Boys Don't Cry - a review for healthcare staff

(See also what the International Movie Database says about Boys Don't Cry)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

TRANSSEXUALISM
– a matter of gender and identity

"Boys Don't Cry” – a matter of ignorance and intolerance

By Owe Bodlund,Professor and Chief Physician, Psychiatric Clinic and the Department of Clinical Science/Psychiatry, Umeå University

The film "Boys don’t cry" is a gripping and at times dramatic depiction of a young, transsexual woman who is trying to live her life in a prejudiced American society. The film provides a nuanced and fairly accurate depiction of the psychological and social drama associated with being a young person trying to live in the desired/opposing gender role.

The description of the surrounding society's lack of knowledge and tolerance for this identity disorder is still extremely topical. Knowledge about and understanding of gender identity disorders has improved in the West, although a great deal remains to be done.

The film is based on a true story, whose tragic conclusion attracted a great deal of attention in the USA. Many transsexuals recognise the description of the battle involved, during the gender change process, in convincing others that they are the other gender psychologically, and that in all respects they want to live in the opposite gender role and be perceived and respected as such.

Many transsexuals share the experiences of the lead character, Brandon, of being questioned, excluded and isolated, and in many cases bullied during their youth. Coming out as a transsexual entails a complicated process, where individuals are often alone in having to convince not only their own family, but also friends, work colleagues, etc., that they really want to change gender and live completely in a new gender identity for the rest of their life – and that it is not a temporary whim or a transitory identity crisis.

As a psychiatrist, I have worked for more than 30 years within this field, both from a clinical and a research perspective, and I have probably met most of the transsexuals in Norrland province. Based on this experience, I will give a description below of what transsexualism is, how these patients are investigated and how treatment takes place, as well as describing a little about how things are for people who change gender in Sweden.

What is TRANSSEXUALISM?

The condition is known as transsexualism according to ICD -10, whereas DSM-IV calls the condition Gender Identity Disorder (GID). It is a lifelong condition, where the person in question perceives him or herself to have been born in the wrong gender, or rather in the wrong body.

Those who apply to change their gender have often been convinced of this since childhood. This feeling has strengthened during puberty, and this is often a traumatic period for the patient when the "wrong" genitals develop.

Transsexuals consequently do not only have a desire to belong to the opposite gender, but also a strong conviction that they are a biological mistake. This feeling normally begins to creep in during childhood, but can also start later as a teenager in conjunction with sexual maturity. The diagnostic criteria consequently describe a condition with a disordered gender identity, where the perceived (psychological) gender does not correspond with the anatomical gender, and that these individuals have a strong desire to change gender physically.

"Transsexuals consequently do not only have a desire to belong to the opposite gender, but also a strong conviction that they are a biological mistake"

"the body needs to be corrected so that it better corresponds with the psychological gender."

It may appear logical that these individuals could be helped to accept and adapt to their anatomical situation through psychological and/or medical treatments.
However, this attitude is not accepted by the transsexuals themselves, and neither has psychological treatment proven to be effective in harmonising the perceived gender allegiance with the biology. For transsexuals, the gender identity is the primary factor – the body needs to be corrected so that it better corresponds with the psychological gender.

Incidence and aetiology

Transsexualism is an uncommon condition, with a prevalence in Sweden of approximately 1 in every 100,000 adults. In 1972, Sweden was the first country in the world to pass a law regulating gender modification measures, and since then we have had reliable statistics regarding the number of people seeking gender reassignment.

During the period 1972-1999, the number of applications for gender reassignment was essentially constant, with approximately 15 approved gender changes per year. The gender distribution was also relatively even. Over the past 10 years, there has been a marked increase, primarily among biological men.

In recent years, 40-55 new cases have been handled annually within the Legal Council at the National Board of Health and Welfare. The gender ratio between men and women is now approximately 2:1. We can only speculate about the reasons for this increase – it may be due to increased tolerance and greater knowledge in society, more easily accessible information about the condition and what can be done in the way of treatment. It is also possible that various cultural trends are contributing towards more people seeking help with this gender identity problem.

Although the condition is uncommon, the general level of knowledge in the population as a whole is now good. Studies have shown that most Swedes are aware of the concept of transsexualism, and that they are essentially positive towards those affected by the condition, as well as being positive towards these individuals being offered both hormonal and surgical treatment. The annual incidence is approximately 45 new cases per year, and there are now a total of around 700 people in Sweden who have changed gender (legally).

The aetiology of transsexualism has not been established, and over time there have been various theories regarding the cause. At present, discussions are primarily focusing on a biological explanation, where it is believed that the impact of hormones during the foetal stage is a strong contributory factor.

There is support for the idea that, in genetically predisposed individuals, short-term hormonal influences during "critical periods" in the foetal stage can result in that part of the nervous system related to gender identity developing in a different direction from the rest of the body.

Earlier psychological theories and explanatory models regarding transsexualism, as well as the belief that the condition could be treated psychotherapeutically, are not supported by the science. The "treatment of choice" is currently medical care in the form of lifelong gender hormone treatment as well as surgical procedures to make the body more like the opposite gender.

Investigation and treatment

In 2001, in the medical journal Läkartidningen, we described the investigation process and the treatment options for transsexuals. The law has been modified somewhat since then, and refined surgical treatment methods have been made available.

Before a gender reassignment can be carried out surgically and legally, a thorough investigation is carried out. This often extends over several years, and is carried out by specialist psychiatric teams at university hospitals.

