Gender Bender

By Esther Hecht
Jerusalem Post - Friday, May 8, 1998

"Although Dana International has successfully exploited her sexuality for showbiz fame, most of the country's transsexuals must struggle to find their place in society."

Three years ago, when transsexual singer Dana International gave a top-flight performance in the Eurovision Song Contest qualifying round but wasn't chosen to represent Israel, pundits said she lost out only because of her gender-bending identity. Now the popular dance-music performer is getting a shot at the international prize tomorrow night in Birmingham (see Time Out piece).

Optimists, including the flamboyant singer herself, like to believe her success heralds a new openness here to the right variety of human sexuality and gender. Israel's laws relating to homosexuals are among the most liberal in the world. Gay discos in the big cities are "in", especially for the straight crowd, and drag queens like Bnot Pesia have come out of the gay clubs all the way to weekly appearances on state-run television.

Dana International is the most visible transsexual in this country, but she is hardly alone. Fifteen Israelis have undergone sex-change operations since 1987 at Tel Hashomer's Sheba Hospital, the only one in the country authorized to perform the surgery, and four are scheduled to so in the near future. Many more, like the singer, have had operations at other hospitals, here and abroad. Yet others have chosen to live according to their gender identity without giving up the genitals they were born with.

Dana International speaks about her change of sexual identity in the most matter-of-fact way. But many transsexuals--those who are still experimenting with plucking their eyebrows or manicuring their nails (gestures the uninitiated wouldn't even notice) and those who have undergone the complex process of a full identity change--don't dare reveal who they are.

Bracha is one of them. So fearful is she of being found out that she agreed to be interviewed only by phone and asked that her real name not be used.

In a voice that is startlingly and unmistakable feminine, Bracha--today in her thirties--says she was only four years old when she began to sense that her male body was a cruel mistake. In her home in Europe, the boy lived in terror that someone would find out his secret desire to be a girl.

I was sure that if I ever let anything slip, everyone would know," she recalls. "I would fix in my head that something was a 'girl' thing, and I would stay away from it. For a long time I wouldn't wear white socks, because I saw my little sisters wore them."

The boy never felt he could tell his parents. Instead, they saw only the result of his pent-up frustration: uncontrollable rages. When he because religiously observant while in college, they saw this as yet another of his strange behaviors. When he married in his early twenties and decided to move to Israel, this was seen as even stranger.

One month after the couple arrived here, something snapped. He had thought marriage would help him live with his secret desires, but it did just the opposite. It was then he told his wife about his realization that "who I am is something I want, but what I am is a mistake. I'm not a guy with a mental problem, but a girl with a physical problem."

The couple managed to stay together for several years and have children. "I loved my wife, and I figured that by force of will I could fight this down," Bracha recalls.

Like other new immigrants, the young man enlisted in the four-month IDF basic training program, but was released seen after on medical grounds unrelated to gender. He even started studying for Orthodox rabbinical ordination.

But routine acts, like haircuts, revolted him. He hated shaving, yet he was also disgusted by how he looked when he let a beard grow, during the counting of the Omer, for example.

When he felt he could no longer live as a man, the marriage broke up.

Following their divorce, his ex-wife refused to allow him to see their children. It is a ban Bracha understands.

"It's difficult to explain to a child, and more difficult to a child you want to bring up religious." Nevertheless, she hopes to contest the ban someday in a rabbinical court, because she doesn't want her children to think, when they are older, that she was here along and didn't care about them.

Bracha says she has heard of couples who have stayed together while one of them was "transitioning"--going through the process of gender change--but this is rare. In the Orthodox world, it is virtually impossible.

And, for Bracha, it was an all-or-nothing decision. Changing her social identity without changing her body--as many transsexuals do--was out of the question, though, she confesses, "the idea of somebody changing their sex is as strange to me as it is to anybody else."

She turned in succession to a sex therapist, a social worker and an endocrinologist here but found them unhelpful. Nor could she learn much from magazines aimed at a transsexual audience. Today such publications are informative and sold openly in book stores, at least in the US, but at the time they were available only in adult book shops, and, Bracha recalls, "there was stuff in them that was pornographic. It made me feel very uncomfortable."

