05 May Gender Dysphoria: The Need for a Global Transsexual Training Manual
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The need for a global transsexual training manual for healthcare professionals (from a relational and holistic perspective); education; better care services and a buddy system: a psychological point of view.
I have made a 20 year therapeutic journey working with people with gender dysphoria and their families; we need to think about removing Transsexual from the T of LGBT and start hearing what is being conveyed by transsexuals and people with gender dysphoria. There is an agonising need to encourage global and appropriate uniformity in the realms of research, understanding and care.
Whether you are a person with considerable experience of gender dysphoria; a person living with gender dysphoria or their significant other; a scholar/ student in healthcare services or an interested party with no other purpose than to understand this phenomenon, I hope that I have written this to be accessible and helpful. If you have little experience of gender dysphoria and you have difficulty with some of the terminology then please first go to this link to become acquainted http://www.nhs.uk/Conditions/Gender-dysphoria/Pages/Causes.aspx
I do not propose this to be a skilled academic piece and it is presented not as an exhaustive account of gender dysphoria but as a message to all concerned about my understanding of the journey made by my dearest patients over the years. It is a precursor to a book that I am working on and an outcry for meaningful and compassionate research.
My language has been targeted to be understood by all audiences. Writing an article on gender dysphoria that may help the reader, their loved ones and the field itself to move forward has proven to be one of the most difficult pieces I have engaged with to date. I find myself very respectful and protective, especially having been witness to people being victim to grievous brutality, unfair treatment on top of the extraordinarily trying issues they are attempting to navigate.
After 20 years (and hopefully 20 more years to come) of working with the issue, it is hard for me to remember exactly how I reacted or what I felt, or indeed thought, when I first came across gender dysphoria. The time at least is clear: I was in Edinburgh in 1990 and a person I knew distantly told me of an acquaintance that confided to her his cross-dressing and fears about gender dysphoria. My informant became disturbed as she was not sure what to make of it and had no-one to turn to and talk about it. Google was not available back then and neither was there a world-wide hub of information on the subject at our fingertips. I remember cross-referencing my search and finding that information from MedLit (medical based research) and PsychLit (psychological based research) contained much contradiction.
What I was learning about cross-dressing and gender dysphoria excited me: its aetiology (where it comes from) was not fully understood and there was debate over whether it could be a medical, psychological or psychiatric condition that is socialised, innate at birth or caught; its impact was also unclear. I have developed a deep felt respect for the life journey and challenges presented by these people and the bravery and civility they bring to the table, despite being not truly recognised by society. My difficulty in writing this piece has been around my own fears of not representing this population accurately or effectively enough.
In the present world of sophisticated medicine, global communication and space travel I believe that gender dysphoria is one of the most misunderstood medical conditions that exist. The public and professional confusion that still endures around gender dysphoria being a “choice” leads to the field offering “elective” medical treatment that is generally not covered on private or socialised healthcare (or offering only limited or ‘token’ services). This lack of education is helping to deprive people of social support, peer understanding, adequate healthcare, early intervention and ultimately the power to end biased medical provision.
I hope that in the future people will be amazed and disbelieving that people with gender dysphoria of the past did not seek help, going through so much of their life in torture, and how the public once naively viewed them. This is what we have to work towards.
Gender dysphoria is a condition where a person is born into the wrong body for their gender, and can affect both males and females (a male gender brain can be trapped inside a female body and vice versa). There have been many ideas about how this can happen biologically; examining the aetiology of gender dysphoria in detail, it is clear that the exact cause of the condition is unknown and there is worldwide and across-discipline debate. In the 20th century it was a common belief that gender dysphoria was a psychological or emotionally socialised issue. More recent findings tend to suggest that gender dysphoria has biological roots the pre-birth gender development cycle. An NHS bulletini on the biological effects of gender dysphoria describes this hypothesis as follows:
“Typical gender development
Much of the crucial gender development that determines your gender identity happens in the womb (uterus). To understand how gender identity can be affected by development in the womb, it is necessary to know how it normally works.
Your sex is determined by chromosomes. Chromosomes are the parts of a cell that contain genes (units of genetic material that determine your characteristics). You have two sex chromosomes: one from your mother and one from your father.
During early pregnancy, all unborn babies are female because only the female sex chromosome (the X chromosome) that is inherited from the mother is active. At the eighth week of gestation, the sex chromosome that is inherited from the father becomes active, which can be either an X chromosome (female) or a Y chromosome (male).
If the sex chromosome that is inherited from the father is X, the unborn baby (foetus) will continue to develop as female with a surge of female hormones. The female hormones work in harmony on the brain, gonads (sex organs), genitals and reproductive organs, so that the sex and gender are both female.
