When Sally met Harry

When Sally, a 35 year old trans woman, found herself in a sudden and unplanned relationship with a man she met by accident, she was reminded of the problems which others have with her mere existence – problems of theirs which influenced her own approach to relationships and sex.

Sally and Harry are fictional people, but their stories are real – composed from a mosaic of real people’s lives and experiences.

They are a device to explore the trials of dating and loving when your sex, and the consequent interpretation of your sexuality, is a regarded as a matter of opinion, rather than matter of fact.

(First published by the author, May 2003)

Just shopping

Sally wasn’t thinking about sex that day in the supermarket car park. In fact, compared with the daily banter of the other women in her office at work, it would be fair to say that Sally didn’t think much about sex at all.

The whole world but her seemed to be obsessed with sex though. Not getting it. Getting it. Liking it. Hating it. Having too much, talking about other people having it – and paying the price of letting it be the motivation for bigger decisions about life.

As a not very sexual person she noticed this a lot. People married out of sexual desire. They deserted others for it. They lied. They stabbed friends in the back. Sometimes they even committed crimes.

Looked at from her rather more detached perspective Sally could see that sex was a pretty poor motivation for doing anything. Joking aside, it was usually over in minutes. Even the desire which kept couples coming back for more seemed a pretty ephemeral thing.

Some said this was nature’s programming in fact – a device to keep human couples together for long enough to nest, and to see their offspring old enough to fend for themselves, but then designed to send one or other off in the pursuit of fresh novelty.

Who would plan major life decisions of any kind on something so ephemeral?

And when your thinking is not confused by lust Sally reckoned that it was rather easier to understand what “love” meant.

Love was not on Sally’s mind as she wheeled her bachelor girl trolley back to her car from the weekly shopping expedition though. Her mind at that moment was focussed on nothing more important than getting home, lighting a scented candle and flopping onto the settee to read her book.

Being single

That was an advantage of single life of course – it could be as simple and self indulgent as you liked, whilst having no less space for other people when it mattered. And having had more than her fair share of problems in 35 crowded years, Sally was well aware of the importance of having one’s own personal space and knowing when to shut the door on the world.

You see, the problems weren’t her’s but other people’s. And when she shut the door they miraculously disappeared.

Sally had had a rather different life experience to the average woman though. She had been born with a penis and, so far as she knew, all the other paraphernalia which are associated with the expectation that you’ll grow up to be a man.

For all that apparent evidence though, Sally wasn’t a man. She wasn’t back then. And she most certainly wasn’t any more.

This isn’t to say that Sally could find it all that easy to “prove” incontrovertibly that she was a woman. But now she knew. Just as everyone she met “knew” as well.

A conundrum

She hadn’t always “known” of course. Maybe that happens for some trans women. More “ordinary” people she met and had talked-to about this curious question said that, when pressed, “they just knew” what they were too. All Sally had known however was that she wasn’t the things other people expected her to be.

It was a really peculiar question to dissect. After all, it’s something most people take so much for granted that they never questioned – either about themselves or others.

She had worked out that it was not simply a case of what you’ve been brought up to believe by others.

After all, that hadn’t happened to her and, in talking to friends who had had children, it was quite apparent that there was perhaps something essential about a child’s self knowledge and behaviour that came before the real onslaught of cultural indoctrination began. She’d read too of children who had been brought up in the wrong gender and “just knew”.

For Sally it had been easy to simply know what she wasn’t, but harder to decide what she was.

If you can only imagine two axiomatic states of being then the question is both obvious and overwhelming in its implications. It is one-dimensional. “If you’re not a man then you must be a woman”.

But if you already know that it’s not that simple then it becomes possible to see into another dimension of possibilities – a two dimensional world in which you could be somewhere defined by a combination of both genders, or a three dimensional one where you might be something else entirely.

Exploring these possibilities is far less terrifying than the prospect of telling the world that you’re a girl. Call it avoidance. Call it philosophy. But intelligent trans women can find lots of ways of putting off the unpalatable. So Sally knew all about exploring the possibilities of who or what she really was.

Just a regular guy

Harry’s life had meanwhile been rather simpler.

Harry was three years older than the attractive woman he was appreciatively following past the line of cars. He had never ever thought for a moment about the question of being a man. He was one of those people who “just knew” – helped, of course, by parents, relatives and friends who knew this as well.

Some had the “proof” of course. His parents and grandparents had cooed over the baby Harry’s cute little willy when changing his nappies and bathing him. And Harry delighted them in being everything they expected of a boy child in the family.

He never stopped to think about it but others relied on different cues when he started going out into the world. So did he. In fact, if any of us were to stop to think about it, we’ve probably never seen most of the people we know unclothed.

It would be difficult to say with certainty whether the man next door had a penis or whether the woman at the checkout definitely didn’t have one. Genitals are the things which midwives look at to tell you what to put on the birth certificate. They’re what you expect to find when you pursue another person with sex in mind. Society doesn’t actually pay much attention to them the rest of the time though.

Like everyone else Harry was used to “sexing people” on a whole variety of other alternative clues. And when it came to women Harry had plenty of experience.

Red blooded

Harry had definitely always been a red-blooded male. He liked women. He liked looking at them. He liked the way they moved. He liked talking to them. And he certainly liked sex with them.

Harry knew where he stood with men too. He wasn’t hung up about homosexuality. A couple of his mates were Gay in fact – and he was confident enough about his own sexuality not to let other people’s worry him.

Harry simply enjoyed being heterosexual, in the way that he also enjoyed being a man. He didn’t think about either question because he “just was” – and nothing had ever come along to challenge the simple fact of either proposition. Besides – Harry’s attention was focussed on Sally’s long, smooth, elegant legs.