Desperate for help, Bracha moved to New York, where she started psychotherapy and then hormone treatment and began to live as a woman. She also experimented with her new identity in a transgender chat group on the Internet, and experience she says was very helpful. "You can be anybody you want, you can try out your personality, you can meet people from all over the world."

But it was only after the surgery that Bracha made another startling discovery about herself. Though she had become a woman in virtually every way, she found she was sexually attracted to women rather than to men. She became close friends with another Jewish transsexual woman and she met her first lesbian lover through the Internet.

Eventually, she returned to Israel a woman. The Interior Ministry says it does not issue a new birth certificate in such cases, but it will register a change in the ID card on the basis of a court order or on presentation of documents from a medical institution recognized by the Health Ministry.

Today Bracha works in the center of the country and lives in what she describes as "a committed relationship" with a gay, religiously observant woman.

Some people in the community suspect Bracha is gay. No one but her partner and her ex-wife knows she is a transsexual. Having grown up hiding her longing to be a woman, Bracha must now hide her former identity as a man. "Stealth"--the most extreme form of secrecy--is how she describes the degree to which she must conceal her sex change. At the same time, she revels in the success with which she has carried it off.

"There's an idea of 'passing,' but there's a level beyond passing--being a 'natural,' [so] even somebody else who is a transsexual might not guess," she says. "It's a very elitist thing. It's obnoxious. I'm guilty of it. Thank God I'm in a position to be guilty of it."

*   *   *

Unusual as Bracha's story is in the Orthodox community, it is similar in fundamental ways to others encountered by Dr. Ilana Berger, a lecturer at Tel Aviv University's Bob Shapell School of Social Work and director of the Israeli Center for Human Sexuality and Gender Identity, a private clinic in Tel Aviv.

Berger earned her doctorate in social work at Rutgers University and specialized in treating sexual and gender-identity problems at Cornell Medical College and the Albert Einstein College of Medicine, all in the US. In the year-and-a-half since she opened the clinic with Dr. Simcha Lazar, a specialist in gynecology and endocrinology at Soroka Hospital, its services have become known by word of mouth, attracting 20 active patients, some from as far away as Karmiel and Dimona. Others are in touch with the clinic through the Internet. Some are married. Many are in high-level positions, including doctors, psychologists, university professors and members of the high-tech industry.

Today, she says, professionals use the term "transgender" as an umbrella term for all people who in some way--secretly or in public, part of the time or all the time, in dress or in behavior--express gender feeling that doesn't match their anatomy, hormonal systems and genetic makeup. Only a small part of this group--those termed transsexuals--feels a need to live fully as a member of the opposite sex.

Precise statistics are hard to come by, but research over the last decade in gender clinics in Europe and the US suggests that between one and three percent of the population expresses some form of transgender feeling, Berger says.

They come from all walks of life, socioeconomic groups and ethnic backgrounds. They are both men and women, though men outnumber women by a ratio of three to one. And, Berger adds, the phenomenon has existed in cultures throughout history, though not all have viewed it positively. "It's not a consequence of liberal attitudes in the 20th century," she says emphatically.

Berger is quick to dismiss other myths about the transgender community.

More than 80 percent of the cross-dressers (also known as transvestites)--who assume the dress or behavior of the opposite gender--are heterosexual men who feel a need to express the feminine elements of their nature, but don't experience the intense conflict between identity and body that transsexuals do. "It's a myth that they are [all] gay," she says. This is easier to understand if one considers that gender identity (a person's sense of who he is) and sexual orientation (the people to whom he is attracted) are separate facets of a person's being, Berger says.

Nor are most transsexuals prostitutes, as is commonly believed. On the contrary, she says.

Why some people feel so out of tune with their bodies is still a mystery, but some research evidence points to biological causes. One such study, at the Netherlands Institute for Brain Research, in Amsterdam, was reported in Time magazine in November 1995. In autopsies, researchers compared the brains of six male-to-female transsexuals with the brains of a control group consisting of two dozen men and women who were not transsexuals. Half of the men in the control group were heterosexuals and half were homosexuals.

