By Dr Tracie O’Keefe DCH, published in Transgender Tapestry, Spring 2003, Issue 101
I remember the famous English woman of transsexual origin April Ashley saying to me: “I just don’t understanding it, darling. All those professionals are just poking their noses in your business. In my day you just took hormones, had an operation, and that was it.” April, as anyone who knows her will tell you, has always been quite an individual in her own right. Because all her life she has had to be a groundbreaker, she took a lot of flack from many of us, so she had to create her strong survivor persona.
Of course there have been many people who have adjusted their sex and gender identity with minimal professional help and done very well in their lives. However, for most people who undergo some kind of sex and gender transition it can, at times, be extremely difficult, confusing, isolating and overwhelming. The truth be told, even April when she was barricaded in above her restaurant in London’s Knightsbridge hiding from the press, could probably have done with some help.
Professionals caring for sex and gender diverse people have to be very sure that when they put their names and signatures to a referral within their clinical practices it does not backfire and haunt them at a later stage. There have been several court cases against surgeons who have performed sex and gender realignment surgery when that person has changed their mind later. A lawsuit for negligence can ruin a professional’s reputation, stop them from helping other sex and gender diverse people, bankrupt them and put their family out on the street, ruin their life and may even stop them from practicing. It is right and proper that all the professionals helping sex and gender diverse people be sure that what they are assisting their patient/client to do is the right thing for that person. Caution and consideration have always been my bywords as a professional therapist, fashionable or not.
There have been many suicides of people who have made some kind of transition and found that life in a different sex and gender identity they were assigned at birth was too much for them to cope with. The issues facing them have not been carefully gone into in therapy and they believed that the transition would solve all their problems – not so.
There have also been cases of intersex people and other sex and gender diverse people who have committed suicide because of what has been done to them by professionals, without their permission. Many suicides have occurred when a person has undergone surgery because of the advice given to them or pressure has been put upon them and/or their relatives to carry out treatment, whether psychological or surgical. This has happened sometimes when the person was a child and sometimes when they were an adult.
So it is a fine power balance that must be sought between people who are sex and gender diverse and want, need or desire to alter their physical, psychological, and social identity or bring them in line with what would be comfortable for them, and the professionals who can help them. In different cultures, that power balance translates differently through tradition and varying intellectual and social equations.
For me as a psychotherapist I enter into a power sharing relationship with the client where we try to help the client find the best way forward for them. I try not to set myself up as gatekeeper to stop anyone doing what they want to in life with their body, mind, spirit or extended life. I believe it is not my place to ever tell a person what they are. I don’t live in their bodies, look out of their eyes or feel what they do and I also won’t have to face the consequences of their action. I try to think of myself a hat-check attendant – I just hold their coat while they figure things out. I might point people in a direction where they can find answers themselves, but I try not to shove, push and never prevent them.
I am a great believer in holding people responsible for their own actions. I always tell people we will talk and talk a great deal, though at the end of the day it is your decision and you can choose. If you get it right, the glory is all yours, but if you do get it wrong that’s also down to you. I refuse to take the responsibility of choosing for my clients. Even clients who have many emotional or social problems can be given the freedom to choose. It’s not that I’m a coward, just a facilitator. If some has a mental illness, then that is entirely another scenario, but the majority of sex and gender diverse people are quite sane, given the chance.
When I write a referral for hormones or surgery I do not say what the person is, just that they have told me what they think they are. My observation is simply that they seem to have explored their issues sensibly and reached some kind of rational understanding of their situation.
Medicine, psychology, and social work are, however, often shrouded in mystery and secrecy. The wishes of the person who is the central component – the patient/client – are often left out of the decision-making process or ignored purposefully. The hierarchy of knowledge and access to services can so very easily be abused by professionals, even though that is not always the intention. Ignorance on the parts of the professionals involved is generally the cause of such abuse.
In addition, there are a group of professionals, who for the sake of their own egos or fear of being sued, do not let their patients or clients make decisions of their own free will. These clinicians I see as being highly dangerous to the health of their clients. They generally belong to the old school of medicine, see themselves as godlike figures and believe they know better than the rest of us. They will protect their power bases at any cost. One of my great friends who is Native American described them as forked tongued. “Is their mouth opening when they speak?” she asked me. “Yes,” I replied. “Believe at your own risk,” she proclaimed. “They used to have rifles, now they have letters after their names. They are the worst kind because at least when they had rifles you knew when they were going to shoot you.” Science and research are the new religions and demigods…pay your money and take your chance.
I remember, at an international conference on gender dysphoria in 1994, sitting next to a psychiatrist who told me that he treated his patient with the Bible. Being a confirmed atheist, I wondered what he did with it. Get them to sell bibles so they could pay for their surgery? Nothing so harmless I’m afraid. His idea of treatment for gender dysphoria was to make them recite passages from the Bible in his office. He told me he was the leading authority on gender dysphoria in his country.
In 1999 I witnessed several clinicians blatantly lie about the statistics from their clinic. One of them also tried to publicly attack me and embarrass me because a patient who had come to me begged me and others not to send them to him. Some patients told me that when attending his clinic they were refused treatment unless they took part in a research project.
When I came to Sydney in 2001 I met some clinicians who were still trying to deny that transgenderism is a reality and believe everyone should fit stereotypical transsexual profiles. They could not get their heads around the idea that someone may just want an orchidectomy or to have their breasts removed. Choice can be just as legitimate as necessity, but that was not pathology, so they could not accept those concepts.