If the sex chromosome that is inherited from the father is Y, the foetus will go on to develop as male. The Y chromosome causes a surge of testosterone and other male hormones, which initiates the development of male characteristics, such as testes. The testosterone and other hormones work in harmony on the brain, gonads (sex organs) and genitals, so that the sex and gender are both male.
Therefore, in most cases, a female baby has XX chromosomes and a male baby has XY chromosomes.
Changes to gender development
Gender development is complex and there are many possible variations that can cause confusion between a person’s sex, gender identity and gender role. Some examples of the possible variations are outlined below. However, it is important to remember that these are not yet fully understood.
In rare cases, the hormones that trigger the development of sex and gender may not work properly on the brain, gonads and genitals, causing variations between them. For example, the sex (as determined physically by the gonads and genitals) could be male, while the gender (as determined by the brain) could be female.
This could be caused by additional hormones in the mother’s system or by the foetus’s insensitivity to the hormones, known as androgen insensitivity syndrome (AIS). In this way, gender dysphoria may be caused by hormones not working properly within the womb.
See the Health A-Z topic about Androgen insensitivity syndrome for more information about this condition.
Other rare conditions
Other rare conditions, such as congenital adrenal hyperplasia (CAH), and intersex conditions (also known as hermaphroditism) may also result in gender dysphoria.
In CAH, a female foetus’s adrenal glands (two small, triangular-shaped glands located above the kidneys) cause a high level of male hormones to be produced. This enlarges the female genitals. In some cases, they may be so enlarged that the baby is thought to be male when she is born.
Intersex conditions cause babies to be born with the genitalia of both sexes (or ambiguous genitalia). In such cases, it was recommended that the child’s parents should choose which gender to bring up their child. However, it is now thought to be better to wait until the child can choose their own gender identity before any surgery is carried out to confirm it.”
Even though we are not certain of why gender dysphoria exists several medical boards world-wide have deemed it a medical condition that is not elective, is innate by nature and needs to be considered as required (not elective) when considering medical and psychological assistance. This was a huge watershed for people suffering with this condition as it enabled research in the area to be funded and forced medical insurance companies and socialised medicine to fund treatments. The development also prompted government and policy changes: in 2004, the UK Gender Recognition Act was passed which allowed people with gender dysphoria to obtain legal documentation such as birth certificates and passports and go as far as marrying their partner of choice irrespective of gender.
Although, there have been immense developments regarding medical and psychological considerations around gender dysphoria, there are still issues, both at street level and in policy provision, in the UK, Europe, Australasia and the Americas. When it comes to a person “outing” themselves (explaining their secret to someone else), being “outed” (somebody explaining a person’s gender dysphoria without their knowledge or permission) or being “read” (third parties observing that they are transsexual), the average person on the street generally lacks knowledge about the condition and this tends to breed phobias, mixed messages and misidentification of the person’s journey in life. In terms of policy, socialised medicine still offers bare minimum services.
Due to the many variables that separate us all in our human experiences no two individuals with gender dysphoria experience the same journey. Having said that, there are some commonalities that do help us understand some general developments in a person’s socialisation, physical development and emotional and psychological reaction to experiencing frustration and discomfort with their given body gender. So, what is the “average” life journey as reported by people with gender dysphoria? Most people I work with explain that they knew they were different from the very start of cognition, around the age of 4 or 5. In general, they learnt quickly to keep quiet about wanting to play with the toys and games usually associated with the opposite, desired physical gender, and about wishing to be treated as a child with the desired physical gender. During this early time, school and home issues develop because of the sense of difference and wrongness they feel. A person with gender dysphoria developing both physically and emotionally from ages 4 to about 11 (or onset of puberty) can experience severe isolation and peer bullying as well as a difficult home life. Familial and peer attachments can be strained due to the person sensing they are bad or wrong in some way and even blaming themselves for all the bullying and isolation they experience. Their self-esteem and self-worth deteriorate rapidly and addressing this forms a large part of the psychological work I engage in when these people are adults.
Adolescence brings on more horrors for the sufferer of gender dysphoria. Sexual maturation can be difficult for any teenager but to understand exactly what a teenager with gender dysphoria has to work through we have to keep in mind their fear of being trapped in a body that is going to sexually mature. A person that is neurologically and soulfully in a physical body that does not match their gender report to me that they experience horror and self-loathing as their bodies course with oestrogen (If their physical body is female) or testosterone (if male), an extremely un-peaceful and debilitating time. They are helpless unless they seek help and they still have to deal with their existing social isolation and fear of “being found out”. They are probably being emotionally and physically abused by their peers and not understood by their caregivers and family; a tragedy for a soul’s journey through life.
