Transsexual (TS) is a subset of transgender, and refers generally to people who identify as a sex other than that they were assigned at birth. It is pathologised as Gender Dysphoria or Gender Identity Dysphoria, It refers to anyone who has a disjunction between the gender assigned to their body, and their gender of identity. As such, it is not limited to those who are transitioning. Children may be transsexual, though there are questions about the competence of young children to make that declaration. Certainly, many people who later transition report that they knew, and told others, that they "were really" another gender. Most often a transsexual identifies as male or female, and when speaking in terms of theory, a female-to-male (F2M) transsexual is sometimes called a transman, while a male-to-female (M2F) is sometimes called a transwoman. In point of fact, most transsexuals would refer to themselves as their gender of identity, e.g. simple as male or female. Note, that not all transsexuals identify as the member of a binary gender, though frequently but not always, those who don't may consider themselves transgender, rather than transsexual.
Physicality of Transsexuals.
Transsexuals are often perceived, and spoke of, in terms of clear gender binaries. The reality is often more complex, with at least some transsexuals being physically intersexed. This is often discovered after they decide to transition, since when intersexing is not obvious, the possibility is rarely investigated. An example may be when a transwoman discovers that she actually had some degree of AIS. Other TS people may have mosaicism, or other forms of intersexing.
Some researchers, and some transsexuals, consider transsexuality itself to be a form of intersexing. Researchers in the Netherlands believed the brain differentiates between male and female at about the 9th week after conception, and believed there is evidence that in transsexuals, the brain develops as one gender, and the body as the other gender (the so-called brain-sex theory). This would make TS a condition with a physical cause, rather than a psychological condition. Some transsexuals consider this the "reason" they are TS, while others are simply content to say that are TS and don't know why. The brain-sex theory has been challengedby more recent data. Other researchers in Spain continue to assert that there are real differences.
Transsexuality and self-perception
The most frequent cliché about transsexuals is that they are "a woman in a man's body" of "man in a woman's body". This might give some "quick and dirty" notion of the situation for mass consumption, but there is a more complex statement that the situation is a disjunction between the sense of self and the perceived reality of the body. Most TS people are not confused about their body, but have their sense of self telling them something else. While some may assert that their sense of self is right, many begin to doubt their sense of self in the fact of contrary physical evidence.
Sense of self is used here to go beyond "identity". It refers to all those things within that simply are. Things like knowing one has a preference for the colour red, and doesn't like broccoli. It is often unmediated by notions of logic, or conditioning. It speaks to our nature. In such a case, for a TS person who feels one gender, and perceives themselves to physically be another, the disjunction may leave one unable to trust one's sense of self. Yet to invalidate the sense of self is extremely painful and undermines all one's feelings. If one cannot trust the understanding of what sex one is, how can anything be trusted?
Unless one is strong enough to assert one's gender of identity as a child (and continue to do so), TS people often try to cope as their gender of assignment, and partially or wholly suppress the sense of self, at least in regard to gender. Frequently, at some later time this results in the situation becoming intolerable. A great many TS people report that their decision to transition came out of a crisis, a realisation that they cannot, and do not want to, continue to live without recognising their sense of self. A decision to transition, particularly among older people, is often the alternative to suicide, and many people have reported aiming a car at a cement pylon or tree as the event that precipitated a decision to transition.
Transition is rarely seen as unproblematic by transsexuals. Most realise that it will always be imperfect, an approximation, particularly for transmen, for whom genital surgery is problematic, very expensive, with results that are far from those desired. Transsexuals know they may face ridicule and rejection and many do, up to and including assault, rape, or murder..In committing to transition, transsexuals commit to adjusting the physical to correspond to their sense of self. Where this process has less than ideal results, there may still be some disjunction between sense of self, and perception of physical gender.
Note that this discussion has been in binary gender terms, with an implied notion of male of female in consistent terms. The reality for TS people is that understanding of gender is often more complex. As a TS transitions, the issue is not whether they are a man or woman, but what sort of woman or man they are. Self-perception evolves.
The transition process in gender terms
The transition process is generally medically mediated, which means transsexuals need not only to deal with their own gender issues, but with those of the medical profession, and those of specific treating doctors and psychologists. Very briefly, a transsexual may be able to get hormones from a doctor or endocrinologist, but the Harry Benjamin standards say any surgery requires a letter from at least one psychiatrist..Few medical professionals (both surgeons and psychiatrists) will actually deal with transsexuality, so a TS person is often limited in terms of who they can see, and must deal with the attitudes of those who do gender reassignment and of those psychiatrists who would consider granting a letter in support of such surgery. This is one of the most persistent problems reported during transition.
The few psychiatrists who will authorise surgery are often referred to as "gatekeepers". Almost all will require at least one year of "real life test", living as a member of the target gender, under their supervision, before granting a letter in support of surgery. Many psychiatrists are reported to have strong binary gender notions, and TS people are sometimes confronted and accused of not being "committed" to their transition unless they perform in conventional gender terms. It can be as extreme as demanding a transwoman only wear dresses or skirts, in spite of the fact that genetic women frequently wear pants. Thus, the gatekeepers may demand gender performance as a price for approval of surgery. There is a degree of game-playing that occurs, and it is seen as demanded by psychiatrists, even while they put up barriers because of game-playing.. The gender roles TS people may feel forced to perform are often not coming from their own understanding of gender.
Finding one's gender
Some transsexuals seem to go from one extreme to another, e.g., the male commando who becomes an ultra-fem in miniskirts. Many TS people find that the transition process can be a time of self-investigation in gender terms. As one lives as one's gender of identity, one has to fit into society and make choices, as any man or woman does, about what sort of man or woman one is. There are a range of roles. As a man one can be a sexist yahoo, serious and thoughtful, or a flamboyant gay boy or any other role one feels comfortable with. As a woman one can be a tomboy, a flirtatious femme. a feminist activist, or any other type of woman one wishes to be. There are as many kinds of man or woman as there are people. One finds one's own way. Of course, not all transmen can be dashing heroic types, nor can all transwoman be fashion models. Physical realities may get in the way. Of course, that is also the case for most genetic men or women.
It is also worth remembering that gender identity is not the same as sexual orientation. Some TS people find their orientation changing, other's don't. This means some TS people will go from apparently "straight" to apparently "gay" or "lesbian". Their gender performance (used in the sense that all displays of gender are "performance") may adapt to be appropriate for this. It occurs that some transmen may "be" effeminate gay men, or even drag queens, while for some transwomen they may see themselves as butch dykes.
Finally, not all transsexuals adopt a binary gender role, although they may start with that. There are TS people who identify as neuters, as eunuchs, as genderqueer. Some identify as transgender, or as transsexual, though that is rare. Such identities are usually taken on after transition, since few transsexuals have the goal of being transsexual, rather than male or female. Rather, identifying as transsexual usually comes about after being male or female, and finding that cuts out part of one's real identity.