Our expert says:
I attach my document that I call Venus to Mars, it is a VERY long process, before we even consider surgery. Call SA Sexual Health Association 0860 100 262 for a referral to a therapist in your area. The person in this country that I consider the best to deal with Gender Indentity Dysphoria is Mr Gareth Hunt. His office is in Sandton (011) 614 - 9859
My first task is to clearly differentiate between gender, anatomical sex and sexual orientation.
Gender is composed of both gender identity and gender role.
Gender identity refers to an individual’s perception of themselves as male, female or a combination of both and to a lesser extent, society’s perception and reaction to their outward presentation. Gender identity usually manifests itself through the presentation of gender role.
Gender role refers to the behavioural expectations based on anatomical sex that are placed on an individual by society. This would be, to a greater or lesser degree, what we think of a stereotypical male or female behavioural presentation.
A person’s gender is actually independent of their anatomical sex. For most people, their gender matches their anatomical sex and they rarely think about the difference between the two concepts. But when an individual’s gender does not match their anatomical sex and this disparity causes emotional problems, the person is said to be gender conflicted.
When this conflict is extreme and lasts for a significant period of time, the person is considered to be transgendered.
Anatomical sex refers to the presence or absence of specific genitalia and internal organs which identifies a human body as being that of either a man or a woman. This is actually an oversimplification as it does not take into consideration such conditions as intersex, but it will serve for the purpose of this introduction.
Sexual orientation refers to whether an individual is sexually attracted to persons of the same sex (homosexual), the opposite sex (heterosexual) or both sexes (bisexual). A transgendered person may be of any sexual orientation, or may even be asexual.
Now that we have sorted through that confusing bit, it’s time to tackle the big “T” words:
Transgender: Originally, this term was used to describe a person who chose to live in the gender role that was opposite of their anatomical sex, but who did not seek genital reassignment surgery. Common usage has diluted this meaning, however, and the term is now often uses to describe any gender presentation is contrary to their anatomical sex.
Transvestite: The term refers to men, usually heterosexual, who enjoy occasionally adopting the clothing, mannerisms and gender role of women for personal satisfaction. This satisfaction may take the form of sexual arousal and / or gratification but may just as easily be of a non – sexual nature. Transvestites generally self – identify as men and have no interest in having permanent feminisation done to their body.
Transsexual: A transsexual person believes with total conviction that they should have been born in the sex and gender opposite that of their anatomical sex. They are not delusional; they are painfully aware of the reality of their physical characteristics and anatomical sex and it is a source of discomfort to them. That being said, there are three categories of transsexual:
Pre-operative refers to someone who seeks gender reassignment surgery but has not yet had the operation.
Post-operative refers to someone who has completed gender reassignment surgery. Post-operative transsexuals are often referred to as “former transsexuals” or “transsexual women”.
Non-operative refers to someone who, for health and personal reasons, chooses not to have gender reassignment surgery.
The majority of transsexual persons who seek therapy for their gender incongruity are those who identify as preoperative, for reasons that will become evident in the next chapter. The other categories of transsexual persons may also seek therapy, but it will most likely be for depression, relationship problems and other conditions / situations that may or may not be related to their transsexual status.
The technical term for transsexualism is Gender Identity Disorder (GID) or Gender Dysphoria and it is listed, defined and subdivided in the DSM-IV (302.85). However, transsexualism is not a mental illness. There is no effective psychotherapeutic treatment for transsexualism; the only effective treatment is to surgically alter the anatomy of the body to coincide with the person’s natural gender identity.
There are some additional terms that have very specific meanings in the context of the transgender community.
Passing: This refers to the person’s ability to successfully cause others to perceive them as being of the gender that is contrary to their anatomical sex. This is often a goal of many transgendered persons.
Clocked: To be “clocked” means to be recognised as a transgendered person when attempting to pass as a member of the gender that is opposite the person’s anatomical sex. This is also referred to as “being read”.
Real – Life Test: Also known as “living full time” or “twenty – four seven” (24/7), this refers to the transgendered person living in the gender role opposite that of their anatomical sex all day, every day. A real - life test for a period of at least one year is considered a prerequisite for surgery according to the HBIGDA Standards of Care (see Chapter 2).
MTF: This is an acronym for “male to female” and is used to identify the direction the transgendered person’s transition is moving.
FTM: This is an acronym for “female to male” and is used in the same manner as MTF above.
GRS: Gender Reassignment Surgery (also referred to as SRS or Sex Reassignment Surgery). With MTF transsexuals, this refers to castration and the reformation of the penis and scrotum into a neo-vagina and labia.
