Body of evidence: A special report into the lives of transsexuals

The up trapped in the wrong gender causes hundreds of people to take their own lives. Surgery gives others a new start, but in many cases the price of happiness is still very high.

HE IS clearly a man. I say 'clearly' because when James Morton walks towards me in an Edinburgh hotel he is dressed like any young professional male, in a suit and tie, he has light beard growth on his face and myriad little signals he transmits suggest masculinity. Should I tell you that once he had breasts, a womb capable of bearing children, that in fact he was female, your eyes would tell your brain that this is a lie. You would feel the confusion that James has felt all his life. Growing up, when he looked in the mirror and saw a female body, he thought, 'Who is that?' For in both his conscious and unconscious mind, even in his dreams as he slept, he was male. "Waking up was just like… 'Oh my God, yes, of course. Back to the complicated mismatch that I have.'"

Even now, things are still confused. James has a legal certificate saying he is male. Underneath the 28-year-old's suit, breasts have been removed, his chest reconstructed. He no longer has a womb. But he does not have a penis. Two gender experts in Scotland, and one internationally renowned expert, Dr Griet De Cuypere, in Belgium, have approved him for surgery. But despite continuing to fund male-to-female surgery, Lothian Health Board has refused to fund phalloplasty, the surgical construction of a penis, which would complete his transition from woman to man. "It's a nightmare situation," says James's doctor, Lyndsey Myskow, associate specialist at Edinburgh Royal Infirmary's sexual problems clinic. "There are a number of people in Lothian who have found themselves in this position."

In Scotland, referrals for surgery come through Edinburgh Royal Infirmary and Glasgow's Sandyford Clinic. Female-to-male surgery is still available for Glasgow patients, funded by the health board, yet James has been waiting four years in Edinburgh. Lothian Health Board says his case will remain under consideration, but funding is only for "exceptional" cases. It's hard to imagine what an unexceptional case of phalloplasty would be.

This is a story about identity. It is not about sex. In the public consciousness, transsexualism is often a vague, confused hotchpotch of ideas about homosexuality, Danny La Rue-style drag queens and sexual fetishes. A nudge, a wink, some Rocky Horror Show suspenders. But for most transsexuals, sex comes way down their list of priorities. It has to. By pursuing their need for the correct gender identity, they inevitably place themselves in a twilight world where their opportunity for sexual partners is greatly reduced. "It's a big deal for me," says James, who transitioned at the age of 22. He was so distressed by the mismatch between the body he had and the one he thought he should have, that he couldn't date. "So I don't really have intimate relationships in my life," he explains.

"Some transsexual people find the desire to have intimate relationships overcomes their discomfort, but for me the discomfort about my physical situation overcame the desire, so I felt really lonely. It just felt this horrible mess, with tangled emotions that I couldn't open myself up to because it would upset me too much."

Historically, there have been figures throughout the ages associated with transsexualism, from the mythical Greek goddess Venus Castina, who was sympathetic to "feminine souls locked up in male bodies", to the 17th-century female thief and male impersonator Mary Frith, otherwise known as Moll Cutpurse. But it was only in the 20th century that gender-realignment surgery became possible. The first operations were performed in 1930s Germany by the pioneering sexologist Magnus Hirschfeld, and there were a number of notorious cases throughout the 1950s and 1960s – including the American GI George Jorgensen, who became nightclub performer Christine, and the Vogue model April Ashley, who never got another contract after it was revealed that she had been born male.

As a child, James was simply a tomboy who went to Cubs instead of Brownies. But at puberty, things became complicated. "Everything became much clearer in terms of people's bodies. There was no longer much leeway for being accepted as one of the boys. I wasn't androgynous-looking. I had reasonable-sized breasts and a high voice. Generally, through school I wore a shirt, tie, a big baggy V-neck and trousers, trying to keep it as gender-neutral as possible. But nobody ever went, 'Oh, that's a boy.' They thought, 'There's a girl who's not making enough effort.'"

