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Whereas the bulk of Western societies believe that one’s biological sex (specifically genitals) irrevocably determines one’s social gender, behavior, and identity, transgender individuals disrupt the connection between biological sex and social gender and create alternative forms of gendered presentations and identities. Generally, transgender individuals vary across four dimensions: (1) biological sex—the actual biology of the individual, including male, female, and many interesexed conditions; (2) psychological identity—gender identity, or to what extent one identifies as a man, woman, or something else; (3) social presentation—how typically masculine or feminine one looks and acts; and (4) legal sex—the sex designation that is listed on various legal documents (driver’s license, passport, birth certificate, and so on) (Lombardi, 2001). It is important to note that individuals will have their own way of identifying themselves. Social workers will need to talk with their clients about how they themselves identify.

CROSS-DRESSING

Cross-dressing refers to the act of individuals of one gender wearing the clothes and accessories of another gender (most notable are men who for various reasons wear the clothing and take on the various social attributes of women). Many men who cross-dress do so as a performance act (female impersonation/drag) or as a form of personal self-expression; while generally not acknowledged in society, many women also cross-dress for performance and self-expression. Many people view cross-dressing as a sexual problem, believing that individuals who cross-dress do so in order to fulfill their sexual fantasies. Indeed, the American Psychiatric Association lists cross-dressing as transvestic fetishism in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) (302.3 Transvestic Fetishism). Focusing on cross-dressing as a sexual paraphilia, however, blinds clinicians to the variety of forms of transgenderism that clients could express without perceiving it as a problem. The DSM classification itself may cause some bias in the minds of clinicians regardless of the actual status of their client (and the client’s own view), leading the social worker to view any incidence of cross-dressing as a problem. It is important to note that cross-dressing in and of itself should be seen not as pathological behavior but as one important aspect of a person’s life.

TRANSSEXUALISM

Transsexualism refers to individuals who seek to permanently change their social and legal gender (man to woman or woman to man) to better match their psychological gender identity. Hormones are usually used to change some secondary sex characteristics, while surgery is used to alter other physical aspects (most notably, but not limited to, one’s genitals). In addition to the medical aspects of transitioning from one sex to another, individuals typically seek to change their social and legal identities in order to fully take on the social role of the gender with which they identify..

The incidence of transsexualism, as gauged by studies outside the United States and using different measures of prevalence, is approximately 1 per 20,000 to 50,000, with the ratio favoring male-to-female transsexualism about 2.3 to 2.5:1 (Weitze & Osburg, 1996). While prevalence rates have been shown to vary, the ratio of male-to-female (MTF) to female-to-male (FTM) transsexualism still appears to favor male-to-female transgender individuals. Bakker, van Kesteren, Gooren, and Bezemer (1993), for example, reported on the prevalence of transsexualism among people native to the Netherlands by counting the number of people who were seen by psychiatrists and psychologists and were subsequently treated with hormonal and sex reassignment therapy. They found prevalence rates of 1 per 11,900 MTF and 1 per 30,400 FTM; suggesting a ratio of 2.5 men to 1 woman. There are exceptions with respect to the ratio of MTF and FTM transsexuals, but these seem to be few. In Sweden it was reported that transsexuality is found equally in MTF and FTM samples (Landeb, Walinder, & Lustrom, 1996). However, this study, like much research on transsexuals, sampled people from gender clinics and mental health settings; this methodology will confound the prevalence downward, as many transsexuals do not (or cannot) access such services. The diversity among transgender people precludes an easy way of identifying a transgender population, but professionals must be aware of many issues when providing care for transgender individuals. Many people who self-identify in diverse ways may still have much in common with each other.

It is important to note that there are significant differences between transsexual men and women in addition to the degree of access to gender reassignment services. Transsexual men and women themselves can have very different needs with regard to types of care. The hormonal and surgical procedures used by maleto- female (MTF) individuals are not equivalent to those used by female-to-male (FTM) individuals. The genital surgeries available to FTM individuals tend to be much more expensive and not as aesthetically or functionally realistic as the genital surgeries available to MTF individuals. In addition, unlike estrogen, all forms of testosterone are scheduled drugs (schedule III), while forms of estrogen and progesterone are unscheduled (scheduled drugs refer to the list of drugs that the U.S. government identifies as requiring special control because of their potential abuse and/or harmful nature).