By Dr Tracie O’Keefe DCH first published in June 1997. Reprinted in Sex, Gender & Sexuality: 21st Century Transformations by the same author, 1999.
The discourse of this paper is centred around the correctness of timing in the administration body-altering hormones to those people with GID syndrome or those who are expressing their less polarised gender roles. Here the GID is a diagnosis arrived at by the client with the assistance of a clinician from the psychological disciplines.
Since this syndrome is derived from the individual’s perception of their physical body being out of line with their mental and spiritual self-image, it can be deemed that it is a subjective experience and a form of dysmorphobia. Since the true aetiology of this disorder is not only unclear scientifically, but also in great dispute according to the perspectives of the diagnosing clinician, a common formula of cause and effect cannot be identified. At the time of writing of this paper the debate about the specific aetiology carries on internationally, with many factions not only disagreeing with but also opposing each other’s opinions. The nature or nurture question is not a consideration here.
When Dr. Harry Benjamin started to treat the prefemisexual, Christina Jorgenson, in the 1940s, he did not ask her whether she had completed a time living as a woman before he agreed to prescribe her hormones. If she had been living a woman, she would have been considered to be a transvestite, because the official interpretation of the male person living as a female is just that. At some of the major GID clinics throughout the world many of the residing clinicians stipulate that their clients must have lived in their desired role for a period of time before they agree to administer hormones. There is no research information to show that those transsexuals who live in role before being administered hormones fair any better than those who do not. An argument may indeed be put forward that the reverse can be true. Plainly the administration of hormones prior to the social, legal and employment change of identity can in certain cases make the transition easier when the time to change roles arrives.
Among those who agree with me on this point are consultant psychiatrist Dr. Russell Reid, the Canadian psychologist Randi Ettner PhD, the endocrinologist Dr Ettner, and the chair of the Gender Trust, Alice Purnell, who is also a counselling psychologist. Some clinicians at major GID clinics, who are forcing clients to live in role before they are ready are placing an unnecessary psychological strain on those people. This causes undue stress to a transsexual who may not physically pass well as a member of their desired sex and gender role to begin with. Counter-transference of the clinician’s expectations of stereotypical sex and gender roles causes the real-life-test to be in default because it is seen by the client as blackmail and not as a free choice.
It is true that many transsexuals present themselves to clinicians when living in their desired gender roles to request hormone treatment. However, this may not necessarily be the right, correct and proper course of progression for each and every client. It is well known that many transsexuals who present themselves for treatment have learnt what is known as “the script”: they have learnt what to say from other transsexuals and they go along and follow a pre-rehearsed performance piece for the clinician.
I have come across many cases where this has happened and the clinician has prescribed hormones and surgery without ever considering the real issues that may be affecting the individual’s decision. When this happens some clients regret transition after surgery. This type of scenario usually comes out of the very large GID clinics that make demands for clients to live in role before the prescription of hormones will be allowed.
I personally know of the suicides of several of the clients of one major clinician in the field who made unrealistic, overly demanding and cruel requests of his patients. Many clients who will live happily as complisexuals may be physically unconvincing in their appearance before the administration of hormones, which take them towards their destination sex and gender. Treatment can have dramatic effects on the appearance of a client and they need to be in control of their own situation with the help of the clinician involved and not under the threats of that clinician.
In fact, the control of the situation should be given over as much as possible to the client because if this does not happen then an over-dependency on the medical system often arises. On this point the American therapist, Napewastin–Schützer, agrees with me. Also, in Holland the gender team, led by Professor Louis Gooren, at the Amsterdam Royal Free Hospital, have a more flexible approach similar to the one I am suggesting.
In our culture there is an anomaly between males and females. For a female to live with the appearance and cultural dress code of a male in the Western world does not carry a great deal of scorn from the public, in comparison with what appears to be a man in a dress. Therefore the physiological and cultural differentials can be biased in favour of premascusexuals getting preferential treatment over prefemisexuals. In the administration of hormones to the gender dysphoric all clinicians must examine their own personal, subjective stereotyping of sex and gender identification.
There is the further consideration of the freedom to chose. The individual has the right to decide the fate of their own body. For the clinician the first consideration must be what is good for the client, but let us remember here that GID is not a classifiable psycho-pathology. Forty years ago homosexuality suffered from the same kind of social and clinical discrimination that GID presently does.
The rise of the transgender movement (those individuals who wish to live as neither male or female, or as both) is now changing the role of medicine in the treatment of GID. In all the caring professions at the end of the 20th century, the clinician’s function is moving towards helping the client and not just deciding their fate in an authoritarian manner.
Sarah Allwood-Muir was the British transsexual surgeon who in 1997 changed her role well after she had commenced hormone treatment. She said it was the best way for her to make the change professionally, since she was a prominent medical practitioner. The American eye surgeon, Renee Richards, in the 1970s did the same thing.
To force a client in a GID situation to wait until they are living in role before allowing them the medication they need is no less than cruel and only serves to bolster the ego of the clinician involved; it may not necessarily best serve the needs of the client.
Most clinicians in GID clinics see clients for less than ten hours before they recommend them for surgery, demanding that the client performs tasks that satisfy the needs of the clinician and not necessarily those of the client. I see people for a minimum of 25 hours, over a minimum period of 18 months, before I will recommend them for surgery. At least one year of that period prior to surgery does require the person to live and work in role.
I have never had anyone who has regretted the decision they made after spending time with me but I do have people who drop out of treatment along the way and return to their former identities. The weeding-out of those who are truly intent upon their course can be better done by offering the client sufficient time and space to explore their own issues and mind-sets; it should not be dependent upon their ability to model a dress or a pair of jack boots.
Hormones are readily available on the black market on the streets of London, New York, Hong Kong, Dehli, Barcelona, and all major international cities and to procure them is not hard for the GID individual. What is needed is more clinicians who will allow their clients to set the agendas, and who will not dictate to them. If the latter happens, it is likely to force the client into acquiring hormones on the black market, where the preparation they consume may be fake, unsuitable or dangerous.
I realise that some factions have criticised this approach by saying it is hormones on demand; however, that is not true. There are many people who I do not put forward for hormone treatment because I believe they have not thought through the issue of their proposed transition. When I recommend someone for treatment I am generally satisfied that they are perfectly serious about what they are doing and have considered it well.
In therapy, during the period prior to surgery, we look at the many pros and cons of what the client is doing but I never use this to prevent hormone treatment being given. A client needs to feel they can trust me to be kind, honest, empathetic, and be working with them towards gaining the maximum amount of happiness from life. I am not judge and jury, but simply the usher.
GID is an incongruency between body and mind, and the administration of hormones seeks to minimise or eliminate that inconguency. It is not a behaviouralist token economy reward that is given to a client who is good, but a medication that can ethically be administered to a suitable candidate for sex and gender realignment, who may have already suffered quite enough torment. It should never be withheld on the grounds of social role performance.
Glossary of terms used in this paper
A transsexual who is crossing the gender barriers from male to female, but has not yet undergone genital surgery.
A transsexual who is crossing the gender barriers from female to male, but has not yet undergone genital surgery.
Complisexual (transsexual) – either mascusexual or femisexual
One who has undergone the transsexual experience, now living in their desired gender role, having had genital surgery.
A person who belongs to one sex and who takes on the appearance of the opposite sex, sometimes taking hormones and having some surgery. However, these people do not undergo genital surgery and have no desire to be members of their opposite biological sex.
This is also an umbrella term used in America to cover the whole of the transcomnunity.