Collision!

Looking back now he claims that it was an accident. Sally, with a cynical grin, still thinks it may have been less innocent. She had reached her car and stopped to unlock it. He – with his mind nearer the road – carried on going. And Sally’s first impression of Harry was formed face down on the tarmac.

It’s a well-worn love story cliché of course. Two strangers bump into each other by chance. Their eyes meet, a celestial choir sings, and the camera unaccountably cuts to waves rushing up the shoreline. It’s that sex thing again. Speeding things up.

For Harry and Sally it wasn’t quite so clichéd.

Their eyes certainly met. Hers glowering in hurt anger – his genuinely worried. Then he laughed at the absurdity. And so did she. Not because it was funny. No. But because his laugh was infectious.

She recognised in that instant a likeable and kindred spirit. Her instincts said that this was a person with a similar sense of humour. More than that there was his smile – his gorgeous boyish smile and the twinkle of something in his eye. And she was genuinely surprised by the effect which that brief glimpse of the strange man’s personality had on her.

As Sally’s face cracked from a scowl into a big open smile Harry also realised that there was more to this woman besides her legs or any other physical assets. For one of those rare occasions in his life he saw more than just the young woman’s body – though sure enough there was plenty to like about that too.

That smile of hers tended to blot out everything else and connected directly with his inner thoughts though. Her eyes were bright and laughing too. In fact her entire face participated in the laugh. Young as she was, she already had those characteristic lines around her eyes and mouth – the tell-tale signs of someone who laughs a lot and does so without a trace of inhibition. A woman whose personality shone through her body.

Love at first sight

Sally did not realise it till later but, in that instant, Harry was hooked. He was already in the early stages of love.

He helped her to her feet, helped put her groceries in the back of the car, and then offered to escort her back to the supermarket and to buy her a coffee whilst she washed her hands.

Afterwards they talked. They laughed. They discovered they had similar interests in films and politics. They began to find that they finished each other’s sentences.

Time flew. The café staff went home. The supermarket began to close. Harry asked for Sally’s phone number. And Sally, for one rare time in her life, gave this strange yet familiar and likeable man the key to enable them to continue this exciting new experience another day.

Blossoming

Over the weeks and months that followed Sally and Harry saw more and more of each other.

Harry thought Sally more beautiful the more he saw of her. She was his height. Slim built. Dark blonde. Clear skinned. She wore very little makeup and he liked that in a woman. She dressed well too – simple but elegant in tailored trousers and pastel-coloured tops.

Sally meanwhile had never dressed for others. She simply dressed to please herself.

For sure it had taken her a while to find her style as a woman. For one thing she had missed the opportunity, which teenage girls take for granted, to experiment in clothes and makeup with her friends. Puberty is the one time in life when women are allowed to get it wrong and to learn from their mistakes.

Nevertheless, she also learned that with the right friends and advice it doesn’t take long to catch up – and she also noticed that all that teenage training wasn’t a sure fire guarantee that other women of her age would go on to be perfect masters of their own style.

Now, fifteen years after she had taken the huge life altering step to be a woman, she had learned how to be comfortable in her dress, and to use clothes as a way of helping to express her overall personality. Nothing more, nothing less.

Having fun together

At first they stuck to neutral venues – the theatre, cinemas, meals in restaurants and day trips in Harry’s car. This all suited Sally very well because it allowed her to keep the relationship at a level where she felt comfortable, whilst she wondered where it would go next. She wasn’t thinking about sex in a speculative way; nevertheless she was a big girl and understood in today’s world what men expect after a few preliminary encounters.

As she got to know more of Harry she found herself liking him more and more too. So when she pondered the very likely thoughts running through Harry’s head it was from the perspective of wanting it to go right. Not just the sex which he was bound to start to press for before too long, but the whole relationship.

She began to realise something new about herself that she’d not appreciated before. She had always known that she wasn’t all that interested in sex at all. It certainly wasn’t a driving force in her life.

Her girlfriends salivated over pictures in the glossy magazines, but that kind of animal desire was a complete mystery to her from either angle.

She had always liked looking at beautiful people – men or women. But she didn’t lust for either. Now she was planning how to go about having sex with this man she had met.

Again it wasn’t for lust. She simply wanted to please him, and to be closer to him too. And, as she touched that thought she could smell his smell and picture herself curled up against his chest and with his arm around her.

Sally knew that sex for her wasn’t problematic, but then she knew that in another way it was.

Fully functional

On a purely technical level she knew that she was capable of having sexual intercourse with a man if she wanted. To put it bluntly “it all worked down there”, although she knew from experience that she needed to have a very high level of trust in the man concerned before going through any of the stages of intimacy beyond outer clothing.

It wasn’t any fear of being “found out” as some people assumed. It had certainly taken a long time to develop confidence in her body image. After all, if you’d started out with a male body you’d probably have trouble accepting it was now unambiguously female-looking as well.

Lots of trans women have body image concerns of that kind in fact – a point to be noted by any fool who might think that people change their bodies in order to be aroused by their image as women. Sally had never thought or felt that way. Lust for herself was a laughable idea. Indeed until she’d experienced enough men telling her how great she looked, she was convinced she looked awful.

And, though it might sound awful to express it this way, the only way that Sally could convince herself to trust what her admirers were saying was to be sure they knew nothing of her past. She had to be sure they weren’t just saying things to be kind or that they were seeing her in any way other than as a woman.

All of which raises that unique ethical problem which trans people have to negotiate with their intimate partners. When to tell them.

An ethical dilemma

Having spent many years pondering what others thought about people like herself Sally was pretty sure that her life was generally problem-free. At least, it was problem free from her own perspective and once she had solved the issue of how to feel comfortable in her own skin.