We all transmit gender signals. James felt he was transmitting the wrong ones. Gender, he realised, was more than genitalia. It was also a state of mind. "I felt like all the interactions just went wrong. People didn't necessarily realise it was a gender issue. They just thought, 'Gosh, that person is really strange, quite weird.' The interpersonal dynamic they were expecting didn't always go to plan. I would forget, not looking in the mirror all the time, how I came across, so I'd be relating to them thinking I looked like a guy – and I so didn't. And they'd be thinking, 'What's happened to her? The dynamic is really weird.'"

He retreated into himself, turning to studying because people think if you are bookish you have no interest in parties and dates. An only child, he felt there was no one to turn to. He was close to his mother, but his father, who would die when James was only 19, was ill with heart disease throughout those teenage years and his mother had enough to contend with. At 16, James had been referred to doctors for depression and anxiety. He was sexually attracted to women so he was told he was "probably just a butch lesbian". But that didn't feel right. Lesbians were happy to remain women. He wanted to be a man.

After his father died, he knew he had to confide in his mother. But it was painful. "I didn't want to hurt her by telling her I wanted to change gender, because I knew she had her dreams and hopes and expectations based on having a baby daughter. So I tried desperately hard to just try to find a way of being a woman that I could feel comfortable with, but it was just such a profound sense of who I am that I couldn't. My mum could tell I was really distressed through adolescence but she didn't know why. I know she was really affected that I wasn't sharing things with her, but I didn't want to hurt her. And what if she said, 'No, I'm not going to accept that'? I just didn't want to put that on the line."

It shows sensitivity to so intuitively understand the hopes and dreams of your mother. Does that make James sound feminine? Only if gender and behaviour are black and white. Ironically, what makes his masculinity convincing is that he doesn't adhere desperately to masculine stereotypes to prove his gender identity. "I wouldn't say I am particularly macho. There are loads of people who are comfortable in the female world who are way better than me at DIY or football or things that are meant to be masculine behaviours.

"I always joke that if you polled my classmates in the final yearbook, they would not have picked me out. They would have picked one of the other poor sods who was a tomboy but more classically butch than I was. I like to think of myself as someone who has tried to integrate masculine and feminine styles of behaviours. I don't want to lose any of the knowledge that I have gained."

There is another irony. Sexual ambiguity has so often provided comic material: the hairy men in dresses in a well-known kitchen towel advert, for example. In real lives, it's the source of enormous pain. Transsexuals' stories often have suicidal moments in them, and James's is no exception. Asked how life would have been if he'd continued living as a woman, he hesitates. "I don't know if I would have made it. I tried to kill myself in my teens. I would like to believe I would have been a strong enough personality to have made it through all the difficulties and the distress, but I don't know that I would have been."

Understandably, there is reluctance to look back on that time. He was 19 and became so low that he actually thought it might be easier for his mother if he killed himself rather than transitioning. "Maybe I was feeling dead to her anyway," he says. "I couldn't see a future where I wouldn't wake up feeling distressed. I just felt like, 'Every social interaction is going to go wrong. Every time I think about my body, I am going to feel depressed. Everything is always going to jar.' I couldn't stand the idea of 60 years…"

His suicide attempt failed. It makes him feel a bit inept but he's relieved too. "If I had died at that point, there would have only been pain and it would have been devastating for my mum."

When he finally confided in her, it felt like going into uncharted territory. "I thought, 'Where does this end up? Please let it be a good place.'" It was. His mother lost a daughter but gained a son. She learned to have new dreams and aspirations. So did James. "There are lots of people that I have met over the years, and I'd like to think their lives have been enriched by knowing me, and my life has been enriched by knowing them, and that the overarching effect of me being alive is a positive one."

FOR MOST PEOPLE, nature is wonderful. Complex beyond our understanding, imaginative beyond our own human creativity. But mistakes happen in nature. Physical deformities, genetic disorders, rare internal malfunctions. We know that, yet when it comes to gender, it's as if nature is infallible, beyond question. Transsexualism is seen almost as some kind of perverse and unnecessary lifestyle choice. So what is the scientific evidence?

