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Transsexuals have the certain feeling of being trapped in the wrong body. They long for a life in the opposite sex and try to conform to it as much as possible externally. This has nothing to do with the desire for disguise. Neither does it mean that they are lesbian or gay. Transsexuals seem to be men or women according to biological criteria - their genetic make-up and hormones are clear. But it is not that simple: In fact, their sex does not correspond to these visible and measurable gender characteristics. This inner certainty is permanent. The term transsexuality gives the impression that it is a sexual problem. That is wrong. It is not about sex, but about identity. That is why they prefer to call themselves transidents. In the current classification systems for mental diseases - such as the DSM-5 - the term transsexuality is also no longer used. Instead, there is the term gender dysphoria, a term that describes the emotional suffering from the lack of agreement between body and psyche. To see transsexual experience and behaviour as mental illnesses is now also considered outdated. Transsexuality is not a disease, even though it still counts as a gender identity disorder according to the criteria of the World Health Organization and the medical diagnosis catalogue ICD-10. Nevertheless, many of those affected are in a mental crisis because of the wrong sex, which is why they seek therapeutic help. They feel ashamed and helpless at the same time, their family and friends react strangely - all this makes them suffer and despair of themselves and their otherness. They often become depressed, torment themselves with suicidal thoughts and use drugs to forget reality. Man-to-woman transsexuals have a harder time in their new role than transmen. When masculine transfemales put on make-up or wear skirts, this is quickly taken offence - also because they are often recognizable as biological men. Women in trousers and with more male behaviour are simply less noticeable. The causes of transsexuality are still in the dark. One thing is clear: there is no such thing as the typical transsexual or the typical transsexual. Those affected can be heterosexual, bisexual, lesbian or gay. But many have the feeling even as a child that they are not a real girl or a real boy. Others only discover their discomfort with the physical sex during puberty. Some really feel disgusted by their vulva or penis. They therefore want to have an operation as soon as possible. Others manage to come to terms with their innate sex for a while. This applies above all to biological men who prefer women as partners anyway. They marry, perhaps have children, until they later follow their inner urge and publicly confess their otherness. How many transsexuals there are in Germany is not certain. Most articles talk about 6000 to 7000 people who want a change of sex and therefore receive medical treatment. Organisations of affected persons, on the other hand, assume that the number is ten times higher. For there is a high number of unreported cases, and by no means all transidentians opt for hormone therapy or gender-reconciling surgery. Since 1995, around 15,000 people in Germany have changed their gender identity by court decision under the Transsexuals Act.

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Why some people have the indomitable desire to change their physical sex - researchers have been puzzling about this for many decades. In essence, the question is whether the feeling for ones own gender is learned in everyday life, at school and in the family, or whether it is congenital. Until the 1970s, experts suspected that the causes of transsexuality lay in early childhood. Depending on the theoretical approach, speculations are made about unresolved fears of separation, a disturbed parent-child relationship or wrong methods of parenting. The main causes are depressive and overprotective mothers on the one hand and passive or absent fathers who are not suitable as male role models on the other. Learning psychologists such as the American sex researcher John and his British colleague Richard attributed the problem to a false imprint in childhood. From their point of view, learning the wrong gender role in the first years of life also programs the gender identity indelibly as female or male. This can happen when parents actually prefer to have a child with the opposite sex and raise their offspring accordingly - for example, when they put on clothes for their son and make him behave like a girl. However, all these assumptions have not been proven. And these hypotheses also cannot explain why so many transsexuals come from families where there are no abnormalities in parents or upbringing. Nerve nodes in the brain: German-American sexual researcher Harry Benjamin, who treated transsexuals with hormones as early as the 1950s, is regarded as a pioneer of biological explanatory approaches. He did not consider transsexuality to be a mental disorder, but suspected physical causes - an assumption that neurobiologists in particular have been working on for years. They are looking for something like a gender identity centre in the brain. The researchers have already found a suitable candidate: a small nerve node in the diencephalon that is known to control sexual behaviour in rats: the so-called bed nucleus of the stria terminalis (BST). This cell bundle appears to be larger and denser in men than in women. Scientists at the Institute for Brain Research in Amsterdam examined the brains of six deceased man-to-woman transsexuals and found structures in the suspicious region that they regarded more as female. But the study published in 1995 is no proof: First, the examination of six brains is not sufficient, the number of cases is far too small. In addition, what is true of rats does not have to apply to humans. And: transidents are not about sexual behaviour, they are about gender identity. Hormonal influences: Hormone experts are following a different trail. According to this, an imbalance in sex hormones during the prenatal phase could be partly responsible for transsexuality. The neuroendocrinologist Professor Günter Karl Stalla from the Max Planck Institute for Psychiatry in Munich believes that he has found evidence for this hypothesis. Stalla and his team determined the relationship between forefinger and ring finger in over a hundred transsexuals. Men usually have slightly longer ring fingers than index fingers, presumably as a result of the male sex hormone testosterone. In women, both fingers are usually almost the same length. The Munich scientists found that the finger length of transfemales was about the same as that of heterosexual women. They concluded that biologically male transsexuals were already exposed to less testosterone during their development as embryos and therefore developed a female sexual sensation in the brain. However, other studies were unable to confirm this finding. It is also assumed that not only the sex hormones but also several factors influence bone growth. Therefore, the comparison of finger lengths among experts is doubtful, and it is still unclear what effects testosterone really has in the brain of embryos. Gene for transsexuality: Australian sex researchers even presented a gene for transsexuality in 2008. In the genome of transidents born as men, they often came across an overlong gene for the formation of testosterone receptors. These receptors play a crucial role in determining whether or not the male sex hormone can control something in the body. The scientists speculate that the overlong gene could lead to the fact that fetuses in the womb already produce less testosterone and that this would promote a transsexual tendency. However, this theory is contradicted by the fact that not all transsexuals examined possessed the overlong gene variant. The researchers also found no comparable deviation in female-to-man transsexuals. Thus, the authors of the study themselves limited their findings to the fact that their discovery could not explain the development of transsexuality alone. Ultimately, the following applies to all biological explanatory attempts: there are indications, but no evidence. The vast majority of those affected are firmly convinced of a congenital brain sex. But most experts today believe that transsexuality is the result of a complex development in which both biology and the environment interact.