The problems all tended to be other people’s. This was especially true of so-called “professionals”, who all seemed to see her life as a problem through the lens of their own preoccupations.

Lawyers saw Sally’s life in terms of legal problems. Her existence regularly made the law into an ass. Medical professionals saw her identity as an illness. Politicians saw her as a set of political problems. Sociologists saw a brainteaser in gender constructivism. Religious leaders saw theological and ethical problems. Sex researchers thought of her in the only way they could – as a sexually motivated problem child.

All these people tended to see the lives of people like Sally from the perspective of their own interests and advancement. They all had a stake in seeing a problem to write about – to be famous for describing – or to charge people to solve.

Only her close friends and family saw her as something other than a problem – a complex and complete human being you could simply love.

Nevertheless, Sally had to acknowledge that deciding if, when and how to tell someone about your transsexual past is a problem which the individual needs to take ownership of themselves. And there are no easy answers.

Should you tell someone the moment you met them? Should you ever tell them at all?

Being realistic

Neither of these ever seemed realistic or reasonable to Sally. Friends who did share her secret pointed out that everyone has things which they keep back before they know someone well-enough.

When do you mention the divorce for instance? Or the children of that marriage? When do you own up about the second cousin who is in prison? And when do you mention the genetic defect which you have a 50/50 chance of passing to your new partner’s progeny?

Sally had theoretical trigger points which she had faithfully promised herself she would adhere to. At first she had decided that she would always tell a man before they had intercourse. Experience soon taught her that that wasn’t as practical as it sounded; so then she raised the bar. She was absolutely certain of the ethical necessity of telling someone before things got serious-enough for people to be thinking of marriage. But what were the milestones in- between?

One thing was absolutely certain. The longer you left it, the more there was at stake. And, as Sally and Harry grew closer, the inevitability of what she would need to do weighed heavier on her mind. What would he think?

Dangerous truth

She knew the full range of possibilities of course. They ranged from rapid assurances of continued and undying love to murder – quite literally.

Trans women have been beaten and strangled for telling an insecure lover that he’s been dating someone with a past like Sally’s. The uncertainty of what the attraction makes of them can drive sexually insecure men into a frenzy of anger at the perception of being “tricked” or “deceived”.

Yet where is the deception in being who you feel yourself to be?

Sally knew that the confusion for some men stemmed from being unable to recognise what they had been attracted to in a woman like herself, and what that meant about their sexuality.

It also depended on how people rationalised her own existence. Was she still the same woman in people’s eyes once they knew her past? Or were all their perceptions swamped by the irrelevancy of factors which were mostly long gone and forgotten? Did it also depend on why people thought she had “changed her sex” in the first place?

The woman inside

To Sally, of course, it had never seemed like a change to her. Once she knew that no part of her identified with being a man, and that she could better understand and explain her experiences as a woman, the rest had all been about helping other people to see that clearly.

Changing her body was as much about making it easier for people to see “the real Sally” as it was about feeling comfortable in her own skin too. It just felt right. And the more relaxed she became about the completeness of her physical transformation, the more she found herself at peace and able to fully express herself. That was when she started to smile in that whole- body way that Harry first noticed in the supermarket car park.

But did it matter that she didn’t have a uterus or ovaries? Was the fact that parts of her body weren’t completely female a problem? What was happening if she fancied a man? Was that attraction between them homosexual because her chromosomes were still those she was born with? Or was it heterosexual because she fancied the man as another woman would fancy him?

More to the point, what did it mean when seen from the other perspective?

In the eye of the beholder

Harry was heterosexual. Of that there could be no doubt. He was a man and he only fancied women. He had been attracted to Sally precisely because he saw and liked her as a woman. Did the fact that someone else might define her differently alter his own sexual orientation?

Was Harry and Sally’s relationship homosexual on a technicality which it required a microscope to detect?

Was Sally a Gay Man because of her physical past and some people’s mistaken ideas about what it said about her mind?

Was she defined by what had once been between her legs or by what was between her ears, and which had led her to be so recognisable as an attractive woman? If so how on earth did one define the sexualities of the many people born with ambiguous genitalia?

More to the point, however, was Harry already a Gay Man without knowing it? Were all those other men who looked at Sally with admiring eyes? Would he have to dump her the moment he knew of her unusual past, just to redeem himself as a heterosexual man? Or was he heterosexual still, because he had only ever been able to see and think of Sally as the woman she appeared to be?

Last but not least – if one came to different conclusions about Harry and Sally would that be at all logical? Can there be a heterosexual or a homosexual relationship in which one half is Gay and the other half Straight.

Which ending?

Sally and Harry are fictional characters of course, assembled from the spoken experiences of all the real transsexual people and their partners whom the author has met over the course of years. The questions and dilemmas are real though.

You can speculate how and when Sally told Harry about her past, and what that would mean if you were Harry.

Some Harry’s run away. Some commit violence. Where there is love, however, there are lots of Harry’s (and their woman equivalents) who realise that it was a human being who they were first attracted towards – and what sort of human being that was.

As a romantic I hope for my fictional characters’ sake that Harry would fall into the latter category. I made him a sexually secure man for a reason – just as I emphasised the emotional as well as physical plane on which their hearts first met.

Sex happens between the legs, but love takes place between the ears and in the heart.

Harry would need to realise the enormous vulnerability opened up by Sally in telling him about her most personal and intimate of secrets. He would need to realise that she might always live in fear of him one day levelling the accusation that “she wasn’t a REAL woman”.