Current estimates suggest that one in 100,000 women are transsexual and one in 25,000 men. In the past, some doctors have argued that surgery is inappropriate because transsexualism is a psychiatric illness. While gender dysphoria – confusion – does appear on the international list of psychiatric conditions, this is more to do with the psychological distress it causes than the nature of the condition itself. "I would absolutely disagree that it is a psychiatric condition," says Myskow, who has more than 20 years of experience in the field. "Anyone who works with transsexuals knows they are just driven, that there is something within them that they absolutely have to get sorted out. They give up so much because this is a real need."

There is undoubtedly something unnerving about healthy bodies being operated on. But is correcting a mind/body imbalance really different to fixing a broken limb, a hole in the heart or a baby's cleft palate? We know what causes these more visible defects. But transsexualism is not fully understood, which makes it more contentious. "We know what it's not," says Myskow. "We know it's not a chromosomal abnormality. We know it's not a hormonal abnormality. We know these patients are not psychotic. But there's no absolute proof of what goes on. We think that it occurs in the uterus, and is probably some influence of the hormones on the developing foetus that is having an effect on the brain that is different from the effect on the body. Parents are often very anxious to know if there is anything they did wrong in the upbringing of these children. There is absolutely no evidence that it is down to upbringing and experience in early childhood. I think it's too late by then – it has already happened."

People with psychiatric conditions who mistakenly think they are gender dysphoric are relatively easy to weed out, says Myskow. Two specialists must approve treatment, and there are three main stages of treatment. The first is hormone treatment, which brings about obvious physical changes; hair growth or breast development, changes to skin, hair and voice. Then patients are given the real-life test of living for a year in their chosen gender. If, at the end of that, they want to proceed further, surgery is an option. But there are dangers. "There is a risk from hormone treatment," acknowledges Myskow, "and we're talking major surgery. There are risks of infection, and clearly you are disturbing the anatomy considerably."

But results can be very good. "Male-to-female transsexuals will function sexually perfectly well. It looks cosmetically very good. There are stories of post-op women going into casualty with a bleed and being asked if they could be pregnant. The other way round is more complex. They are able to have intercourse because they have a penile implant that enables them to get an erection, but the penis is made from skin from the forearm so they just have the sensation of the forearm – if they are lucky. In my experience, many female-to-male transsexuals wouldn't go as far as phalloplasty. However, there are patients in relationships for whom it's really important to have a penis."

There seems something immoral about leaving a person halfway through such a traumatic transition. But James knows public support is limited, despite the psychological extremes he has been driven to. If he wants surgery, he may have to move to another region of Scotland. "It's a postcode lottery, and because it's not a sympathetic topic NHS policymakers think they won't get flak from the general public for cutting surgery – in fact, they think the general public would approve. I don't know if it's because they don't understand how much of an impact this has. It's no more a conscious decision to be a transsexual than any other part of your personality."

JULIA GORDON'S EARLIEST memory is of a man in black lighting the gas lamp outside her Glasgow tenement home. It is a shadowy recollection, a vague awareness of darkness, fear and anxiety. "My first memory is of being a very frightened little boy." That fear lasted much of her life. Now 60, she smiles as she recalls the child who was always left out when football teams were picked. Back then, she didn't smile. "It was crushing." She asked for football boots for Christmas, hoping they would bring acceptance. "I got the boots, and my experience was exactly the same. I was still an outsider. It felt really sad at the time."

I first met Julia ten years ago, for a story I was writing. She lived in Inverness, dividing her life between teaching piano as a man and living her private life as a woman. I met her as both. I was fascinated, I remember, meeting her masculine persona for the first time, experiencing a sense not just of physical slightness that I had been unaware of meeting her as a woman, but somehow of less emotional solidity. Whatever signals she transmitted, they were inexplicably stronger when she presented as a woman.

Transsexualism is a spectrum, not a fixed point, and Julia, now retired, did not want surgery back then. She was, she said, not defined either by masculinity or femininity. Her sense of self went beyond gender labels. "My whole life has been a search for identity. I was worried that if I had surgery people would think I saw myself as a woman. I don't think for a minute that it makes me a woman, because a woman is not a body… a woman is a sense of who she is, a mental construct that is supported by the shape she is."