So, what of adulthood for a person with gender dysphoria that is in the closet? A large proportion of the patients that have worked with me over the years are high achievers in some sense of the word. They explore how this channelling of effort to be the best at something was rewarding and made them able to negate thinking of their gender dysphoria and find positive opinion from peers, family and caregivers. All patients report how important it was for them to succeed in something that they and others viewed as worthy, as it helped lift their sense of the world to a tolerable state. Many patients reported to me that they abated suicide, self harm or self-medicating with drugs and alcohol because they had this success to hold onto, making life worthwhile. It was a part of themselves that was accepted.
During adulthood, a person with gender dysphoria may portray themselves as living a quite “normal” and publically “acceptable” life just as we are all socialised to believe there is a “right” way to live. They often fall in love, get married, live with their partner of choice (or not as the case may be), have children, hold down a job and, invariably, put huge amounts of effort into keeping this identity going. However, all of this is at the cost of being who they really are and what they so need to be. In addition to these activities that help negate their gender dysphoric feelings, most people with the condition help stay true to who they are by cross-dressing in private, role playing with self and/or others or otherwise creating a secret world they can visit to have a few moments of assimilating the gender they identify with. Being in adulthood and in the closet with gender dysphoria leaves us with the high probability that this person has experienced a lifetime of being socialised for the wrong gender. This gender training on how to act to be safe, loved, nurtured, cared for and accepted is a betrayal to their true, engendered life role. This socialisation, more often than not, promotes the person to grow feelings of guilt, self-loathing, hopelessness, anxiety and solitude.
There is no other medical condition known to me that has its sufferers feeling the need to hide their painful and, by its nature, destructive medical condition from their support network, including guardians and healthcare professionals. However, this is still the case in the 21st century.
Death rears its head hugely in my work with gender dysphoria. Sadly, suicide is a major issue whether completed or attempted. I cannot explain the number of times we receive a voicemail or call from a person wanting to see me for work with gender dysphoria and we find that they have taken their life before being able to make the appointment. I have always advocated to people attending transsexual groups or clinic sessions that they are the fortunate people that made it to support. From my point of view all these tragic life experiences and deaths are senseless and needless. The only way we can change the perception of gender dysphoria in the eyes of the public, our families and peers is to educate and be real about the life experience. Anyone, either personally or professionally, who states that gender dysphoria is a choice, elective, unnatural or a psychiatric or psychological condition needs to be educated about the life and times of those with the condition living in the 20th and 21st centuries. In addition to post-industrial, Freudian and medically driven ideas around gender and its aetiological roots, recorded knowledge from global tribal and folklore experiences would also help dispel common thinking about gender dysphoria. It is well documented that tribes and islanders of yesterday’s world treated people with gender dysphoria with respect and gave them responsible and blessed positions within their society; by publicising such behaviours and attitudes it may also expend some of today’s stigma.
Not all people that have explored their gender dysphoria have opted for gender reassignment surgery or hormone therapy. Sometimes, it is enough for a person to share their experiences and engage with that part of self they have denied for so long. Some people are entrenched within their world and feel that for various reasons they would not, at this time in their lives, necessarily feel benefit from adapting their physical body to match their gender. For others it is quite a different story.
Adults, by which I mean 21 years plus, decide they cannot manage their gender dysphoria alone any further for many different reasons and at very different stages of their adult life. I guess from my own experience working with my patients it is generally a significant life event, that has nothing to do with gender dysphoria, that makes a person shift and feel that they really need to do something about their issues and can no longer stay as they are. Such life events may be the death of a significant other; divorce; children leaving home; being discovered when in their secret place and state; experiencing desperate loneliness, hopelessness and suicidal ideation or a failed suicide attempt. What I am also seeing more and more frequent of late, is the person that attends for clinical work in their later years, about 55 to 65 years of age. A poignant feeling often communicated by this age set is that they were born in the wrong body and all they want to do is to be able to die in the right body so as to attain peace and wholeness. In general, the later year people coming to terms with their gender dysphoria do not wish to follow the surgical route although some do. However, they are rarely regretful about their life choices to date; many have children and grandchildren, have built up fond memories and accept that their life brought them to being who they are in this stage of their being. Regrets are discussed but amazingly they tend not to outweigh treasured moments.
People not wishing for physical modification to assimilate their gender and instead wanting to work on themselves and find peace are not uncommon. But whether wanting gender reassignment surgery or not, any clinician working with people presenting with gender dysphoria cannot make any rash decisions about the person’s wants and needs until some way into formulation and therapeutic goal making. Our therapeutic aims and ethical responsibility is to make sure that there is nothing else going on that could be mistaken for gender dysphoria such as body dysmorphic disorder (BDD), or a strong psychological reason that makes the person wish to move away from who they are. More and more common in recent years is for some people from the Jewish faith to present for gender dysphoria rather than homosexuality because Judaism tends to classify gender dysphoria as acceptable as it is viewed as a medical condition while they often will not accept homosexuality. It is our job in therapy to work with people to make absolutely sure they have gender dysphoria and understand that any surgery is not fully reversible; should there be other types of help that may benefit them more than work with gender, we help them get access to the appropriate services.
