How can trans women trans men have sex

How does sex with new gender work?

Berlin - Trans- and intersex people are often so suffering that they have to seek psychological and medical help. Hannes Ulrich, 42, is a psychologist and sex therapist. He works at the Institute for Sexual Medicine at the Charité. There he offers therapy for people who have problems with their gender or who are between the sexes. We meet in one of the institute's consultation rooms for a conversation about transsexuality.

Dear Mr. Ulrich, what actually makes a woman a woman, what makes a man a man?

We could philosophize about it for weeks. Even people who describe themselves as intersexual or transsexual cannot answer that correctly. One has to differentiate between biological gender, gender identity and gender role. The gender roles - what is considered to be typically male or female - defines society. But identity comes from within. And if that is not correct, we are talking about gender incongruence.

So, with transsexuality, is it about the body conforming to the identity?

Exactly. It's about identity, not aesthetics. One patient did not come to us until he was 45 years old. He knew from childhood that something was wrong with him. He was going through puberty and breasts were growing. He found it so repulsive that he tied it off. He couldn't look at himself in the mirror. Nobody has seen these breasts for 30 years. He was socially withdrawn, thought he was crazy. Then he saw a TV report about transsexuality. And immediately knew: this is me. He later had his breast surgically removed. He came out of the hospital with fresh scars. The first thing he did was lay down on the beach. Arms up, chest out. He felt sublime.

Transsexuality is becoming more and more present. Can one speak of a trend, maybe even a fad?

These terms are a slap in the face for those affected: Should my suffering be a fad? It is true that more people are coming to us wanting gender reassignment measures. Mainly because it has become more socially acceptable. The stigma has decreased.

What numbers are we talking about?

We assume 0.3-0.6 percent of the population.

How many of the people who come to you are really transgender?

About 90 percent. The self-made diagnoses are accurate. But we are also responsible for the ten percent for whom the diagnosis is incorrect.

If someone wants to “transform”, how is the process, which authorities have to agree?

According to the guidelines of the health insurance companies, a therapeutic reflection process should take place first, i.e. at least twelve sessions within six months. Then an indication for hormone therapy is made. That's what a psychotherapist does. If a sex reassignment operation is to follow, you have to wait at least another six months.

So, someone like you is the instance?

Yes, but I don't want to be a hurdle. I see myself as a supporter. I am trying to find out how the stress of suffering can be reduced. And I prepare the patients for hormone therapy, because the wishes are often utopian.

How utopian?

A biological man will never become a perfect woman, even if we are medically very advanced. In the case of trans people, it is always an approximation. And every medical intervention is associated with risks. People need to know what they are getting into.

What are you getting into?

Hormone therapy is a second puberty. Emotionally things are often haywire. If you have to justify yourself to your parents, friends, at school or at work in such a phase for not including them, it can lead to people regretting this step, even though it is actually the right one.

Does that happen often?

In one to three percent of the cases. There is a trend of hormones being prescribed much faster than the guidelines suggest. There are institutions that disregard the guidelines. They say that identity does not need a diagnosis. There are general practitioners who write prescriptions for hormones simply because they want to help trans people.

Of those who do hormone treatment, who decides to have sex reassignment surgery afterwards?

Trans women go on. Mainly because it's easier to remove the penis and build a neovagina. When a trans woman goes to the gynecologist, the first time he does not see any difference. When building a neopenoid, on the other hand, skin is removed from the forearm, the urethra has to be lengthened and it often leaks. You have to build in an erectile tissue, but it doesn't work naturally, but via a built-in pump that is connected to a water basin in the abdomen. By applying pressure to the pump, water is fed into the artificial erectile tissue. The penis straightens up.

But that has nothing to do with sexual arousal?

This is purely physical stiffening. It doesn't look natural either. That is why many trans men decide to go on living with their vagina, with their "front hole".

What about trans women’s sexual experience?

Orgasmic experiences are possible for trans women and men as well, whereby the sensory system is much lower because nerve cells are destroyed by the operation. But the subjective experience is sometimes more intense because I experience it with a genitalia that fits my identity.

Why do trans people have such a need to immerse themselves in the gender role paradigm to insert?

This gives many people support, also because others will read you accordingly. But in the course of the therapeutic process it is reflected: What does a penis mean to me? Is a penis even important to my manhood? How do I want to live my sexuality? There is no one right way.

How many end up choosing genital surgery?

The scientific data on this is not good. Overall, around 75 percent of those affected opt for gender reassignment surgery, but this also includes mastectomy, i.e. the removal of the breast, and other interventions.

What role does sexuality play for trans people?

It is secondary. For most of them, it's about identity. There is also a great risk in this because sexuality is not initially reflected upon. Only when the pressure of suffering with regard to identity is gone does sexuality come. And then some realize: crap, I don't have a penis anymore, but I would like to have penetrative sex.

So whether you are sexually interested in men or women has nothing to do with gender identity?

Nothing.

How can you prevent wrong decisions?

Sexual preference is there. But it is often suppressed, although it shows up in the masturbation fantasies of all people, regardless of whether they are trans or cis. But many trans people don't masturbate because they reject their genitals and don't want to touch them. You can still encourage her to watch porn, for example, to see if she gets aroused when two women make out with each other, a man and a woman or whoever.

Are there people who regret gender reassignment and want to reverse it?

Absolutely. In retrospect, they ask the questions we would have asked them.

Are these people who weren't with you before?

We haven't had a case like this yet. But there are people who come to us afterwards. For example, those who reject their femininity because they cannot find a partner. I just have a case of a biological man who is attracted to children, i.e. is a pedophile. He finds it totally abnormal and has the feeling that it is a typically male problem. This is total nonsense. He's had a sex reassignment and is still heartbroken because nothing has changed in his sexual preference.

Do the health insurance companies actually cover all the costs?

Yes, even if it's still a struggle with nose and jawbone corrections. But that only applies to people who clearly assign themselves to a gender, not to people who define themselves as non-binary. If a non-binary person who is biologically a man wants to have breasts, then the health insurances do not cover any costs. We are not that far yet.

Interview conducted by Susanne Lenz.

This text appeared in the weekend edition of the Berliner Zeitung - every Saturday at the kiosk or here as a subscription.