But then her father died. "It had an effect on me that even today I find quite difficult to understand. It was so liberating. Almost as soon as I heard, I knew I was going for surgery. Obviously, I guess I had feared his reaction. We always had a difficult relationship, and to even contemplate his disapproval if he ever found out didn't bear thinking about. He was a very distant person. There was no warmth."

Her parents had held together only tenuously; her late mother stayed for her three children. Julia says everything she did as a man felt like failure, and yet she does not believe her father influenced her sense of masculinity, even though she became emotionally distant, like him. "I was a very cold fish. No emotion. It was too scary for me. People found me a difficult person to know – I don't think they wanted to know me."

Her first experience of cross-dressing was simply part of sexual exploration in puberty. But over the years it became a retreat, a place of inner peace. "When I cross-dressed, in some strange way it enabled me to connect with my emotional self and allowed emotions to surface that didn't overwhelm me." Women, she thought, were emotional beings. Men weren't. Wasn't her sense of masculinity skewed, then, rather then her body? She simply couldn't change that, she says.

At times, she clung to male stereotypes. "I chopped down trees and hauled timber. I put effort into trying to present myself as a man." At 19, she married, but left six months later. By her mid-20s she was suicidal. Working in hospital laboratories at the time, she had access to poisons. She took a bottle home with her. "It was an option. Life had never felt so difficult."

Music provided rare sanctuary. "It has been so important in my life. I have always experienced music as a way of expressing myself emotionally. It was a positive, nourishing experience, and there weren't many around. On many occasions it was my salvation, especially when I was really low, suicidal. I remember going to the piano and just working out the sadness. At other times it would lift me, just kind of hold me, stop me going further."

Julia married for a second time in her late 20s, and this time it lasted 13 years, producing a son and a daughter. But she knew this was just another desperate attempt to conform. "I knew I wasn't in love. I didn't know what love was but I knew it wasn't this." Bringing up the children was "delightful for a while" but the old fears and confusions surfaced again. "I'm not sure how much of becoming a father was tied in to my need to normalise how I functioned in life as a man, a husband and therefore a father."

Deciding to live her life as a woman was inevitably traumatic, but she only has one regret. "I want to stop hurting people." Her ex-wife lives in a nearby town, and Julia can imagine she feels angry and betrayed. But surgery has brought fulfilment. "It was an opportunity to add a few more finishing touches to the picture I had been creating all my life." It did, though, bring rejection. She has a close relationship still with her daughter, who even as a teenager said the important thing was that Julia should be happy. But her son, who lives in Glasgow, wrote her a letter. "He said that in view of his impending marriage, his career, he felt – I'm paraphrasing here – that he would only be able to sustain a relationship with me as a friend, not as a parent, not as who I am." Did she receive an invitation to his wedding? "No."

It hurt, she admits. "But any time I am in a difficult place, struggling to know what to do, I ask myself the question, 'What would love do?' And it's quite clear that what I need to do is let him lead his life, the life he chooses. I can't ask others to give me that if I can't extend it to other people."

Julia trained as a counsellor after transition, and enjoys an informal role as agony aunt to friends. She wants as much love as possible in her life but thinks romantic love is a fantasy too far. Sexual orientation is separate from gender, and she is still attracted to women. But she has never operated well sexually, and opted for surgery knowing her life was likely to be asexual in future. "Though, despite that awareness, there's always the little hope that maybe not…" Has she never been in love? "Perhaps tomorrow," she says, and smiles. "But not yesterday."

MARTHA HAND STILL remembers the dress her sister wore as a bridesmaid. It was so lovely. But Martha was an 11-year-old boy at the time. A few years later, when her sister moved out, she found the dress in a closet. "I remember picking it up and thinking, 'It would be fantastic to try that on.'" Was she scared? "I had to make sure there was nobody else about, that I wasn't going to get caught. We had a work room in our loft space, and I used to go up there and hide and take clothes with me." By the time she was a teenager, she spent her paper-round money on a secret stash of clothes and make-up. "I always suspected my mother knew but she never admitted it."

