Not Treating Transsexualism

By Dr Tracie O’Keefe DCH, presented to the Northern Gender Dysphoria Conference, Gateshead, UK, April 1997

This may seem a funny title for a paper delivered to the gender dysphoric and their carers or even the ex-gender-dysphoric, if indeed, for some the issue of the dysphoria is gender, and not a matter of physiological sex. Further to this I shall question the fact that all patients who come into treatment, necessarily experience any dysphoria at all, and who instead may simply be transient and fluid compared with a statistical average that deems itself to be normality.

Over the years I have come into contact with literally thousands of people, who have at some time been unhappy with their sense of gender identity or physiological sex and one thing has become plain. Much of the treatment they received has consisted of two basic axioms: a possible physical metamorphosis and what professes,at times, to a be a form of psychoanalysis to determine the cause of their condition.

Unfortunately, many people who go through such dramatic physical treatment to bring their bodies in line with their own internal images of themselves, receive very little counselling to help them to acclimatise to their new lives after treatment. Just the other day I received a telephone call, from a colleague who is a psychologist. She had a patient who had just gone through gender reassignment treatment and was extremely depressed. My colleague, who is a well respected clinician in her own field, was horrified that her patient had been allowed to receive major sugery and hormone treatment without being prepared for her new role in life.

There are, of course, those clients who present themselves, categorically stating that they do not want any such interference from a clinician and all they want is hormones and surgery. However from the group that is now post- reassignment I have noted that a number of these ex-clients have gone on to live unhappily in their new roles; some have developed drugs or alcohol dependency, others have become obsessional or reclusive with few social skills, and still more common is the ex-client who becomes long term unemployed.

Further still I have encountered clients who have come to clinicians to ask for help in exploring what may be an appropriate route for them to take through their sex or gender life. After all, not everyone is male or female identified: some people identify themselves as transgendered and others as the third sex, that which is neither male nor female. These people have not been satisfied with the kind of reception they have received from clinicians who have set themselves up as experts in gender or sex issues. They have complained, that since they were not prepared to take a stance of being male or female, they felt they were left out on a limb without any form of collective identity or understanding.

So what is the differential that determines whether a post-operative or ex-gender or sex-dysphoric person w ill succeed in being happy in their new role or not? Here, of course, I measure success and happiness by the client’s own subjective measures.

Well, confidence seems to be the main factor and the confidence not just to be taken as their destination sex, but to be comfortable in the persona that accommodates the fluidity of their sex, gender and sexuality. Many of the most physically convincing transpersons(by heterosexual models) that I have met have not been happy after treatment, so it seems that merely being undetectable or “unread” as Kate Bornstien called it, is not enough.

Some of the most well-adjusted transpersons I have met have been quite open about their sex reaffirment, even thought they actually had no requirements to do so. This openness has now become more permissible due to the public’s changing attitudes to those who rightfully should be classified officially under the intersexes. Trans-education has certainly made it easier to transform in 1997 than it was in 1967 or 1977.

However, such emotional re-adjustments generally come about after much soul-searching and that process can cause a very large dent to a transperson’s ego. In short, all people who have undergone such a metamorphosis will openly tell you that, at times, it was hard and very damaging to their confidence. For the well-educated or well-heeled, who may have many resources at hand, the transition can appear easier, but this is not necessarily so. For the economically, educationally or emotionally disadvantaged, managing their condition, identity, confusion and fighting for personal peace can prove devastating.

What is desperately needed both in the private sector and in the British National Health System, including the major gender identity clinics is an expansion of the treatment they offer to include more counselling to the transient gender-dysphoric. Of course I hear the cry of “where does the extra money come from?” and that is an inescapable and realistic consideration; however it is not mine, because I am a psychotherapist – not an accountant.

It is plain that the “operate and hope-for-the-best” mentality in treating gender dysphoria does not work in a large number of cases. It leaves many of the ex-patients dysfunctional emotionally, socially and in the workplace. Perhaps it is time for those who take on the responsibility of being clinicians to re-evaluate the kind of treatment they are presently offering. To treat cancer by simply cutting off the affected limb is only a portion of the treatment that the clinician can offer and since that would not be acceptable to cancer patients, why is this “operate and hope-for-the-best” approach in transsexualism accepted as normal?

There can be an attitude amongt patients whereby they are almost afraid to talk of their worst fears or greatest aspirations. They believe that this might in some way disqualify them from a transformation programme, being perceived as trouble-makers and refused treatment. So these clients stick to the well- known script that neither deviates nor chall enges the form of the classical transsexual profile, thereby hopefully guaranteeing them the surgery and hormone treatment they may think they so desperately need. But the price of their not asking for more, for that extra help that they may need to be able to deal with life, post-transition, is sometimes high as they remain dysfunctional and fail to attain the happiness and success they sought.

Too many people are coming out of treatment believing they have either passed or failed as their destination sex. For some transsexuals it may be important to be legally, socially and privately accepted as their destination sex; however, for the clincian to collude in such a trial is to ultimately set their clients up for failure.

Now in 1997 things are hotting up, trans-people all over the world are communicating and comparing notes on treatment standards, political situations and the changes in the law to afford all trans fluid people their human dignity. The trans-community is beginning to challenge legislators, authoritarian physicians, and unegalitarian social pressures. So, as the seesaw tips in our favour and we consolidate a community identity of TRANSPRIDE, the psychologists, psychiatrists and psychotherapists need to understand that more ego strengthening would help the treatment programme be more effective.

The goalposts of male and female are no longer soley the issues that affect the trans-fluid community Whatever a patient declares themselves to be when they leave a clinic after treatment, they must have the confidence to defend their identity and not have to compromise their inner self to the ideologies of others’ outer selves. More counselling for each client who goes through a transformation programme should be an integral part of the treatment to equip them with that confidence.

Just the other day I arrived home from a nice holiday in the sun to find someone had written a derogatory posting about myself on the internet, citing me as being a “Self-confessed transsexual”. Their aim was to discredit me professionally because they object to some psychological research I am publishing. And their attempt failed simply because they showed themselves to be ignorant and prejudicial. Fortunately, I have the knowledge and confidence to stand up to their onslaught.

By not treating just the gender- or sex dysphoria and by implementing a more holistic approach to the trans-community, clinicians can then hopefully assist clients to become confident in whatever gender or sex role they identify with.