Prerequisites for gender balance

Age: At most every second transsexual wants an operation. More and more often, however, it is teenagers or even children who push for medical treatment with their parents. They are afraid of the irreversible consequences of puberty. Wide shoulders, beard growth, a male bass - all these are characteristics of a sex perceived as wrong, against which the scalpel can no longer do anything later. Sometimes even twelve-year-olds swallow hormones to stop the physical changes. The doctors are faced with a dilemma: On the one hand, time is of the essence. On the other hand, they cannot be sure whether there is really transsexuality, especially in puberty. Sometimes there is a completely different problem behind the desire to change sex - a mental disorder, sexual abuse or early signs of homosexuality. In addition, puberty can only be postponed for a limited period of time due to health risks before the adolescent has to make a final decision for or against an operation. In Germany, such far-reaching medical measures are only permitted in exceptional cases for under-18s. The experts are still debating whether they can be held responsible at all.

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Psychotherapy and everyday life test: In principle, hormone therapy and gender adjustment are linked to several years of psychotherapeutic support and assessment. Unlike in the past, there is no longer any attempt to talk transsexuals out of their convictions. Psychotherapy should help them to become clear about their expectations of the new gender role and the liveliness of their desire and to re-examine their decision. However, many affected persons and experts consider the German treatment standards dating from 1997 with their rigid rules to be long outdated. Their criticism: Neither the indication, nor the duration and frequency of psychotherapy are oriented to the individual case, whereby the procedure is often unnecessarily delayed and made more expensive. The prescribed everyday test is also controversial: one year before the medical treatment, the transidents have to rehearse the social change of role 24 hours a day. However, many patients find this forced coming out unreasonable and shameful, especially as their external sexual characteristics have not yet changed. The professional societies are currently working on a guideline that should be completed by 2015 and set current treatment standards. The image of transsexuality as a mental disorder is now also considered outdated. In the next edition of the ICD, the international classification of diseases, it should be ensured that transsexuality is no longer psychopathologized. Hormone therapy: Those affected do not understand the medical measures as a transformation, but as an adaptation to their true psychic gender. Prerequisites are a thorough physical examination and hormone therapy. In the first step, the man-to-woman transsexuals are treated with the female sex hormone estrogen for about half a year. In this way, the pituitary gland (the so-called hypophysis) receives the signal to curb the production of the bodys own sex hormone testosterone. The pituitary gland is a kind of measuring and control centre in the brain that ensures that a certain total amount of sex hormones is always present in the blood. It does not care whether they are male or female. If a man is supplied with female estrogen from the outside - through tablets or syringes - the pituitary gland immediately recognises this and orders the male gonads to produce less testosterone. As a result, the female estrogens in the body become significantly overweight: the skin becomes thinner and drier, the hips and buttocks round off, the testicles shrink, the desire to have sex dwindles and sperm production dries up. Beard growth and male voice remain against it. Female breasts develop, but very often they do not reach the desired size. This problem can be solved later with the help of implants. The beard hair can only be permanently removed by needle electroepilation. In this very time-consuming procedure, each individual hair root is destroyed with a current pulse. Another possibility is laser epilation. With the laser, male hair can be removed faster and more extensively, but the method is usually only effective for a limited time.

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