The scientists found no important differences, except in a section of the hypothalamus, called BSTc, that is responsible for sexual behavior and orientation. All the men in the control group, regardless of their sexual orientation, had a BSTc that was 50 larger than the women's. But the BSTc in the transsexuals was more like the women's than the men's; in fact, it was on average slightly smaller than the women's.

The findings are not conclusive, because the transsexuals had been taking estrogen for many years and this may have caused a change in the size of the BTSc (though another finding suggests that estrogen has no effect on its size).

In any case, the researchers said, the size difference they found may not be the only biological motive for the desire to change sex. Whatever the precise biological causes, a mismatch of the body and the brain probably begins in the early stages of fetal development.

There are several syndromes affecting sexual identity that have a clear genetic cause, but they are unrelated to transsexualism, according to Prof. Ariel Rosler, deputy head of the endocrinology department at Hadassah-University Hospital in Jerusalem's Ein Kerem neighborhood.

Rosler's team has identified the cause of one syndrome--familial pseudohermaphroditism--that transforms "girls" into boys at puberty.

The opportunity to study it arose when Rosler set up an endocrinological clinic in the Gaza Strip in 1977. In the 10 years that the clinic operated, it treated more than 80 cases, all of which turned out to be from a single, large clan with a high rate of intermarriage. The condition effected one out of 100 to 150 males in the clan and rendered them sterile.

Because they lacked an enzyme that stimulates the production of the male hormone testosterone, they were born with female organs and were raised as girls. At puberty, their bodies produced a small amount of testosterone that causes facial hair and male sex organs to appear, and their personalities began to change. The "girls" said that they felt attracted to girls and not to boys.

According to Rosler, the transition was a cause for rejoicing: "In this society males are preferred; they were happy." But the team had no Arabic-speaking psychiatrist to monitor and deal with the emotional aspects of the change.

Treatment consisted of hormones to boost testosterone levels and surgery to correct the sex organs. Children brought to the clinic at a young age were able to undergo the transition before puberty. After the genetic cause was isolated, doctors could identify the defect in the fetus and start treatment soon after birth. But Rosler says treatment has not been available in Gaza since the clinic closed, in 1987.

Though this defect is virtually unknown in Israel, Rosler says his department sees about 10 to 20 Israeli Jews each year with a variety of conditions that affect sexual identity. These conditions, he says, are "medical," as opposed to transsexualism, which he labels "psychiatric."

How complex the relation between gender and biology is can be seen in cases in the US, where doctors operated on infants whose sexual identity was unclear at birth, assigning them the sex they most resembled. Some of those children grew up angry and frustrated, because even though surgery had corrected the physical anomaly, their gender did not match the sex the doctors assigned them, Berger says. They are now suing the doctors.

"This sheds light on the gender-identity issues of transgender people, who are biologically normal," Berger says. "Gender is not just what you have between your legs." In fact, the diagnostic labels used to describe transsexuals are changing, and so, consequently, is the approach to treatment. Instead of referring to "primary transsexuals" and "secondary transsexuals," professionals now speak of early presenters" and "late presenters," depending on the age at which the person first sensed gender incongruity.

This is no mere window dressing, Berger says. In the past, professional persuaded youngsters considered to be "secondary transsexuals" to behave in accordance with their biological gender. "Some of the attempted suicides are a consequence of the professional telling [youngsters] what they should be or are, or what they shouldn't be," she adds.

The age limit at which treatment may begin has been eliminated in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV), the diagnostic bible of mental-health professionals. This means that the gender feelings of children can be acknowledged, though Berger says clinicians generally do not begin medical treatment before a child is 18. Her youngest patient is seven years old.