A real woman

But what is a real woman? It seems such an obvious question because few are ever called to think about it. Take away the reassurance of other people’s agreement, however, and each of us is on far shakier ground – required to scratch around and ultimately agree that we “just know”

Does it depend on reproductive capacity? If so, how does one define the status of women after hysterectomy or menopause – or those whose bodies were simply never quite as unambiguous to begin with?

Does it depend on how you are brought up? If so, where would you place a Sally who was born female-bodied but whose parents socialised her as a boy for some reason?

Or does it depend on how you think – and how others find it easiest to think about you?

Do you – like Sally – “just know”?

Revisited: A most memorable and inspiring speech

A few weeks ago I dusted off a report that I had written back in 1993 about the seminal Council of Europe colloquy entitled "Transsexualism, Medicine and the Law"

In that last blog I described how the whole conference represented an epiphany for me, and how moved I was at the end.

Part of the reason for feeling so emotional at the conference close was this final contribution from the endocrinologist, Professor Louis Gooren (pictured right).

Here is that speech in full. It remains as relevant for campaigners today as it felt when hearing it for the very first time. You just have to wonder why, 18 years on, the same arguments are still necessary in some quarters.

The transcript is taken from the official proceedings, published by the Council of Europe.ISBN 92-871-2805-7

Closing address by Professor L.J.G. Gooren University Hospital, Amsterdam

Ladies and Gentlemen

When I address this audience as ladies and gentlemen, it is not my first association that I am addressing a group of human beings with vulvas and vaginas on the one hand, and a group with penises on the other hand. This introduction, this approach, might sound abrupt or even odd to you, but it brings us right to the core of the matter.

When I address you as ladies and gentlemen, I am referring to the kind of person - woman or man - that you became after your birth, when your sex was determined by the criterion of the external genitalia. This being established, your boyhood or girlhood, your manhood or womanhood, became a matter of indirect evidence.

Your genitalia are normally not apparent or obvious in your social environment. Clues as to your being a man or a woman come from indirect sources. When we grow up, we develop a sense of being a man or a woman, on which we hardly ever reflect. We are what we are, either a man or a woman. For this sense of belonging to one sex of the other the term gender identity has been coined. We communicate this sense of belonging to the one sex and not to the other to the outside world in our gender role.

At the roots of this gender identity/role development lies the criterion of the external genitalia, as determined immediately after birth, but along the course of development of the gender identity/role, the genital criterion is not the first association when we talk about men and women in daily life. The reason why I am so elaborate on this subject is that most legal systems pertaining to the determination of sex pay absolute reverence to this one criterion of external genitalia, while there are several criteria or characteristics of sex, such as the genetic and the gonadal ones, the criteria of the internal and external genitals and of the sexual differentiation of the brain.

The latter one, the sexual differentiation of the brain, is a rather new issue. I cannot say we have a complete picture, but the scientific information can no longer be ignored, and it goes without saying that it has relevance for the subject of transsexualism.

What I said earlier about the relatively loose connection between the genital criterion of sex on the one hand and the gender identity on the other, is not at all new information. Let us have a look at a very nice piece of tapestry made in Alsace (presently France) in the 16th century. It is now in The Cloisters Museum in New York City. It depicts the wise King Solomon. The lady in the picture has decided to put his wisdom to the test. She has two flowers in her hand, one a false, artificial one, the other a true flower. They look very much alike. The King is asked whether he is able to tell which is the true one and which is the false one. He says: "Wait and see to which one a bee will go. That is the true one".

The next question pertains to the sex of two children, a pair of twins, one male, one female. They are dressed exactly the same. Can the King distinguish the male twin from the female twin? He can, he throws an apple at each of them. The girl twin will catch the apple with her knees together leaning slightly backwards, whereas the boy twin will move his knees apart, and move slightly forward to the King. Next they are asked to throw the apple back to the King. The girl twin will throw the apple back moving her arm in the lower half of a circle, whereas the boy will hurl the apple back moving his arm in the upper half of a circle.

The lesson to be learnt here is that the wise King Solomon, in order to determine the sex of the two twins, did not use the criterion of the genitalia. He could easily have asked the children to lift their skirts. He did not! He relied on the indirect information of the body language of both twins. Which is what we do in our daily lives. Nothing new under the sun.

Let us now pay some attention to the biology of becoming a man or a woman, or sometimes, and this is unfortunate, becoming something in between. This slide shows the entrance of the cathedral of San Gimignaiano in Tuscany (Italy), and God taking a rib out of Adam, this creating Eve. This story undoubtedly applies to the first lady on earth, but you in the audience have a different history of becoming men or women.

At conception it was decided - let us assume by the laws of chance - that your chromosomal pattern was 46,XY or 46,XX. Except for the chromosomes, there is no distinguishable difference between a future boy and a girl in the first 6 weeks of development. After the first 6 weeks, the indifferent gonad becomes a testis in the case of a 46, XY pattern, and an ovary in case of a 46, XX pattern.

All the following steps in the differentiation process are dependent on the hormones produced by the testis before birth. The next step in the differentiation process is that of the formation of the internal genitalia. These are completely identical ducts in boys and girls. In the presence of testicular hormones produced by the boy foetus, one pair of ducts will become prostate and deferential duct, while the other pair goes into regression. In a girl foetus, the development is the contrary: there are no testicular hormones, so one pair does not develop, the other pair becomes the uterus and oviducts. A couple of weeks later, the external genitalia develop from a common principle. In the presence of testosterone, as is normal in a boy, the external genitalia become a penis and a scrotum in a boy. In girls there is no testosterone around, and the external genitalia develop into a vulva and vagina.

It has always been assumed that the sexual differentiation was completed with the formation of the external genitalia. But it is NOT. Since the beginning of this century we have known that the brain, too, undergoes a sexual differentiation. This has been firmly established scientifically in lower animals, and it occurs relatively late in development, in most species just before or shortly after birth.