So what am I talking about? Well, I am talking about removing the need to pathologize people if they wish, need or desire to alter their sex or gender appearance. That of course would mean changing the name of the Harry Benjamin International Gender Dysphoria Association from using the phrase “gender dysphoria” and replacing it with something like “sex and gender diversity”. Ideas like these are very popular with many members of the sex and gender diverse community. Many of them are even members of the HBIGDA, but they are afraid to put their name to such a motion until the present-day ruling faction of the HBIGDA indicate that it would not be upsetting to key members.
There is a counter argument, however, to taking that route. Some people propose that such a name change will give the insurance companies a let-out from paying for treatment because they will argue that the treatment is elective and/or cosmetic, and not a necessarily life saving. The same is also said of government funding for such treatment and surgery. Also, people who have not already had surgery become nervous in case the funding could be removed, leaving them with very few options. When people need treatment they are often at their most vulnerable and financially disadvantaged.
However, women receive funds for abortions without having to be pathologized. Some women choose to have their breasts removed if they are in the high-risk cancer group without having to be pathologized. Men have vasectomies and circumcisions without having to be pathologized. So why should people who are sex and gender diverse who wish, need or desire to change themselves be treated differently from the rest of the human race?
Some of you reading this will have heard before about clinical abuse by professionals. I wish I would no longer have to write about such things, but such abuse is an ongoing occurrence within the world of those who set themselves up to treat people who are sex and gender diverse. Writing such things has made me very unpopular with many other professionals who would prefer these sort of matters were buried and never came to light, and this includes members of HBIGDA. Although clinicians say they do not consider transsexualism and sex and gender diversity a mental illness, a vast percentage of people being treated who are sex and gender diverse are indeed treated as if they are mentally ill.
When at the 1999 HBIGDA conference I spoke of such abuse, board member Leah Schaefer asked surgeon Michael Brownstein to form an ethics committee. I attended the first meeting of that committee around a dining room table in London and it was said it would set out to do great things. Certainly a code of ethics was wheeled out, which to be honest, could have belonged to any professional association, but it has never been implemented.
In the latest HBIGDA newsletter for members it was announced that the ethics committee had been reduced to being an educational committee. Ethics committees are not set up to be educational, even though that may be part of their criteria. They are set up to tell members of professional associations how they must and cannot behave. They are regulatory bodies that assure the public that their members will behave in an ethical manner.
When I asked that committee to support a motion that clinicians should not be allowed to withhold treatment after a three-month assessment period, I was told the committee did not want to get involved with controversial issues. This proposal went down like a lead balloon and members of the ethics committee ceased to communicate with me. The reality is that, in my opinion, at the moment the ethics committee is little more than window dressing.
In fact, I was excluded from that committee without ever being informed, and I only found out when I received the latest HBIGDA newsletter. I asked Michael Brownstein to be placed back on the committee but was refused. The ethics committed has been reduced from around 20 members to a select three, or maybe four as I was told by president Eli Coleman. But it has been made clear that in no way was I allowed to be the fourth, even though I also represented many views of the gender community, as well as being an experienced clinician. What I was also told was that no one can sit on the HBIGDA committees unless the board approves them – so much for democracy. I am aware that some members of the HBIGDA hierarchy consider me a live wire or loose canon and that many of my ideas threaten to upset their apple carts.
The old power base at the HBIGDA is diminishing and they fear their demise. Jamison Green, the trans activist on the liaison committee recently circulated an email that requested members to be more open and honest about the running of the organization. That is unlikely to happen at the moment until the HBIGDA is run predominately by people who are sex and gender diverse themselves, placing many of the old school members in their place of service, not dominance.
There is no doubt in my mind that there is much transphobia within the HBIGDA based on the fear that the lunatics are taking over the asylum. Well, for those of you who are afraid, let me tell you that we the trans, androgyne and intersex people of the world are taking back control of our own lives. I have heard from some clinicians who do not want to be a member of the HBIGDA because of the way some members treated their clients. I personally have witnessed wonderful work done by many dedicated professionals who are members and they are clinicians to whom I would give medals if I had them.
The intersex community is deeply paranoid that they may end up being treated as badly as the trans community if they allow the central core of the HBIGDA to dictate treatments for them. I understand exactly where they are coming from. There is no doubt that the way some of the members are treating their patients/clients at the moment constitutes several violations of human rights. I do believe, however, that the HBIGDA is worth fighting for, but in an altered form from how it is presently run.
I personally may not survive that transition, since my bridges are well and truly singed with the current HBIGDA board. As I have said, there are many fabulous members of the association who treat their clients amazing well and who are prepared to listen to what sex and gender diverse people want. Of the clinicians in the world who are highly abusive to sex and gender diverse people, some of these are not members of the HBIGDA and some of them are. If the HBIGDA refuses to take responsibility for monitoring and directing its members, then it begs the question: why should anyone trust its members?
Its time for more big changes. First and foremost the name of the association needs gender dysphoria removed from its title, as it is no longer applicable for many people that professionals come into contact with. We are sex and gender diverse and the professionals need to catch up with the world’s sex and gender diverse communities – remember dinosaurs are a long time dead.
The HBIGDA must not only stand for ethical treatment of people who are sex and gender diverse, but also stand against unethical treatments of the very same. To do otherwise is less than professional and responsible. Turning up at a conference every two years and patting each other on the back was not why I joined the HBIGDA and certainly not what I pay my membership fee for. I want change and I want it now – my fellow sex and gender diverse peers have suffered enough.
If you have thoughts on or support changing the name of the HBIGDA, and/or wish to see clinicians prevented from withholding treatment, please write to me directly.