Martha is an attractive woman. The interesting thing is the almost Diana-like mixture of shyness and coquettishness that she transmits, a look that somehow sweeps up from under eyelashes. It is almost impossible to imagine those same signals coming from a masculine body. Yet Martha has not had surgery. Hormone treatment has given her breast development, but from the waist down she is still male. She suffers from diabetes and is uncertain whether surgery is going to be physically possible. It depends on her mood how she feels about her incongruous body. "Sometimes it can be hilarious; sometimes it can be painful."

Gallows humour. Martha has had the same suicidal tendencies as many other transsexuals, made the same desperate efforts to conform. She works in radio communications for the police and is an executive member of the National Transgender Police Association. It is not uncommon for transsexuals to gravitate to uniformed service and macho environments to try to 'cure' themselves. Martha married in 2001 and divorced three years later, but had been with her partner for ten years. They worked in the same place, and though the split was acrimonious, Martha asked her employers for as much protection for her ex-wife as possible. "She hasn't spoken to me in almost four years. I don't think she knows who I am. My whole appearance has changed, my whole demeanour."

When she confessed to cross-dressing, her partner had asked her not to do it. Martha complied until a few months before the wedding, when it all started again. She just needed to get it out of her system, she said. But in all those years she conformed, she was filled with an anger that is difficult to reconcile with the reserved woman she seems now. "I was just an angry person. With hindsight, I can say it was about how I felt about myself, but at the time I didn't really know what was causing it. I was terrible with my mum and dad, always in a strop. My ex-wife would probably say the same, that I was angry to the point of brutal."

It was listening to a transwoman on a police training course that sparked off her own transition. "I sat there and went, 'Oh my God.' Her story was very similar to my own. I was diagnosed with severe clinical depression, and that's when I started to explore myself and my feelings more fully."

Martha would go home and drink whisky until she really ceased to function. "I remember the doctor saying, 'I think you're depressed, can you tell me what the problem is?' I just cried. Even then, I didn't want to acknowledge it."

If it can be a struggle for transsexuals to accept themselves, it is also a struggle for those around them. Martha's sister hasn't spoken to her since she transitioned, and while she is close to her mother, they only talk on the phone. Her mother has seen her only once as a woman and never wants to again. Her father still comes to see her but insists on using her masculine name. "I can't really say, 'Can you stop doing that,' because I suppose for him I will always be a son. I guess I can maybe see that point of view. I don't hold it against them. I don't say, 'Why are you doing that?'"

If she does have surgery, will she feel a moral obligation to risk more rejection and tell prospective partners? Not necessarily. "But if I felt it mattered, yes. It depends how many vodkas I've had!" Now in her 30s, relationships are restricted. "If I need companionship and can't attract a man because I have the wrong plumbing, and can't attract a woman because I have the wrong plumbing, there is a whole subculture of transpeople who'll be attracted to me. I'm a strong believer that appearance is secondary to the person."

IT'S THE USE OF the word 'subculture' that really hits home. Martha waiting for her male genitals to be removed; James waiting for his male genitals to be added; Julia saying she has found peace but not partnership. Their struggles, their resilience, their courage make them deserving of a love that has so far eluded them. It might always elude them. Socially, people might be happy to accept their chosen gender. Sexually? They are stuck in Martha's 'subculture'. Even the surgery that is meant to define them often defines only their difference to other people.

The Sex Discrimination Act and the 2004 Gender Recognition Act protect transsexuals both in the workplace and in society. Legislation is crucial. But legislation can't govern the laws of human attraction, or make your mother or your sister or your son not just love you, but love you enough. Gender dysphoria is a brutal conflict to resolve. Being true to the gender you feel yourself to be can make you less authentically male or female to other people.

This is underlined after the interviews. There's a late-night phone-in on the car radio about nightmare blind dates. A male caller says that, for a laugh, his friend once set him up with a dinner date who confessed 'she' had once been 'he'. I shift uncomfortably at the presenter's forced laughter, thinking of Martha and Julia and James.

We all want to be loved for who we are, but the fact is that we are also loved for what we are. When what we are is somehow in doubt, it means a lifelong struggle for acceptance.

"So what did you do?" the presenter asks.

"I made my excuses and left," said the man. r

Dr Lyndsey Myskow (0131 225 5656, www.medicalternative.com); Gender Trust UK (0845 231 0505, www.gendertrust.org.uk)