, and a greater range of inflection (rise and fall) of voice all contribute to a more feminine impression. You may work these points yourself, with the help of a mirror (to practice freer face movement) and a tape recorder. If you feel you need professional help there are speech therapists in private practice, and associated with speech therapy centers, who take a special interest in voice problems of male-to-female transsexuals.

Hormones will not appreciably reduce beard growth. Electrolysis of the beard is an essential complement to hormone therapy. This will be discussed at length later.

You will notice a decrease in libido (sexual desire), after following a program of hormone therapy for some months. Most male female transsexuals consider this to be a helpful modification in adding to the new role.

All transsexuals must continue to use hormones throughout their lives postoperatively, to ensure the maintenance of hormone-stimulated development of physical characteristics of the opposite gender, and to prevent some possible health disorders. It is therefore advisable to see your physician conscientiously every six months after surgery, to check on hormone dosage and for physical examination.

ELECTROLYSIS

A course of electrolysis of the beard requires from one to two years for completion. Before recommending the male-to-female transsexual for surgery, his physician will expect him to complete at least half of this process. There are several important reasons for this recommendation.

If, after surgery, when you are now an anatomical female in all other respects, there is still noticeable evidence of beard growth, you are very likely to suffer from feelings of confusion as to your present gender. Your confusion may be reflected in the response you receive from others, thus compounding your difficulties. Many physicians experienced in working with transsexuals have noted that serious psychological conflicts block the successful adjustment of those patients who have not undergone adequate electrolysis, and who, in their opinion, would otherwise have done well.

It is true that a certain amount of time, expense and discomfort is associated with electrolysis. But it would be most unwise to seriously jeopardize your chances for a fulfilling new life by neglecting to attend to this important aspect of total therapy.

You are strongly advised against purchasing one of the electrolysis machines available on the market for self-use. This is an operation which requires long and careful training. If it is clumsily employed, there is a distinct danger of scarring at the site. For this reason, one should also take care to choose an experienced profession operator.

If you do not at first have the money or the time to see an electrologist, there are various commercially available wax preparations which you can use at home for hair removal. You will find that the process must be employed every one to two weeks, depending upon heaviness of beard growth, If you choose this method temporarily your doctor will give you a prescription for estrogen oil, which should be applied to the skin daily. The use of wax and estrogen oil often softens and thins the beard, facilitating the process of electrolysis later on.

SURGERY

Well ahead of the time when surgery is scheduled, you should begin to follow a regimen to develop optimum physical health. This would include exercise, plenty of rest, a balanced diet, and vitamin supplements. A person who is in good health will enjoy faster healing after surgery. Some physicians recommend megadoses Vitamin C, since that vitamin is known to promote the healing process.

Some surgeons prefer to perform the operative procedure for male-to- female transsexual in two stages, the first in the doctor's office and the second in the hospital about a month later. Other surgeons will complete the work in a single process, performed in the hospital. The male organs are removed and labia, a clitoris and a vagina are constructed. If cosmetic surgery, such as breast implants or nasal reconstruction, is desired, this is undertaken at a later date after healing from the initial surgery.

The degree of possible sexual pleasure after surgery cannot accurately be predicted. For some, the capacity for orgasm may be lost, but many others report that they are now experiencing it for the first time. ln surgery for the male-to-female transsexual, sensitive genital tissue is used to line the vagina and to create a clitoris, and there may even be a small amount of natural lubrication during intercourse. Most male-to- female transsexuals report a high capacity for orgasm after surgery.

There is at present no technique for the transplanting of reproductive organs. Therefore, following surgery, both male-to-female and female-to- male transsexuals are sterile. Married transsexuals have adopted children through social agencies, and the wives of female-to-male transsexuals may choose to bear children through donor insemination.

POSTOPERATIVE CARE

It is essential that the male-to-female transsexual conscientiously follow her surgeon's instruction on the use of the vaginal form. This is a device designed to keep the vaginal passage open during the six-month period following surgery. During surgery the vagina is packed with gauze. When healing is well advanced the gauze is removed, a you will be instructed to insert and keep the vaginal form in place most of each day for the first few days of use. After this period, your surgeon will advise you to insert the form several times a day for one or two hours at a time for the next six months or so. This is most comfortably done while reclining in a warm bath, which relaxes the muscles. Warm (not hot) baths are recommended for twenty minutes twice each day for the first few weeks after surgery, to cleanse the incision and reduce any swelling which may occur. Your surgeon also show you how to lubricate and stretch the vaginal passage twice daily, another important factor in postoperative care.

To repeat: these practices, which will be explained in some detail by your physician, should be followed faithfully. Failure to do so could result in closing up of the vaginal passage. Be sure to see your physician without delay if, after your return from the hospital, your temperature should become elevated, or if you should experience unusual discomfort or swelling in the surgical area or difficulty in urination.

You will be cautioned by your doctor not to use the vaginal passage for intercourse for a period of at least two to three months following surgery. If you ignore this restriction, there is a serious risk infection or rupturing of the sutures.

