A Paper to be Presented Before the Ethics Committee of the Harry Benjamin International Gender Dysphoria Association: Galveston, Texas, October 2001 by Dr Tracie O’Keefe DCH
NB Due to the war in Afghanistan, Dr O’Keefe was unable to attend the above conference.
The medicalisation of sex and gender variances under descriptions of pathology and dysphoria has, since the publication of papers in the early 20th century, often accelerated into the disempowering of clients who request contra-hormone administration. Many clinicians throughout the world are still today withholding such drugs beyond a time period which is beneficial to that client group. Those clients can at times be denied such requested treatment until they satisfy unobtainable goals or gratify the egos of the clinicians beyond what would be acceptable in other branches of medicine or psychology.
This client group, when applying to a clinician for such treatment, is in a vulnerable position and they deserve to be treated with the kind of reverence that any other group is entitled to. It would be unacceptable for a clinician to deny medication for chronic insomnia, insulin for diabetes, or drugs for cancer. Such clinicians’ abuse, whether intentionally or through ignorance, can cause phenomenal psychological and social damage to members of this client group, ranging from suicide, taking up crime to pay for illicit drugs, or driving a client to murdering their therapist through frustration.
It is now time for HBIGDA to re-address this matter by proposing a time limit for withholding such medication by implementing a new clause into the Standards of Care. Since the SOC recommend that a client ought not to be issued with hormones until three months investigation has been completed, then it would be only fair and humane to the client group for clinicians not to be allowed to deny hormones, if requested, after the first three months of treatment. I propose that the ethics committee support this change to the SOC.
Diane was 25 when she abandoned her role as a biological male living in Earls court, London, England, in the early 1970s. Because she was of Mediterranean physical type she had a heavy beard growth and did not pass well as a female in society. Most of the time she worked as a transvestite prostitute as that was generally the only work she could get.
Her coping skills were limited and she took to heroin and barbiturates to try and blot out the realities of her day-to-day struggle to survive. The psychiatrist she sought help from refused to give her hormone treatment for two years because he believed that until she found work other than in the sex industry, she was not a suitable candidate for sex and gender realignment.
Eventually Diane committed suicide by overdosing with sleeping pills, which she had bought on the street from a drug dealer. She had become so profoundly depressed that she believed she would never qualify for the kind of hormone and surgical treatment that she felt she so desperately needed.
Ted, a biological female, had heard so many horror stories about the kinds of treatment offered or withheld at his local Gender Identity Unit from people who had attended that he decided not to seek professional help. To the average person he appeared to be a young teenage man with short hair but he moved in the lesbian community and passed as a butch dyke. Others in the lesbian community referred to him as a dyke passing as male, even though he had not had any sexual contact with women.
After four years living in the lesbian community he contacted me in 1998 requesting help in confirming his secretly held male identity through hormone treatment and surgery. When asked why he had not sought help before, he said he had heard that it was really hard to get hormones from doctors who had the right not to give them if a person did not pass a whole barrage of tests.
At the end of the four years hiding in the lesbian community, he was heavily into cutting himself to such an extent that he had ended up hospitalised after severing a major vein in his wrist. He said he had not intended to kill himself but that the cutting helped him cope with the frustration about his identity. The psychiatrist at the emergency room had referred him to me and he had only attended under threat from his family to section him because of his cutting.
Victor, a biological female, had been prescribed masculinising hormones by a private psychiatrist, but after a time he ran out of money and had been unable to find work. In order to continue his treatment he went into an NHS programme at a gender identity unit in England in 1996. The psychiatrist who took over his case refused to give him hormones because he said that he would have to start all over again in that particular hospital’s programme and be reassessed. By this time Victor had been living as a male for nine months.
In desperation Victor took to shoplifting to generate enough money so that he could go back to continue his treatment with the private psychiatrist. He gained several convictions but the court was reluctant to send him to prison because of his physical status. Before the time he had needed the money to go back to the private psychiatrist, he had never been in trouble with the law.
Rose came to see me in 2000 after having been in psychoanalysis with an eminent practitioner for four years. At the beginning of the therapy Rose, a biological male working as an accountant in New York, had declared she believed he was a transsexual woman and wished to transition. The analyst did not believe that was the best thing for Rose and convinced her to get married and remain in analysis three times a week for four years to get to the roots of what the analyst called a deviation.
The analyst became firm friends with the client’s new wife and between them they convinced Rose that she would never get hormones or surgery without the analyst’s recommendation, and the analyst refused to do that. After an attempted suicide Rose took legal advice and severed all ties with the analyst and the wife, and left America.
After seeing Rose for three months I referred her for hormone treatment but the general practitioner at that time took it upon herself to inform the ex-wife what was happening and the psychoanalyst and ex-wife wrote to me threatening to get me struck off for treating the client against their wishes.
In treating clients who identify as having sex and gender dysphoria and those identifying as sex and gender variant, who want hormone treatment, the clinician is in an all powerful position, being the access point for the medication that those clients need, want or desire. Unfortunately far too often those clinicians have overstepped the mark of authority and denied the medication for reasons that defy reasonable and humane explanation.
Ultimately it must be the client’s decision how they need, want or desire to live the rest of their life, and after initial screening and advancing, the clinician should not be in a position where they may be able to project their personal philosophies upon an unsuspecting client. Clients who are denied hormones unnecessarily suffer damage to their physical, mental and social wellbeing.
When working with sex and gender variant people it is common to hear endless stories of people being denied hormone treatment for reasons of moral superiority of those treating them. This is often due to cultural difference, but because we are an international association we need to be guiding those who are afraid to treat clients for fear that they may be contravening medical guidelines.
I propose in this paper, that as a starting point for change, the ethics committee support the motion that a clause be inserted into the HBIGDA SOC (Standards of Care) which stipulates that a clinician, after seeing someone for three months who wishes to take contra-hormones, should not stand in the client’s way and should support them in taking on the identity that the client feels is right for them.