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Concerns regarding the lack of effectiveness of gender reassignment

 
  

Page: 123(4)56

 
 
elene
17:21 / 12.11.05
One might well trans-out, Ganesh, but hope it's merely transitory. I appreciate this opportunity for discussion, though I haven't as yet really used it. I think this thread still has somewhere to go, it's just such a difficult thing to talk about.

No, I can't support the autogynephlia theory in any way. I only mention it because it seems to present a fetishistic motivation that is in no way disturbed by SRS. I can't say whether the fraction of transsexuals motivated by this form of eroticism is very large, as it's supporters insist, or very small as say it's opponents. I don't doubt that it is the primary motivation for some transsexuals though, if only because some claim it's theirs.

I'm not sure what the motivation for SRS is at all. Or rather, I imagine, the set of motivators, because I think these generally change during transition, and I suspect there is also more than one possible initial motivation. The accounts of others and my own feelings leave me with the strong impression that the final motivation is almost always the same. To finally become acceptable to society in the only way society is capable of truly accepting us. I can't be the only one who finds this disturbing.

No, I can't imagine a transvestic fetishist, or someone who merely wants to be smooth, or someone who wants his own tits a likely good candidate for SRS. It seems likely some coherent sense of identity as a woman is required for long- term stability. I doubt that's in itself a sufficient motivation for SRS though.

The only mechanism I know by which transvestic fetishism could lead to a desire for SRS is the "slippery slope," becoming convinced one is transsexual, or rather in this case that one is a transsexual, by peer pressure and association. If this is how I imagine it to be I'd be more concerned about those in a great hurry to obtain SRS than those expressing reluctance.

Has anyone watched the recent US TV series Transgeneration from the Sundance Channel. It's an extended documentary dealing with four young transgendered people. I think it illustrates some of the issues we're talking about very well.

On another matter, I do think that every tranny on HRT will eventually choose to either have SRS or an orchiectomy. An orchiechtomy will however tend to make a later SRS more involved as there will be less material left to work with. There's a natural reluctance to choose an orchiectomy early.

Personally I have another problem with an operation. I fear leaving my body with no natural source of sex hormones. I imagine a collapse in the world economy or something similarly unlikely leaving my dying of the effects of osteoporosis. I know it's irrational. This is the sort of thing that one can worry about though. Of course what it means is that I don’t feel safe. I'm getting better though.

Concerning 'X trapped in a Y's body', I am definitely a woman in the body of a man, now after years of HRT and living as a woman, and that's not a fantasy or a feeling, it's my physical and social situation, and I'm very conscious of the symbolic significance of becoming a "real" woman via SRS. It's not something I'd have said when first sought help though - really, no one's that naive. The concept was no doubt originally a self-description by people who really were women (/men sorry I'm totally leaving f2ms out of this, as they're always so competent anyway), and was picked up and used by others who still had a long, long way to go - but who wanted to.
 
 
Ganesh
21:42 / 13.11.05
Athene/Ellen: yeah, my trans fatigue is indeed transient! Think I'll back off a little from this thread anyway, though, to give others the chance to post. I feel I'm hogging it a bit.
 
 
elene
10:11 / 14.11.05
You're certainly not hogging it, Ganesh, your opinions are in great demand because you're not trans but are involved, know a great deal about us and have been willing to share this knowledge.

I've considered my own position once again. I did re-read the thread, but I remain a libertarian on transgender issues. I consider transition one of the most natural things a person might wish to do, though I also understand why most people would never wish to do it. I want to see a transsexual find a way to live as her target gender by herself. I feel that's the best test, demanding an investment of personal effort, an acceptance of personal risk and the resilience to make it work. I think the relevant medicine should be freely available - but not usually sponsored. But it is clearly unfair - and unwanted - that someone who does show promise of succeeding in the desired gender-role should be held back by poorly paid work or some other external factor.

I consider transition the opposite of a cure. If she's not strong enough to help herself she must be made stronger.

The "relative necessity or urgency of someone's desire to have a different body" is pragmatically assessed in other ways, most notably the Real Life Experience. You might argue that the RLE isn't a particularly accurate way of assessing this, but what is? ... So how might one go about quantifying need/urgency?

Is is right to allocate these resources based on a concept of relative urgency? It sounds like a recipe for emotional blackmail, and for transitions by people who, while they do feel they urgently need to do this, are not competent to make a better life for themselves in their new situation. Surely the likelihood of leading a happy life must be the deciding factor. Surely this is what we wish to enable.

It's not about getting a vagina, it's about getting a life. Perhaps this is what RLE is meant to measure? Or does it rather measure the degree of one's obsession with one aspect of this - the operation?

Sorry how tatty (and personal) my last post was by the way. I sent it unedited and in a great hurry rather than risk deciding not to send it the following day - something I do rather often. And Ellen will do, thanks, that's my name.
 