Let us take the example of a rat. If a normally developed male rat is castrated on the first day after his birth, his brain will have a female sexual differentiation; if, by contrast, a female rat is given testosterone immediately after birth, she will have a male sexual differentiation of her brain. This implies that the female rat with her female genitalia will copulate in the pattern of a male rate, and conversely, the male rat, deprived of testosterone after birth, will assume the typical copulation position.

What we see here is that male animals, through hormonal manipulation, can be led towards female sexual patterns, and conversely, female animals towards male sexual patterns. Again, this is firmly established sexology of lower mammals such as the rat and the guinea pig.

What do we know about man, the human species? We know that the human brain, too, undergoes a degree of sexual differentiation. Three areas of the brain have now been documented as being sex-dimorphic. One of them is the so-called sex- dimorphic nucleus in the lower part of the brain, the hypothalamus. Surprisingly, the sex difference becomes manifest only 3 to 4 years after birth. This is amazing information.

Long after you were born and after your sex had been determined by the criterion of the external genitalia, your brain still had a long way to go to become sexually differentiated; it does not do so not before the age of 3 to 4 years. These scientific findings may shed light on the problem of transsexualism where we find a contradiction between the genital sex on the one hand and the gender identity on the other hand.

The process of sexual differentiation is characterised by the following:

1. Sexual differentiation is a multi-step process, not a one point decision
2. Each step is characterised by a bi-potentiality; each time the developing organism is at a bifurcation of the male or female development
3. Each step has a critical period in the course of development. Only during a window of time can this particular step take place. No backtracking
4. The sexual differentiation process has not been completed at birth: the sexual differentiation of the brain occurs between the age of 3 to 4 years.

So far I have described the orderly normal sexual differentiation of becoming a boy or a girl, a man or a woman. It is unfortunate that this process is liable to errors. In about 5 in every 1000 individuals this process has shown some errors. It is also a bit of an admonition to those who always state: so God created man in His own image: male and female created He them. Doctors can testify: in the vast majority of cases with impeccable result, in about 5 in every 1000 individuals there are sex errors. The sexual differentiation has not followed its normal course.

I will now show some of these sex errors, and the list is by no means exhaustive. It can be concluded that there may be contradictions between the genetic sex on the one hand and the other criteria of sex on the other hand.

In the clinical syndrome of androgen insensitivity, for instance, all the cells of the body are insensitive to the action of testosterone. While the first two steps of sexual differentiation are normal (the chromosomes, the formation of the gonads) the other steps follow the path of the other sex. These subjects are identified as girls at birth and are raised as girls. They are infertile, they have no ovaries, they have no uterus; but they do have testes. They are legally registered as female and almost always engage in a marriage with a man.

Another example is the clinical syndrome of the congenital virilising adrenal hyperplasia. If this occurs, the first steps of sexual differentiation follow the pattern of a girl: a 46,XX chromosomal pattern and ovaries, but due to abnormal production of androgens by the adrenal, the external genitalia virilise, become more or less male, depending on the degree of the severity of the disease. In severe cases, these children are taken for boys at birth and raised as boys. They marry women, but cannot become fathers because they have no testes. Instead, they have ovaries.

Now back to transsexualism. It is likely from the available evidence that in transsexuals the pattern of sexual differentiation of the brain has not followed the pattern typical of that sex: in other words, the nature of the chromosomes, the gonadal and genital development are in contradiction with the brain sex; at least with the sexual self-image of which we assume the substrate to be in the brain.

There is some evidence to confirm this assumption. In a collaborative study with the Dutch Brain Research Institute, Professor Swaab could demonstrate in postmortem investigations that in two male-to-female transsexuals the sexual-dimorphic nucleus of the brain showed a similarity with the female pattern. This was not the case in a third transsexual. The suprachiasmatic nucleus was unusually large and showed a similarity with the pattern found in homosexual men.

There are some interesting findings with regards to brain functions. Women do better on verbal tasks than men; and men, by contrast, do better than women on spatial ability. Men are better at findng the way than the average women. Several studies indicate that transsexuals show similarities in verbal and spatial performance with the sex they view as their own.

In conclusion, there is now evidence which needs further corroboration that in male- to-female transsexuals the sexual differentiation of the brain is cross-sex to the other characteristics of sex, and vice versa in female-to-male transsexuals.

Transsexualism manifests itself early in life. On this slide you see two brothers of the same family. The younger boy feels and presents himself to the world as a young man. His brother, a future candidate for a sex change, is showing clear signs of cross sex behaviour, look at the body angle. The next slide shows that this cross-sex behaviour persists in time. Here you see the same person a couple of years later, persisting in cross-sex behaviour.

I come to the end of my talk. As a biomedical expert I arrive at certain conclusions and I arrive at certain recommendations for legislators.In summary, legal and sex assignment by the criterion of the morphology of the external genitalia:

• Is based on only one of the five criteria of sex presently known; the other criteria are gonadal, genital and brain sex
• The criterion of the external genitalia does not imply that chromosomal sex or the sex of the internal genitalia are concordant
• Sexual differentiation of the brain is not completed at the moment of birth. This takes place between the ages of 3 to 4 years, well after birth
• Assignment to sex on the criterion of external genitalia is an act of faith, but well founded and time-honoured. Only 1 in 10,000-30,000 will be a false prognostication
• Such an expedient practise does not require a change It works extremely well in daily life

In order to do justice to the rare individuals in whom sexual differentiation of the brain postnatally has not followed the path prognosticated, for example, by the external genitalia, the law must make provisions. If we have the constitutional right to be treated equally and the same by the law, the law must do justice to the rare individuals in whom sex errors of the body occur. This is a personal misfortune, but no ground for unfair treatment.