Finally, mention should be made of the proper use of pronouns when addressing or referring to a transgendered person. As a general rule, a transgendered person should be addressed and referred to with the pronouns that are appropriate to the person’s gender presentation.
THE ROLE OF THE THERAPIST
The therapist has a rather unique relationship with their transsexual client, one quite different from that which they share with their other clients. With a transsexual person, the therapist takes on many different roles – guide, teacher, support person, resource, critic and devil’s advocate among others – depending on the client’s level of knowledge and awareness. They also act as “gate-keeper” to the medical support and surgical procedures the client needs.
The transsexual client can be a challenge to the therapist in many ways, not the least of which is that the client often knows more about the medical and psychological aspects of their condition than the therapist does. Because the condition is relatively rare (affecting an estimated 1 out of every 10,000 people), the transsexual client frequently finds themselves having to educate the very doctors and therapists they sought to treat them. This is especially true if the person is seeking help outside of the major metropolitan areas.
Why would someone go to a medical / psychological professional who knew nothing of the condition that afflicted them? More often than not, the answer to that question lies in the scarcity of qualified Gender Specialists and the Standards of Care for the treatment of transsexuals established by the Harry Benjamin International Gender Dysphoria Association (HBIGDA).
HBIGDA is comprised of well-meaning professionals in both the medical and psychological sciences who have developed a set of Standards of Care which they consider to be the minimum requirements for proper care and protection of both the person with Gender Dysphoria and the professionals who provide treatment. The therapist who works with a transgendered individual must become familiar with the current HBIGDA Standards of Care, if for no other reason than it delineates the requirements for determining a client’s acceptability for hormone therapy and GRS and has become the accepted standard of most reputable GRS surgeons.
The Standards of Care require that a candidate for hormone therapy be seen by a therapist for a period of time before hormones can be prescribed. They also establish the requirements of the minimum period of time required for the “Real Life Test” prior to GRS and the specific letters of referral that the client must present to the GRS surgeon before surgery will be performed. These requirements give the therapist a great deal of control and responsibility over the future treatment of the transsexual. It is surprising, then, that the typical transsexual client often approaches therapy with mixed feelings and animosity.
The transsexual community has had a long standing love / hate relationship with the psychiatric profession and the medical / psychiatric establishment is largely to blame for this. Transsexuals have, more often than not, been misunderstood and misdiagnosed by their caregivers who frequently have allowed their own personal prejudices to adversely affect their judgement. Even well – meaning caregivers have made the mistake of diagnosing their transgendered client as having “borderline personality disorder” since both conditions have similarities in the way they manifest in the individual. They are not, however, the same or even related conditions.
Perhaps as a result of this common misdiagnosis, the transsexual person has been accused of being manipulative in their interaction with their caregivers. This was undoubtedly true in many cases in the past, but not because it was in the transsexual’s nature to be manipulative. Rather it was due to the requirements set by the medical / psychological community that a person needed to fit a specific profile in order to be considered a “true” transsexual and worthy of hormone therapy or GRS surgery. Prior to 1990, this profile had a very narrow and rigid set of parameters which required that the “true” transsexual have a specific history of transgendered feelings and actions, an outwardly feminine appearance and demeanour and a sense of repulsion at their external genitalia. If the client did not conform 100% to these preconceptions, they were denied access to hormones and GRS. Under these circumstances, it is not surprising that the transsexual client felt it necessary to tell the therapist exactly what they wanted to hear rather than risk everything by telling the whole truth.
Less informed therapists have sometimes accused the transsexual clients of being in denial of their homosexuality and / or seeking GRS in order to “legitimise” their homosexuality. This diagnosis says more about the therapist’s personal prejudices than anything else and shows that they do not understand the concept of the separation of gender and sexual orientation. Surely the last thing a homosexual man would want is to have his penis sliced open, turned inside – out, sewn back up and stuffed inside his body.
Fortunately, over the last 10 years the medical and psychological community has developed a greater understanding of the transsexual condition and the varied ways in which it manifests. This understanding has opened the door to more honest communication between the therapist and their transsexual client.
So what should the therapist expect when first approached by a transgendered person seeking therapy?
Although transsexuals come in all shapes, sizes and colours, there are enough similarities and commonalities among members of the transgender community that it is reasonable to attempt to describe a “typical” client.