 
David Batty
14:46 / 17.11.05
I think it's broadly accepted that 'transsexualism is not amenable to psychotherapy or psychotropic medication', but pretty much every noun in that sentence is open to interpretation/debate.

Are you aware of any recent research on the use of psychotherapy though? My impression is that it hasn't even been considered as an options in decades & that some community groups would actively oppose any attempt to compare its effectiveness with 'traditional' treatment. I am sure contemporary psychotherapeutic practice is considerably more advanced than when Benjamin et all began to popularise SRS. I'm not saying it would be an alternative for all, but it might be for some.
 
 
*
20:46 / 17.11.05
Some trans people do seek that out, of course. I wonder if there are sufficient numbers to do a study on patients who have already chosen that route?
 
 
elene
10:29 / 18.11.05
Hello David,

I had some (I suspect) classical psychotherapy a few years ago and feel it did help me quite a lot. It helped put me in touch with some things in my past I'd never really coped with. Though I never took sex/gender issues off the table, I always hoped actually that I could make some progress transitioning with the help of this therapist and without having to travel long distances to visit an expert, I never felt we came near handling them. My therapist thought that both my father and my mother had behaved in ways that had tended to undermine my proper identity as a man, or boy I suppose, if I understood him correctly. As far as I know that's where psychotherapy's always going to look for a cause. I wasn't convinced.

One of the problems therapy has in this regard is that people like me don't consider this a problem. Oh I've ninety-nine problems, David, but well - you know? Therapy can help a lot but as a cure it'd be a lobotomy. I'd lose myself.
 
 
David Batty
14:18 / 18.11.05
Well I can't imagine it's very helpful is approached as a 'cure' in the traditional sense. But there may be a role for talking therapies (not just psychotherapy) in helping some GID patients explore their ideas about gender. I interviewed a good number of MTF patients who had such strict, traditional (outdated) notions of masculinity and femininity they could not conceive of 'showing emotion' unless they underwent SRS. There is an issue here, I believe, about how men are - or at least have been - raised/socialised. The community has focused so much attention on tiny studies which some activists claim shows proof of transsexualism being a biological condition (the brain studies, which compared only a handful of born women's and transwomen's brains & has not been peer reviewed) yet very little on social/environmental factors (perhaps out of fear these might undermine their cause). I'm not saying that environment/parenting would explain all cases of transsexualism, but what would be interesting to explore is whether there are higher rates of regret & reversal among patients with outdated concepts of gender.
 
 
the virgin queen
12:35 / 30.11.05
Ok so I jusp in without reading the whole thread (it's bloody long you know!)

Some things to consider:

1. The Guardian is so f*cking Genderqhobic (the term I prefer) it's disdurbing. A year or so ago they published an opinion peice laughing at the idea that a Gender Varient person could be raped and warning us that if we didn't shut up and disapear then we deserved violence done against us.

2. I read and reserched this story when it came out and basicly the 'study' was as loaded and a loadend thing could be: the data was aproched, quite plainly, with a preset agenda (all hail the spirit of Charles Fort for pointing out how dangerious that is), published in a paper that (as I stated) has a proven record for this sort of hatchet job, the study group was disafected people not a general group of Gender Varient people.

3. the observed 'failour' rates (ie. those disatasfied with treatment) are, in the most expreme estimate, less than 4% (though there has, as far as I know been no study done.)

4. It's the f*cking Guardian. Did I tell you they published an artical threatening Gender Varient people with violence? Did I tell you they published another one about how treatment should be withdrawn on the NHS? That the same artical called Gender Varient preople rediculis and reactionary?
 
 
the virgin queen
12:46 / 30.11.05
looking at the last post before mine...

David Batty wrote:

there may be a role for talking therapies (not just psychotherapy) in helping some GID patients explore their ideas about gender.

--I advise you read Joanne Miewertz' 'How Sex Changed: a history of Transexuality in the United States' (forget the publisher - Harvord University press perhaps?) she documents the history of 'the talking cure' and points out that no theripist could ever 'cure' a client and shows up the reactionary nature of menny of those arguing this.

You also said:

I interviewed a good number of MTF patients who had such strict, traditional (outdated) notions of masculinity and femininity

--perhaps you did find this but you've obviouly not been keeping tabs on contempory Gender activism that, taking it's cue from Foucault, Derrider and Judith Butler, now argues that to acheve any lasting changes we have to regect gender in any way, shape or form and move beyond thinking of ourselfs as beings who exist within the dominant discorse of the bi-genderd system.

I, for instance, do not call myself a woman but a Femme. To do a bit of a Buttler I'm embrasing a performance of gender not a gender as such. I'm not the only one.

I recomend (more books)

Howell, C., Nessle, J and Wilchins, R. 'Genderqueer: voices from beyond the sexual binary. Alyson Press.