Ladies and Gentlemen.

I hope I have been able to communicate to you that transsexualism is not an isolated phenomenon in the area of sex errors of the body. It is one on a sliding scale.

In some people you will find contradiction between their genetic sex and the other variables of sex. In other people between their genetic sex and gonadal sex on the one hand, and their genital and brain sex on the other. Finally in transsexuals there is a contradiction between the genetic, gonadal and genital sex on the one hand, and the brain sex on the other.

For all these people who have had the misfortune to incur a sex error of the body in their development, solutions have to be found.

It is part of our anthropology, and of our human existence, that we recognise only men and women in our social system, which reflects on our personal status. In other words, there is no room for intersexes, socially, legally and psychologically.

Medical experience teaches that being intersex makes a person subject to social abuse; such a person becomes a freak. It would be absolute medical ignorance, medical incompetence, even abuse NOT to rehabilitate a person with a sex error of the body. Sex errors of the body cannot be corrected in the true sense of the word. The only option is a rehabilitation to one sex or the other. Rehabilitation does not pretend to be a cure. It is exactly what the word says: rehabilitation makes the bestof a condition that cannot be corrected essentially and fundamentally.

The guiding principle in this rehabilitation process is to assign a person with sex errors of the body to the sex in which he/she will function best, psychologically, socially, erotically, sexually.

Again, I want to stress that reassignment of transsexuals is a medical intervention on a sliding scale. It is not essentially different from procedures in other sex errors of the body. The same interventions including genital surgery are done in other cases of sex errors of the body.

This brings me to the issue raised in some of the legal material I have been reading in this context: Can it really be done? Sex reassignment in transsexuals? In other words: is the feminisation of the body by hormones and the construction of a neovagina, a true authentic sex change or is it a construct, an artefact, a modification only of the body? My answer would be that it is as much a sex change as it is in other cases of intersex. Many of the intersex cases will have contradictions between the variable, the criteria of sex. Many will be unable to produce children; it is a rehabilitation to the best of our ability, not a cure.

There can be no psychomedical ground not to treat these people respectfully; we must provide them with reassignment treatment which meets their needs. In the cases of intersex, and this is particularly true oftranssexualism, medical treatment does not bring resurrection from one's ashes; it is not a cure. It is not a completely new start, it is a rehabilitation process. We must accept the given fact of sex errors of the body and continue from there. We must create the conditions for successful rehabilitation to the male or female sex as much in cases of transsexualism as in other cases of intersex subject.

 

We're all in this together. No... Seriously!

David Cameron and George Osborne may have turned the phrase into a cause for cynical mirth. Yet, when it comes to diverse communities working in each other's interests, the words 'We're all in this together' really have to mean something

A few years ago, when I was first elected for what was to be a three year term as chair of the North West Equality and Diversity Group (NWEDG), I made a little speech about the responsibility I felt I would be taking on.

The North West Equality and Diversity Group

The NWEDG was originally set up in 2005 to help the North West Development Agency (NWDA) research and consult upon its' first ever regional equality and diversity strategy.

NWEDG subsequently went on to be jointly supported by Government Office North West and what was then called the North West Regional Assembly. These three public agency sponsors were followed later by the strategic health authority (NHS North West) and the new Equality and Human Rights Commission.

The group brought together many dozens of stakeholders from every equality strand, along with organisations from the public, private and voluntary sectors. It functioned as a critical friend to the public sector agencies, but also grew into the most comprehensive locus for discussing equality and diversity in the region.

By the time I decided to step down as Chair in April 2010 the NWEDG had over 100 members. I was succeeded by two joint chairs, Paul Martin (of the Lesbian and Gay Foundation) and Louise Barry (of Merseyside Disability Federation).

Following the announcement of the NWDA's intended demise, just after the May 2010 general election, Paul and Louise now have the unenviable task of repositioning the group to survive in the new world under the coalition.

However, I digress...

A philosophy of mutual advocacy

My little candidate speech concerned the inevitable question in peoples' minds whenever someone seen as a single issue advocate takes on the responsibility of leading and representing people from different communities.

To my colleagues at the time I was perhaps best known for having been a very successful advocate for the rights and needs of transsexual people. It was inevitable that, because I was there initially to make that voice heard, people might think that was my sole interest or the limit of my capability. However, as chair I would have duties to represent everyone.

The viewpoint I spelled out wasn't just a ruse to get elected though. It was something I had always believed in and tried to practice.

I explained that, as their chair, I considered it would be my duty to learn continuously about the needs and agenda of all the equality groups who belonged to the group, as well as the concerns and limitations of the public sector sponsors.

Our intersecting interests

As I explained to my colleagues, I never considered myself to have a single set of issues to begin with.

• As a trans woman whose background wasn't apparent to strangers, I had plenty of experience of many of the concerns faced routinely by other women. I had met glass ceilings and pay differentials. I knew when I was being patronised. I knew the fear of deciding whether places were safe for me to go at night. I was a carer. And I had a personal experience of how and when public services hadn't taken my needs into account.
• Having a mother in the terminal stages of Alzheimers, and having worked for five years helping to manage a medium size social care provider, meant that I also had a position from which to appreciate how disability affected people directly, and as carers or relations. I understood why the social model of disability and our use of language and presumptions mattered, for instance.
• I couldn't do anything about the colour of my skin. I'm white, British. Yet when my friends and associates from other backgrounds told me of their experiences I had the empathy and consideration to listen and be aware of my privilege. I also knew what it was like to be a stranger abroad, when you find yourself as a minority in another culture.
• Then, of course, all those years of working with other members of the LGBT communities meant I had a start in understanding the issues which were at the top of the agenda for gay, lesbian and bisexual people ... plus an encyclopaedic knowledge of the different kinds of trans people.
• Lastly, being in my mid fifties at that time, and seeing how my parents coped in their eighties, I also had a stake in the issues of ageing.