*   *   *

Though Dana International and Bracha speak matter-of-factly about the sex-change treatment and operation, it is actually a long, complex and highly regulated process. The protocol for the standards of care prepared by the Harry Benjamin International Society for Gender Identity, a society of professionals who treat transsexuals, requires at least one year of psychotherapy, two letters from mental-health professionals, hormone treatment, and living a full year in the gender they want to adopt (though some of these may be concurrent, Berger says.

The process normally begins with psychotherapy, an exploration of gender feelings that she describes as "very in-depth, very confrontational" and that can take a few months or as long as two years.

Trying out living as a member of the opposite gender and hormone treatment enable the person to start experiencing not only socially but physiologically what the other sex feels. The last stage is considering whether to have surgery, and if so, where.

For women, full-scale surgery entails removal of the ovaries, uterus and vagina, as well as breast tissue, and fashioning a penis. For men, surgery involveremoval of the penis and testes, enlargement of the breasts and creation of a vagina.

In Israel, people seeking surgery are usually referred to Sheba Hospital for evaluation by a medial committee that includes specialists in psychiatry, psychology, social work, gynecology, endocrinology, urology and plastic surgery. The evaluation takes a minimum of two years, Berger says. The operations are done in the hospital's plastic surgery department.

Sex-change operations have also been performed outside of Sheba Hospital, in violation of Health Ministry regulations that require evaluation by a media committee (Sheba is the only hospital that has one). According to a recent report in Ha'aretz, one such operation come to light when a woman who had always felt she was a male had the contents of her breasts removed, then changed her mind and sought to have her breasts enlarged. The report adds that some of the men who approached the Sheba medical committee for approval had already undergone breast enlargements at other hospitals.

There has been at least one case here of a botched sex-change operation, also performed outside of Sheba. In 1994, Tel Aviv transsexual Daniella Nahmias won a malpractice suit against plastic surgeon Dr. Roni Moskona in which she claimed the operation had made it difficult for her to urinate and had left her "asexual" and unable to enjoy sexual relations.

But surgery is often not the treatment of choice, and there is a growing trend in the clinical professional community to offer other solutions, Berger says. Some of her patients say they are unwilling to forgo the pleasure they derive from their anatomical sexual organs.

After surgery, transsexuals are still able to achieve orgasm, but they say it takes them longer and that the quality of the orgasm is different.

"But that's not the main reason they wouldn't undergo surgery," Berger says. What is most important for her patients is "the ability to lead a truthful life that expresses their essential feeling of being male or female." She encourages them to give up the either/or view of gender and sex and embrace a more pluralistic view. This will make life less confusing for them, she believes. But, she says, some transsexuals are just as prejudiced as the rest of society when it comes to gender and sex, "and will go the whole 100 yards, including surgery."

It might be expected that sexual minorities would band together to lobby for acceptance and equal rights, and in fact this has started happening in recent years in the US. It has not happened here, thought the attitudes of homosexuals toward transsexuals are starting to change, according to Dr. Diana Luzzatto, a lecturer in gender studies at Tel Aviv University.

In the mid-Eighties, when Luzzatto studied the ways in which Israeli homosexuals had organized to promote their concerns, she found that they distanced themselves from transsexuals. "Their main, declared goal was to be accepted by society, and there was still a criminal law on the books, so it was important for them to present a 'normal' image. Transsexuals didn't fit that image," Luzzatto says.

She adds that now that Israeli society has become more accepting of homosexuality, the gay community still has a problem with transsexuals. In just the way that veteran immigrants tend to view with disdain those just off the boat, homosexuals tend to maintain their recently acquired legitimacy by stigmatizing another sexual minority.

But there are other voices in the gay community, she says. Among the letters to Hazman Havarod, the gay monthly, debating Dana International's representing Israel at the Eurovision, some have expressed satisfaction. One, in the December 1997 issue, even expressed identification with Dana International by referring to Shas MK's objections as being grounded in homophobia.

But despite the popularity of the singer, of drag queens depicted in the movie Priscilla Queen of the Desert, and of Bnot Pesia, when it comes to real life, Israel society at large is hardly accepting of transsexuals.