The person who walks into the therapist’s office for that first visit will often be between the ages of 35 and 50, educated (four years of tertiary education or more), intelligent, knowledgeable and well – read. Although they have been aware of their gender conflict since an early age (typically around ages 4 – 5), it is at this point in their life when they find they must confront the problem and attempt to finally resolve it. They probably will not look particularly “feminine” or display mannerisms that are associated with effeminate males. Often they will have married, fathered children and tried desperately through the years to live up to the masculine ideal they felt was expected of them. Naturally, they feel a sense of failure carries over into many aspects of their lives.
The client may be in a committed relationship with a wife or lover who may or may not be supportive (or even aware) of their transsexualism. While this brings an additional dynamic to the client’s psychological and emotional state, it is not in and of itself sufficient reason to deny hormone therapy or GRS. It is, however, an important aspect of the client’s life that must be addressed in session.
As a rule, expect the client is already well – read and knowledgeable about their gender situation and the various options for treatment that are available. They will be familiar with the HBIGDA Standards of Care and what must be accomplished in order to be approved for hormone therapy and GRS. Their feelings of discomfort at their gender conflict are so severe that they are driven to say or do anything that they believe will gain them the medical attention they need.
Lastly, and crucially, they will be distrustful of psychological professionals in general due to their preconceived ideas of the adversarial nature of the therapist / client relationship based, in large part, upon the true stories of other transsexuals who have been mistreated at the hands of their therapists.
This obviously does not set the ideal environment for a therapeutic session and there are clearly some obstacles that must be overcome before any real progress can be made.
The first thing the therapist needs to do is establish the client’s level of knowledge about the nature of gender dysphoria and it’s recommended treatment. They should also determine the client’s awareness of outside resources (books, periodicals, web sites, etc) and the availability of support organisations both locally and nationally. The therapist may need to take on the role of teacher and educate the client if they are not sufficiently knowledgeable in these areas. However, the client will quickly lose what little faith they may have in the therapist’s ability to help them if they feel they are being “talked down to” or treated as if they were ignorant when, in fact, they know as much or more about these things than the therapist does.
A most difficult and critically important task before the therapist is to establish a relationship of trust and respect with their client early on. While this holds true in any therapeutic relationship, it is of the utmost importance when working with a transsexual client. Until this relationship is established, the client will not feel free to speak honestly about themselves and may believe they need to tell the therapist what they think the therapist expects to hear.
Trust and respect can best be established by setting the client’s mind at ease that the therapist holds no pre-conceived ideas of who and what a transsexual should be. This can, in part, be achieved by acknowledging that is the client alone who can determine if they are truly transsexual and how far they should go in their transition. The therapist is there to help the client learn to ask the right questions of themselves and then to help them learn to question their own answers.
Once the therapist establishes a foundation of trust with their client, the real work can begin. Since transsexualism is not a condition that can be cured, the focus of the sessions should be on helping the client understand themselves and the options that are open to them better. By doing this, the therapist becomes more of a guide than anything else and the client has a sense of sharing a journey of discovery with them rather than viewing them as an obstacle to be overcome.
After a few months of regular therapy sessions the client and therapist may feel that the client is ready to begin taking hormones, but only after the therapist has confirmed that the client is aware of the effects, both long – and short – term, of this treatment. If both parties feel the client is ready, the therapist should write a letter of eligibility for the client to present to their internist. It is the internist who will ultimately decide if the client’s current state of health allows for hormone treatment and prescribe the specific hormone regimen the client will follow.
Soon after the client begins hormone treatments, the therapist may notice a change in the client’s state of mind and overall attitude. Many transsexual client report feeling happier and more emotionally balanced once they begin taking oestrogen and this is clearly evident in their demeanour. This improvement in the client’s mental and emotional well – being, often marks the beginning of real and substantial progress in their therapy.
From that point on, the landscape that the therapist and their transsexual client travel together will hold many similarities to those the therapist has explored before. There will be relationship issues, employment and financial concerns and the fear of growing old alone, to name a few. The singular difference in this instance is that all these issues and concerns will be filtered through the lens of the client’s gender identity issues. Ultimately, a progressive series of personal discoveries will lead the client to a better understanding and acceptance of themselves.
Through the course of therapy, the client may come to the conviction that they are transsexual and that GRS is the right course of action for them. If the therapist is convinced that the client is both sincere and mentally stable, the client should be evaluated and either approved for these procedures or referred to a Gender Specialist for further evaluation.
When the therapist and client work together in this way, the outcome can be very rewarding for both parties. The therapist will see their client grow and mature into a happier person who is all the stronger for having faced the challenges of being a transsexual in a sometimes unforgiving society.
Dr Elna McIntosh
PhD, D. Ed, MPH, Clinical Sexologist
(011) 787 – 1222
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