Excepting individual variations, I reckon this isn't a unique experience of mine. In Equality and Diversity jargon we call it 'intersection'. It's the fact that most peoples' opportunities and limitations are a combination of factors relating to their direct or indirect experiences of gender, race or ethnicity, disability, sexual orientation, religion or belief, age, economic position, and status as carers, parents, spouses, etc... Few, if any of us, are just one thing.

Where we don't have these experiences ourselves, we know or care for people who do. And, in some cases, age will bring more our way. I may not have any serious impairments today but I accept I may become disabled in one or more ways before I die.

So, I wasn't setting myself up as unique in having a knowledge or interest in all these other strands of diversity besides the obvious one. I was just reminding people that we all have this ability if we stop to think.

Speaking in support but knowing our limitations

As I explained to my colleagues, I had also kept my ears and eyes open enough to be aware of my own limitations - to have an idea of how much I didn't know, and to want to try and narrow the gap.

I'm also aware of the risks of being arrogant. A little knowledge can be a dangerous thing. Or, as I often express it: "None of us knows what we don't know we don't know"

Yet, within those limitations it had struck me that there are all things we can do for each other. As their chair there would be times when I had the opportunity to try and convey important aspects of everyone's individual concerns and agendas. Being a good chair would mean working to increase my knowledge continually so as to do this better.

I would always try to create the opening for experts on disability to talk for disabled people, or for lesbian women to talk expertly about their concerns. It's one thing to spot the opportunities. It's a different thing to think you can replace the true experts.

Something everyone can do

But I was clear this wasn't just something the chair ought to do. I invited my colleagues to consider how they could do it too.

Why shouldn't stakeholder experts from (say) the disability organisations talk more often about sex, race and LGBT issues when they had an audience, for instance? Disabled people face these issues too. There really are old and young disabled black lesbian trans women. If they were caring about the whole of their communities then it meant thinking about having a care narrative that's fully inclusive.

If we all did this then the biggest beneficiaries would be some of the smallest communities, who would gain from many more people talking about their issues. So, yes, I admitted that it would be rather nice if everyone talked more about trans issues too.

But it also meant something for our engagement as a group. It meant that people around our table should not begin to think of tuning out and checking their Blackberry if the next item on the agenda should be something they imagined didn't concern them. I was setting out my leadership approach.

That means you

This philosophy of mine is something I've tried hard to stick to, albeit not always perfectly.

As an equality and diversity consultant it's something I'm bound to do of course. We all do. Those of us who purport to be able to teach the subject need at least a working knowledge of every community's needs and issues, along with the humility to want to keep learning and avoid repeating mistakes.

Yet I'm not sure that everyone shares that vision.

When I use facebook or twitter to write or 'retweet' news about some equality issues then I can spot the different ways in which my different audiences react. Some will pass on the items about women's rights, racial discrimination, mental health or physical disabilities, sexual orientation, age and so forth. But it's interesting how often they don't. Especially when the news is about trans issues.

But just imagine if they did. Just imagine if everyone tried my approach more often and widened the scope of what they told their own followers. Think how much more diverse and aware all our conversations would be.

After all, we are all in this together.

 

Meet the Team

Over the last few months I've written a lot about my colleagues in the Equality, Diversity and Human Rights team at NHS North West.

Now there's a chance for you to see them.

This photo was taken recently as part of a professional shoot for a new publication, and because we are forever needing new and original photos for things like our newsletters and blog.

Who's who

On the back row, standing at the right is Shahnaz Ali. Shahnaz is the SHA's Associate Director for Equality, Diversity and Human Rights and is therefore our boss and, technically, my client.

Shahnaz has public sector experience going back decades, along with a history of black and minority ethnic community activism in her youth. She is best described as a visionary and a consummate networker and influencer.

Her ideas (which it's my job to help deliver) take E&D strategy to levels which few (if any) other people have gone in the UK. She's a pleasure to work with. Our talents are complementary and we often drive each other on by bouncing ideas around.

Standing on Shahnaz's left is Loren Grant, Assistant Director of Communications. She is responsible for all of our team's publications, news and engagement. She produces our monthly newsletter, writes content for our HELP portal, organises all our events, runs our Health Equality Stakeholder Engagement (HESE) consultations, and takes charge of publishing all our resources such as the LGBT History Timeline and our forthcoming guide to Sexual Orientation Monitoring. She sits opposite me and shares my interest in cycling. Again, it's always so much a pleasure to work with Loren as we can bounce ideas off each other.

Sitting next to me on the right of the picture is the newest recruit to our team, Annette Donegani, who is Shahnaz's new PA. Annette comes to us with experience from working in a local Foundation Trust and her title belies her experience. She's only been with us a couple of weeks as I write this and yet it feels already as though she's a full part of the team. As we're such a small group, Annette is also rapidly learning how to do things such as updating HELP, organising events, and so forth.

And lastly, seated on the left of the picture is myself. My role as programme manager is to make sure all our threads of work run smoothly and are completed on time. As an equality and diversity consultant, I have a big input into Shahnaz's vision and look after the detail work on our major developments like the Equality Performance Improvement Toolkit (EPIT) and the forthcoming E&D Competency Framework.

I like this new photo of our team as it really captures how we are together.