When your surgeon tells you that intercourse may be safely engaged in, he will also recommend the most favorable positions which your new internal structure allows. He will advise you to urinate and empty the bowels before intercourse, in order to provide the maxim space in the vaginal passage, and to use large amounts of lubrication for comfort and facility when the penis is penetrating the vaginal cavity.

Certain easy-to-follow, common sense precepts of health care should be observed postoperatively by both the male-to-female and female-to-male transsexual. Adequate rest is important, and a premature return to work would be ill-advised. The male-to-female transsexual should avoid prolonged standing immediately following surgery, prolonged sitting may at first be uncomfortable. It is important keep the weight stable, and especially to avoid any weight gain, so as not to overburden the surgical area.

A balanced diet, including plenty of protein, will promote healing. your physician may suggest that you use a multiple vitamin supplement, with generous amounts of Vitamin C. Salt and salty foods should be avoided by the male-to-female transsexual, and adequate water and roughage should be taken to prevent constipation, which can strain the wall of the new vagina.

MARRIAGE

The question of whether a postoperative transsexual should disclose to a prospective mate that he or she has undergone surgery is primarily an ethical one, but it has legal implications as well. Failure to discuss this matter gives valid grounds for annulment or divorce in that the marriage may be considered to have been entered into fraudulently.

To date there is no clear legal opinion on the validity of marriage contracted by postoperative transsexuals. However, from a practical viewpoint it is unlikely that legal problems will arise unless divorce or annulment proceedings are initiated.

The precedent of impotency, which is accepted grounds divorce in most states, can be invoked by the wife of a female-to-male transsexual. ln the case of a male-to-female transsexual there is no definitive legal viewpoint, since heterosexual intercourse is possible. If a transsexual discloses to her husband, prior to marriage, that she cannot bear children, theoretically her options are open as to whether she also must reveal that she is a transsexual, although presumably if does so her legal position is stronger in the event of divorce proceedings. The courts in this country have yet to hand down definitive decisions in such cases.

Having discussed these problematical legal aspects of marriage entered into by transsexuals, it is important to add that many transsexuals have without publicity contracted enduring and successful marriages which are accepted without notice or comment by members of the community. Furthermore, they have brought their children into the marriage, have adopted children, or, in the case the female-to-male transsexual, the wife has borne children by means of artificial insemination.

Neither a birth certificate nor, usually, any proof of sex is required in applying for a marriage license. A driver's license or a voter's registration card is considered adequate for this purpose. The voter registration card is easily obtained, on presentation of such means identification as a library card, and proof of residence in the district for the required period of time.

CAUTIONARY REMARKS

It is likely, as well as understandable, that prior to surgery, while subject to inner stresses and limitations of outer circumstances and opportunities, you may have been impeded in the development of your potentials for living a full and fulfilling life. Your interests may well have been restricted by your problems, your energies exhausted by them. If your whole life until then has been centered on the goal of achieving surgery, once it is achieved you may be unpleasantly surprised to find yourself in a predicament comparable to that of the newly retired man who devoted himself exclusively to his job, never cultivating any outside interests, and now finds himself depressed and at a loss, his life seemingly at a standstill.

Now that your life-long problem has been resolved, and after the initial euphoria, you may unexpectedly find yourself facing a void. The obvious answer is to fill it, and without delay. ln this situation, some transsexuals find that they benefit from the counseling and support of a sympathetic therapist. Others will begin independently to investigate their world and its possibilities. You will learn to apply newly-released energies to the development of your talents, and to the exploration of the broader range of social relationships and career opportunities now open to you, perhaps for the first time. If, before surgery, the single area of gender identity comprised the whole of your self-knowledge and occupied all your attention, there can be intense pleasure and release in discovering yourself now as a total human being.

Another common stumbling block experienced by transsexuals can be the excessive and unrealistic expectations, cherished for many years perhaps, of what life will be like after surgery. Surgery indeed can solve your one major problem, but if you anticipate that it will magically solve all problems, you are due for a disappointment. Life will certainly be more rewarding now. You will be more comfortable, more at ease with yourself than formerly, and other people will be more at ease with you. You can begin to take advantage of many opportunities for self-development and career advancement that were not available to you in the past. But the postoperative transsexual must realize that he has this in common with every other human being, that he too must meet the challenge of all the common difficulties that arise in any life: the occasionally troubled relationships, the possible job frustrations, the temporary depressions and setbacks.

Now that you have been relieved of your one consuming problem, you may discover in it one positive aspect that can be uniquely enriching. Having lived the life, however hindered preoperatively, of bc sexes, you can enjoy a rare capacity for immediate empathy with people of both sexes, for understanding intimately their points of view and feelings. Where other people may exercise intelligence, imagination and sympathy in their human relationships, you have the additional resource of direct experience of "both sides" of life. If you use this asset, allow the old burdens to fall away, confront life with new curiosity, realism, courage and determination, you can discover, like many transexuals before you, the unexpected joys of a true rebirth, more hopeful and better-prepared for a second chance.