Nor has Judaism traditionally been tolerant of deviations from clear gender roles, so it has had to consider situations in which gender is in doubt. Talmudic literature grapples with the case of the hermaphrodite (a person born with both male and female characteristics and organs), as well as the tumtum, whose gender cannot be determined. There is also a debate over the case of a man who sprouted breasts from which milk flowed, after his wife died and left him with a newborn infant. And long before transsexual surgery was readily available, rabbis were discussing the many implications of apparent changes of sex.

According to a review of recent Orthodox considerations of sex-change surgery by Yeshiva University Talmud professor J. David Bleich, in his Contemporary Halakhic Problems (Yeshiva University Press, 1977), the operation itself is forbidden--for women because sterilization is prohibited, and for males because it involves castration, which is prohibited. The Gemara (Shabbat 110b) derives the prohibition against castration (of humans and animals) from the verse, "And that which is mauled or crushed or torn or cut you shall not offer unto the Lord; nor should you do this in your land." (Lev. 22:24)

Even hormone treatment for purposes of sex change may forbidden because of the broad interpretation of the commandment, "A woman shall not wear that which pertains to a man, nor shall a man put on a woman's garment." (Deut. 22:5)

After a person has undergone surgery, there are many practical halachic questions, including who is an appropriate sexual partner, whether a divorce is necessary if the individual is married, whether circumcision is required (in the case of a female transsexual), and which religious obligations apply.

How these are resolved hinges on whether or not a change of sex is deemed to have occurred in the eyes of Halacha, for which the external organs are generally considered the decisive factor.

Bleich's own position seems to be that since gender is irreversibly determined at birth and since the substitute organs are not capable of reproduction, there has been no true change. But he mentions the dissenting view of Rabbi Eliezer Waldenberg, a judge in the Supreme Rabbinical Court in Jerusalem, who maintains that surgical reversal does effect a change.

Waldenberg's view in this matter is a minority position, according to Dr. Mordechai Halperin, a medical ethicist who is director of the Jerusalem Medical Center for Impotence and Infertility and also an ordained rabbi. Halperin sides with Bleich and adds that only if medical science were able to produce anatomically precise organs might there be room to consider that a change had occurred.

As Halperin sees it, the rule of thumb is that a person's subjective sense of gender does not make it permissible to violate a halachic prohibition. Thus, he says, prior to an operation a man who is a transsexual may not have sex with another man because sodomy is forbidden, and even after surgery it is not permissible because the operation has not changed the legal gender.

Can a transsexual contract a valid marriage? Bleich cites one source, the book Besamim Rosh, which says a man whose genital organs have been removed cannot contract a valid marriage as a man. Nor, Bleich infers, may a male-to-female transsexual enter a valid marriage as a woman, since there are no true female genitals.

Regarding divorce, Waldenberg has ruled that no divorce is necessary to permit the remarriage of a woman whose husband has undergone sex-change surgery. He argues that if the person in question can no longer contract a marriage as a male, this condition automatically terminates any existing marriage.

As for circumcision, in the case of a female-to-male transformation, it is clearly unnecessary, Bleich says. According to one source he cites, it would be unnecessary even if the new organ were physiologically similar to that of a male in every respect, since the requirement applies only to those who are male at birth.

Bracha, who studied in a yeshiva, was fully aware of the halachic prohibitions. "Halachically, I was wrong to transit," she says. She didn't ask a rabbi for a ruling, because if the answer had been negative, she wouldn't have been able to go ahead with the sex change.

"I look at it like this: It's forbidden to use the telephone on Shabbat, but if you life is in danger, you are obligated to use it. I was desperate. I had considered killing myself many times. I'd be dead right now if I hadn't transitioned."

As for her status following the surgery, she follows Waldenberg's ruling that she is now a female in the eyes of Halacha. This means not only performing the commandments to which women are obligated, but also reciting the appropriate morning prayer.

After years of having to bless God for not creating her a woman--"it was like swallowing broken glass"--she may now recite the blessing thanking God "who has made me in accordance with His will."

Copyright Jerusalem Post, 1998
Reprinted without permission