 

Coming Soon .. A new 'how to' guide for monitoring sexual orientation

Everything you always wanted to know about Sexual Orientation Monitoring ... but were afraid to ask

One of the nicest things about working where I do, as the programme manager for Equality and Diversity in one of England's Strategic Health Authorities, is the ability to have a hand in commissioning and influencing some really useful tools, resources and good practice to advance LGB and T equality outcomes.

I've written a lot this year about our programme of work and why it matters.

Things we do

Earlier this year my colleagues and I at NHS North West launched a brand new timeline exhibition to educate NHS staff about lesbian, gay, bisexual and trans people's history, their challenges and their contributions to medicine and healthcare. The exhibition went on the road in February and has been receiving great feedback. Very soon we'll also be launching the online interactive version, which features a more detailed booklet and this film as well.

We've also invested in initiatives to promote sexual health for lesbian women, and to foster the creation of a more LGB friendly environment in GP Surgeries, piloted in the Greater Manchester area.

We spend on these projects to lead by example and establish best practice where it doesn't already exist. In that way we help create the case for local NHS organisations to then follow-on by funding such things more routinely themselves. (Admittedly the latter is difficult in the current climate).

Of course, we also invest around other diversity areas too.

For instance, we are currently promoting research into how breast cancer and screening particularly affects South Asian women. We also sponsor events such as the annual Disability Living Awards and Disability Awareness Day, and we engage closely with partners from all the equality strands to consult and obtain advice on a wide range of issues through our Health Equality Stakeholder Engagement (HESE) approach. We also work in less visible ways behind the scenes in areas such as gender identity.

And all this is on top of our cross-cutting activities, such as developing a national competency framework for NHS E&D leads and operating the ground-breaking Equality Performance Improvement Toolkit (EPIT) which we pioneered.

So, our recent work on sexual orientation and gender identity projects is only a small part of what we do as a whole. However, as work around race or ethnicity, gender and disability has been underway for more time, and people are less familiar with areas such as sexual orientation, there's a genuine case to invest in playing catch up in specific ways.

The need for monitoring

Monitoring is the term to describe any kinds of data collection which contribute to understanding the detailed demographics of service users and the workforce. When done well, this data helps employers, commissioners and providers to improve what they do -- whether that's improving the diversity of the workforce to more accurately reflect the population, or configuring services so that they work better for the people who use them.

Most people are familiar with being asked for this kind of information -- when applying for a job, for instance, or when registering with a new GP.

Asking people for information about their age, sex, race / ethnicity, disabilities or religion is generally not very contentious. It's familiar and people are relaxed about asking for and giving this kind of information about themselves.

Some organisations have also experimented with collecting this kind of information on sexual orientation.

Until the new Public Sector Equality Duty came into effect there was no formal impetus to do this and most organisations shied away from the prospect. Now that the new public sector equality duty is in effect, however, they now need to think more seriously about doing it.

As in any other area, if the organisation doesn't collect such information it cannot possibly claim to know whether it is meeting peoples' needs and not unintentionally discriminating.

What, where, when, why ... and HOW

The prospect of monitoring for sexual orientation is met with fear by some organisations -- mainly fear of the unknown.

To rationalise those fears managers often come up with lots of suggested barriers. One of the most popular is the notion that patients or staff will be offended by being presented with questions about their sexual orientation.

This is odd, given that medical professionals are trained to routinely ask far more intimate questions about every conceivable bodily function and to poke around our orifices and excretions. Asking someone's orientation is not as though you are asking them when and how they last had sex. You're just asking about the kind of life they lead and who they are likely to share it with. For Doctors and nursing staff that should be a fundamental of building a picture about their patient.

Other suggested barriers include complaints that computer systems aren't built to collect this data, or that staff would be embarrassed or feel it inappropriate to ask some categories of patient.

In keeping with our philosophy of using our resources and influence to break new ground and establish best practice for others to copy we realised that there was a serious need for a matter of fact guide answering all the usual questions and fears about sexual orientation monitoring. Better still we wanted to provide some practical examples where people are already getting things right.

Asking the experts

We commissioned a team from the Lesbian and Gay Foundation to do all the detailed research and writing for us. In turn, they recruited a steering group of experts from across the public sector (not just health) to ensure the final guide would cover every aspect of the topic and provide the best advice and case histories.

The guide is now in the advanced stages of layout and production. We all had our photos taken for it today, for instance. We plan to launch it at LGF's resource centre in Manchester's gay village on Monday 12th June. (If you'd like to be there contact LGF for places).

It's just another resource to add to the arsenal of tools which NHS staff need in order to ensure they meet the needs of all of the population they serve, rather than only a part.

Many more tools like this are still needed, of course. As I said at the outset, filling those gaps is a great part of what we do. It's just a shame that we soon won't be around any more in the present form to do much more.

A new film about LGBT history and involvement with medicine and the NHS

A few months ago I blogged about the launch of a new timeline exhibition which my colleagues and I at NHS North West had produced with technical input from our partners, the Lesbian and Gay Foundation and the Trans Resource and Empowerment Centre.

The LGBT Timeline, spread across twenty large display panels, charts significant historical milestones involving lesbian, gay, bisexual and trans people from ancient history to the current day, with particular attention to those people and events which connect with the development of medicine, health care and the NHS.

It complements a similar timeline of Black and Minority Ethnic peoples' contributions to the NHS which we produced for the NHS's 60th anniversary in 2008.

I explained at the time that the bookable LGBT exhibition was only the first component of this major new development, which also includes a printed booklet, an interactive online resource and a film in DVD and online form.

The interactive resource will be accessible by anyone and will be launched shortly. In the meantime the film is ready and you can view this below.

For details of how to book the exhibition and how much it will cost please email equalityanddiversity@northwest.nhs.uk