What could make you feel so ill at ease with yourself - so all pervasive that it affects your every thought, action and feeling? What if you are born one gender yet feel you are another? You feel it so deeply, that you will risk any and every change to achieve congruity between your true self, the self you 'know' yourself to be and your external 'self'.
The clinical term gender dysphoria refers to this fundamental incongruity between the hormonal milieu that shaped us in the womb and how we appear physically, on the outside. It's a quite profound aberration of self-image.
Enormous personal difficulty and social isolation may be risked for gender authenticity. There are no easy answers to gender dysphoria - individuals may choose to change their entire external world - social, legal, physical, hormonal to match their inner state. - this deep all-pervasive calling to be your true self takes enormous personal courage.
As a reconstructive surgeon I have had the privilege of meeting some remarkable individuals traversing across continents and cultures to change their external physical gender- deeply brave and deeply committed.
Perhaps as a society we have to decide which is the truest state of being, why do we have to be one gender or the other? Why such a binary division? What about simply accepting the myriad inter-states with no changes?
Self-image is a mental schema of self, which includes physical appearance, but also hope, dreams, personality. People vary considerably in how far they can change yet still retain a consistent sense of self. For others, changing the physical self are lengths they are prepared to go to achieve a personal image of wholeness.
As a plastic surgeon, I recognise the profound psychological dimension to my work - plastic surgeons we habitually suture back hope, wholeness, wellbeing. We are repairing self-image and for people with gender dysphoria this requires dramatic and deliberate change.
Society readily expects us to do this for the "deserving" as a moral and social good. The woman with breast cancer, the man with disfiguring injuries caused by a road traffic accident, the wounded soldier, the child born with a cleft lip and palate.
Society happily accepts the 'deserved' nature of reconstruction to alleviate suffering, fear, loss. We can justify operating for hours, meticulously reconstructing a life. The intense need to be 'whole' again, to feel complete and your 'self' is entirely understandable.
But what if there is no discernible pathology, no words like malignancy or metastasis, or risk? ...what if you are just not at ease with yourself - the true meaning of the word disease... Dis-ease.
It is then that society has struggled to balance moral and social good with the need for reconstruction of a new "self".
Slowly, as scientific research has developed our understanding of the biological nature of gender dysphoria, society has become more aware and accepting of the kind of suffering, fear and loss that trans people face - every bit as much as people who develop the physical pathologies of cancer, trauma or other disease.
Regardless of the motivation for surgery or the hoped for outcome, surgery always elicits, fear, anxiety, hesitation, It takes courage to seek to change yourself. There is no place for cockiness or conceit when you're in a thin hospital gown. Truly, there are no brave surgeons, only brave patients.
When I look at any patient, whether for reconstruction, gender reassignment or an aesthetic procedure, I see an individual on a difficult quest, their empowerment comes through knowledge, they are motivated, curious, searching for solutions. Their choices are brave and heartfelt. It takes will and determination to change from your old self to a new imagination of self.
The transformation can only ever be proactive, surgery is not a passive or light undertaking and the real change needs to be psychological and ideally preced any physical transformation.
The end of the transformation journey comes with recognition of your own true power - the power to self-actualise, to realise your potential, to find self-fulfillment.