To start with, medical and psychiatric evaluations are carried out, including a general somatic investigation, intended for example to exclude patients with an intersex condition with hormonal and/or chromosomal deviations. The psychiatric investigation is intended to establish a diagnosis and to exclude patients with an underlying psychotic illness, advanced drug dependence or cases of feminised homosexuality or transvestic fetishism.

The investigations also look at whether the gender identity problem has existed for a long time or whether it is an expression of a temporary life crisis. The duration of the patient's desire to change gender is determined on the basis of the patient's own accounts, discussions with relatives, as well as based on the relatively long observation period and contacts that the patient has with the investigation team.

During the observation periods' "real life test" lasting 1-2 years, the patient is expected to live in the desired gender role, which examines the motivation and driving force for the gender reassignment.

The "real life test" period provides the patient with time to consider and the opportunity to change his or her mind before irreversible measures are implemented. If the patient and the team are convinced of the diagnosis and that there are no serious contraindications, hormone treatment commences using opposite gender hormones.

In practice, this means that the decision has been taken to implement the gender change. An application is sent to the Legal Council at the National Board of Health and Welfare, certifying that the patient is at least 18 years of age, unmarried, a Swedish citizen or permanently resident in the country, along with a detailed statement from the treating psychiatrist.

The Legal Council then adopts a position, in part regarding the change of first name, although it also approves surgical intervention relating to external and internal genitals. After the completed gender correction surgery, the patient receives formal confirmation of the new gender identity, which also entails changing the control figure in the patient's personal identity number.

In Sweden, surgical treatment is centred on the plastic surgery clinic in Linköping and Karolinska Hospital in Stockholm. The clinic in Linköping specialises in gender correction of transsexual women to men (W-M), whereas the Karolinska Hospital focuses primarily on men to women (M-W).

Hormone treatment entails biological women (W-M) receiving testosterone injections (e.g. Nebido every 10-14 weeks) and biological men (M-W) receiving oestrogen orally or transdermally.

For W-M, the hormone treatment leads for example to increased muscle mass and bodily hair, a deeper voice and facial hair growth, growth of the clitoris and, not uncommonly, an increased sexual urge alongside the cessation of menstruation.

For M-W, the hormone treatment results in an altered fat distribution towards a female pattern, breast growth, and occasionally reduced bodily hair and muscle mass. The surgical treatment for women to men involves mastectomy, the removal of internal female reproductive organs and the reconstruction of external genitalia in order to construct a penis, either via phalloplasty including taking skin from the underarm or side of the abdomen, or plastic-surgical construction of a miniature penis based on the enlarged clitoris.

For men to women, the surgery includes the removal of the testicles and penis and the construction of a neovagina using inverted penile skin. The clitoris is constructed using parts of the glans penis.

M-W frequently also require epilation/laser treatment against beard growth and occasionally breast implants. For both genders the consequence is infertility, although the cosmetic results are often satisfactory. However, it is not uncommon to have complications as regards sexual function and occasionally also urination.

The aim of both hormonal and surgical treatment is, as far as possible, to modify the body so that it better corresponds with the psychologically perceived gender allegiance, as well as for the patient to be able to pass as the opposite gender in the eyes of others. These objectives are achieved in the vast majority of cases.

Prognosis – how are things for people who change gender?

Gender reassignment is an extensive and irreversible action, and we might anticipate that there would be numerous cases of patients regretting their decision, yet Swedish and international studies show that the frequency of this is only 2-3%.

Numerous follow-up studies have been conducted, both internationally and in Sweden. In three repeated Swedish follow-up studies, it has been found that between 70-90% of those who have changed gender are satisfied with the results and satisfied with living in their new gender identity.

They are also relatively satisfied with the cosmetic results and genital functions. The majority of patients who have changed gender live a normal life in terms of work, partners and friends. In many cases, those around them are not even aware of the gender reassignment that the individual has undergone.

In a recent follow-up study from Umeå and Lund, we have observed that 95% of the patients are satisfied, approximately 70% are also satisfied with the results of the operation, and more than 80% perceive their general health to be just as good or better after changing gender. Almost half have a partner, and 70% of both genders are satisfied with their current sex life.

"...modify the body to that it better corresponds with the psychologically perceived gender allegiance..."

Summarising comments

Gender reassignment as a treatment for transsexualism has been carried out since the middle of the last century, and was legally sanctioned in Sweden in 1972. The treatment methods have subsequently been developed and surgery has been dramatically refined, with improved cosmetic and functional results.

In the West, ever greater emphasis has been placed on psychological care during the actual gender change process, emphasising the fact that support from those near to the patient can be decisive for the outcome.

As we wrote in Läkartidningen in 2001, scientific evaluations continually and unambiguously show that gender reassignment is the best treatment we can offer to transsexuals. Investigations and treatment should be handled by specialist teams (within public health care) comprising professionals with psychiatric/psychological expertise, surgeons and endocrinologists.

In selected cases, close co-operation with logopaedists, phoniatrists and skin therapists is also required.

The potential to change gender is statutory in Sweden, conditional upon an extensive investigation and observation period. The social and relational aspects of changing gender are important areas of focus for us in the investigation teams – when we diagnose, treat and try to support transsexuals through the process.

The film "Boys don't cry" describes the individual fate when one young transsexual biological women tries to convince those around her that she wants to live as a boy/man, as well as the social and emotional complications that arise when the outside world is ignorant and intolerant.

The film presents a portrayal of the deeply rooted, constant nature of the problem of gender identity in transsexual individuals. They have a legitimate desire to live fully in the other gender role, a lifelong endeavour that is probably based on biological and genetic grounds.

The film looks at and stirs up deeply rooted preconceptions and fallacies.