One size does not fit all in the transgender community.

RICHARD RASKIND HAD BEEN captain of Yale’s tennis team and enjoyed some success on the American amateur circuit. He went to medical school, became an ophthalmologist, served in the United States Navy, married, gained a pilot’s license, and competed in the US Open. Then, at age 41, after 10 years of psychoanalysis and a divorce, he underwent a sex change operation and emerged as Dr Renee Richards.1 Renee Richards moved to California and joined a new medical practice. But when she was recognized playing in the women’s section of a local tennis tournament, the press attention became overwhelming. At this point, she decided to become a professional tennis player, on the women’s tour. When several women pros complained of what they thought would be unfair competition, the resulting fracas was only settled by a 1977 New York State Supreme Court decision, ruling that, because of her sex reassignment surgery (SRS), she was indeed legally a woman.2 Richards went on to reach the women’s double finals at the 1977 US Open. She returned to a career in pediatric ophthalmology in New York and still serves on the editorial board of the Journal of Pediatric Ophthalmology and Strabismus. “I am quite happy with the way my life has turned out,” she recently told Elizabeth Fee. “I made the decision after a lot of soul searching. Hopefully, with the progress being made in psychopharmacology, such drastic moves as sexreassignment surgery will not be necessary for everyone.” In 1999, she gave an Associated Press interview in which she said, “I wish there could have been an alternative way, but there wasn’t in 1975. . . . Today there are better choices, including medication, for dealing with the compulsion to cross-dress and the depression that comes with gender confusion.”3 People who have undergone SRS vary in their satisfaction with the results. Some Web sites contain warnings “for those considering MtF [male-to-female] SRS,”4 warning, for instance, of reduction or loss of sexual feeling and appetite, for both emotional and anatomical reasons. SRS may sever nerves in an area where nerves are essential to sexual arousal and response, although surgical techniques continue to improve. Some male-to-female transsexuals who go through SRS experience problems because, after the operation, they still possess masculine facial features despite the obvious feminization of the rest of the body. Although facial feminization surgery can address this particular problem, such procedures may cost upwards of an additional $30 000. But surgery should not be regarded as the gold standard for all. Indeed, the example of Renee Richards is but one specific case in a continuum of responses to “gender dissatisfaction” that both men and women may experience to a greater or lesser degree. Counseling for “gender dysphoria” should help each individual clarify what troubles him or her, what he or she wants, and what steps, if any, will help him or her get there.5 The medical, surgical, legal, and emotional issues involved need expert interpretation, including the odds of achieving what one seeks, exploration of the risks and practicalities involved, and the likely financial and legal consequences. Counseling requires skilled professionals who can integrate detailed and accurate information with psychological skill and sensitivity. Legal requirements for SRS as a condition of changing one’s gender need to be carefully reexamined. Overall, encouraging a greater diversity of transgender options seems the best policy for the near and more distant future in terms of increasing the success rate of transgender care and expanding the possibilities for human happiness.6