A person whose manner of speaking has been set for some time past and who wishes to speak in a different way needs to develop greater flexibility of the vocal organs and the lungs, both in order to loosen the set way of speaking and to acquire the new way. Thus, exercises are necessary as a first step and should be continued until the new method of speaking has been perfected. The flexibility obtained in this way should also enable the speaker to alternate easily between the new and old ways of speaking.

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The first time I saw my forty-one-year-old daughter, Geraldine, she was being wheeled into a hospital room after major surgery. She was hooked up to intravenous tubes and was barely conscious. When her doctor assured me that she was going to be fine, I was very relieved. But in spite of this good news, it was a day of mixed emotions for me. You see, when my daughter, Geraldine, went into the operating room a few hours earlier, she had been Gerald, my son. Geraldine is a transsexual, a person who believes he or she is the victim of a biological mistake and is trapped in a body that is incompatible with his or her real sexual identity. Because they are so unhappy, some transsexuals choose to undergo a sex-reassignment operation, as my daughter did. I know this is hard to understand. However, I now accept what Geraldine did and why she did it. When I look at her today I see a content, self-assured woman. And when I compare her with the very troubled man she used to be, I believe she made the right decision.

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Sex steroid treatment is associated with side effects. The number of deaths and morbidity cases in 425 transsexual patients treated with cross- gender hormones were evaluated retrospectively and compared with the expected number in a similar reference group of the population. The number of deaths in male-to-female transsexuals was five times the number expected, due to increased numbers of suicide and death of unknown cause. Combined treatment with estrogen and cyproterone acetate in 303 male-to-female transsexuals was associated with a 45-fold increase of thromboembolic events, hyperprolactinemia (400-fold), depressive mood changes (15-fold), and transient elevation of liver enzymes. Androgen treatment in 122 female-to- male transsexuals was associated with weight increase >10% (17.2%) and acne (12.3%). In both groups persistent liver enzyme abnormalities could be attributed to other causes than sex steroids (hepatitis B and alcohol abuse). Much of the morbidity was minor and reversible with appropriate treatment or temporary discontinuation of hormone treatment. Thus, the dilemma of prescribing cross gender hormones in view of the needs of these patients is not resolved. Explanation of possible side effects and careful clinical judgment remain the cornerstone of the clinical decision to prescribe cross- gender hormones. Furthermore, follow up of this relatively young population to disclose long-term side effects and to elucidate the association of sex steroids with coronary heart disease, as well as efforts to reduce the risk of thromboembolic events, are required. Transsexual seek to adapt their bodies to the opposite biologic sex to which they perceive themselves belonging. Hormonal treatment plays an important role in this process.1 Ideally, the given hormone treatment should suppress the secondary sex characteristics of the original sex, as well as induce those of the opposite sex to the fullest extent and in the shortest possible period of time. Therefore, there is an inclination to maximize hormone dosage, which may involve health hazards.

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