Sexuality and gender dysphoria
It may be an idea to dispel the myth of homosexuality, bisexuality and gender dysphoria. Are transsexuals really gay? The fact is that there is absolutely no correlation between gender dysphoria and sexuality. It is as random for the non-gender dysphoric population as it is for the gender dysphoric population. To give an example, on more than one occasion I have had female to male clients present to me, ranging from being in their mid-twenties to sixty years old, that have children, husbands or partners that they adore but need to change their body gender to match their soul or neurological gender. Some of these report that they are attracted to females; some report that they are gay men inside a female body and some are unsure. The male to females that I work with similarly tend to have partners, wives and children and can identify as being attracted to females or males or unsure. Some people need to be some way along the road of hormone treatment and gender reassignment before they can judge their sexual attraction; for some it seems to develop alongside their journey, while others are certain from the outset. I work with people that are in a conventional relationship of man on man, woman on woman or heterosexual and continue that relationship through gender reassignment and keep their love for each other strong and special. Other relationships do not make the transition and a period of adjustment is necessary. Still others sense that not transitioning and keeping their partners is their preferred choice given their personal circumstances. We have to bear in mind that people with gender dysphoria represent the population in general when it comes to sexuality. It seems that the gender dysphoria does not influence sexuality or vice versa.
The media is having various debates about teenagers electing to go along the route of hormone treatment and gender reassignment surgery. The main question is that of what age is considered to be OK enough to transition with parental consent? Recent studies into teenagers that have transitioned show that with careful clinical assessment (to eliminate other conditions as mentioned above) people that engage with gender transition at an early age have less issues with being physically read; have an increased sense of self-worth and go on to lead happy and well-adjusted lives. If we, for a moment, consider all the stages of gender reassignment there are umpteen points at which any person without a severe sense to put right what is wrong would opt out of treatment. Even the most desperate and determined people have some apprehension at one stage or another as it is a lot of work and a lot to endure, especially the initial real-life test.
Gender reassignment surgery, and the road leading up to being given the go ahead to have the surgery, is complex and a bit like the layers of an onion. Each stage brings with it joys, challenges and ultimately more peace. People don’t come out of the same mould; therefore each person undergoes varying degrees of treatment to get as close to what they need as possible. We can have female bodies that are petite or we can have female bodies with heavy distribution of female fat and breasts; small hands and feet and rounded female looking faces. There are also masculine traits to some female bodies; some have angular faces and noses assimilating more to the male body, with larger hands and feet; a smaller distribution of fat and smaller breasts. Once a female to male person, with the help of their therapist, decides upon gender reassignment there are choices to be made that are not elective but necessary to help that person become at peace with them selves.
For female to male clients, testosterone hormone therapy and dressing close to their male personality type is usually the first step towards rectifying their birth defect, which is what we generally agree to call this medical condition in therapy. The hormones tend to bring on a desired effect within a few months; the voice will deepen, facial and body hair will develop and fat will start to redistribute. In addition to physical change, mood change takes place: the testosterone can bring on mood swings and aggressive and/or assertive behaviour. Doses often have to be tweaked several times in order to help the person reach a balanced mood. Post hormone therapy, and when a successful real-life test has ensued, a psychiatrist will sign over to gender reassignment surgery which can involve some of the following: double mastectomy; full or partial hysterectomy; facial masculinisation surgery and/or penile implant or penile development using the person’s skin. Not something to go through lightly but when the person is assimilated to their comfort level there is no peace like that witnessed at that moment; being with a patient after their reassignment surgery is one of the most rewarding moments of my work. There are advantages for a female to male person, as they tend to achieve an excellent public appearance and are generally difficult to read. One downside is that sexual ability for a male transsexual body can have its difficulties as the penis is a complex organ. However, surgical work is getting better and more effective each year and usually an acceptable result is found for those undergoing this type of surgery.
Male to female physical assimilation is as complex as female to male. The first step is the hormone therapy and voice coaching; deportment classes are generally provided. Although the hormone oestrogen works extremely well at redistributing body fat, developing breasts and dampening or eradicating sexual urges, it does not affect the male voice. Voice coaching helps change the voice to a more feminine delivery. Oestrogen also gives the person in transition a calming effect, and the dislike for the penis and the sexual urges that bring attention to physical unrest tend to drift away. This hormone also induces mood swings but more in the nature of weeping and feeling overwhelmed and melancholic, all of which are embraced by the male to female as this is more where they want to be with their personality.