Festo-Sterling, A. 'Sexing the body' (I forget the subtitle) Basic Books.

erm can't think of the others right now but you won't go wrong reading Stone Butch Blues, damn fine novel.
 
 
Ganesh
12:50 / 30.11.05
Also perhaps worth pointing out, Virgin Queen, that your recommendation of further reading material (to the author of the article in question) might be viewed as more credible if you yourself had taken time to read the thread first.
 
 
the virgin queen
12:56 / 30.11.05
Can I also throw in a bit of an unexploded bomb and point out that 'the talking cure' is not clinicaly proven and that some have argued that it is a myth, indeed it has been called a 'seculer religion.'

The Guradian peice I mensioned in full:

Gender benders, beware

Julie Bindel
Saturday January 31, 2004

Guardian

I am not the only one who worried that the introduction of the Human Rights Act might backfire on those of us who worry about little things like rape, murder, child abuse and prostitution. Certainly some of the fears many feminists had about fancy lawyers defending all sorts of scum in the name of "rights" proved well founded. HRA cases have included the right of a man accused of rape to hear details of a complainant's sexual history for the benefit of his defence and - turned down only after serious deliberation - serial killer Dennis Nielsen to be allowed gay pornography in prison, based on the argument that heterosexual serial killers are allowed theirs.
In countries in which real human rights violations blight the lives of millions, there is confusion about why we westerners are using the act to argue, for example, that a man has the right to sunbathe naked in his own garden. Is that really the best we can do?

It's not all bad news, however. The British Columbia supreme court in Vancouver recently overturned an earlier decision of the human rights tribunal that Vancouver Rape Relief had breached the human rights code when it refused to allow Kimberley Nixon, a male to female transsexual, to train as a counsellor of female rape victims. In 2002, Nixon had won $7,500, the highest amount ever awarded by the tribunal, for injury to "her dignity".

The arrogance is staggering: having not experienced life as a "woman" until middle age, Nixon assumed "she" would be suitable to counsel women who have chosen to access a service that offers support from women who have suffered similar experiences, not from a man in a dress! The Rape Relief sisters, who do not believe a surgically constructed vagina and hormonally grown breasts make you a woman, successfully challenged the ruling and, for now at least, the law says that to suffer discrimination as a woman you have to be, er, a woman.

The Equal Opportunities Commission, your best friend if you are a man wanting to get into nightclubs free on Ladies' Nights, has a lot to learn from this. Last summer, it supported the case of five male to female transsexuals, only one of whom had disposed of his meat and two veg, on the grounds of sex discrimination after a pub landlord objected to one of them using the women's toilets. The claim was rejected, with the judge stating that although he accepted the claimants' wish to regard themselves as women, a person's wish "doesn't determine what he is". Quite. Call me old-fashioned, but I thought the one battle we feminists won fair and square was to convince at least those left of centre that gender roles are made up. They are not real. We play at them. We develop traditional masculine or feminine traits by being indoctrinated, not because we are biologically programmed to behave in those ways.

Feminism is supposed to be based on the premise that prescriptive gender roles are a cause of women's oppression. When I were a lass, new to feminism and lesbianism, I was among the brigade who would sit in the women's disco wearing vegetarian shoes and staring in disbelief at the butch/femme couples, mainly because they were having a better time than me. "Oh, but they're emulating heterosexuality!" we would gasp in horror as the butch ran her Zippo up the femme's fishnets. "What's the point of being a lesbian if you're going to behave like that?"

I look back on them with affection and, yes, nostalgia. At least those women were women, and hadn't gone to gender reassignment clinics to have their breasts sliced off and a penis made out of their beer bellies. Their attitude was, we're comfortable in our own skin, let's be women but subvert what that means. Could we really have imagined back then that unpicking constructions of gender would result in Kwik-Fit sex changes on offer to all and sundry?

Twenty years ago, when I worked on an advice line for lesbians, I would take call after call from self-hating, suicidal women who had experienced horrific homophobia. Thanks to feminism and gay liberation, that situation has altered radically. What a disgrace, therefore, that our legacy amounts to this: if you are unhappy with the constraints of your gender, don't challenge them. If you are tired of being stared at for snogging your same-sex partner in the street, have a sex change. Where are those who go berserk about the ethics of genetic engineering yet seem not to worry about major, irreversible surgery on healthy bodies? Also, those who "transition" seem to become stereotypical in their appearance - fuck-me shoes and birds'-nest hair for the boys; beards, muscles and tattoos for the girls. Think about a world inhabited just by transsexuals. It would look like the set of Grease.

When feminists suggested that the true "gender outlaws" were those who didn't give a toss about conforming to masculine or feminine norms, it sounded so persuasive that even some straight people took it up. When it got to the stage where my mum was wearing jeans and trainers rather than her usual skirts and heels, I started to feel a bit like the wonderful Daffyd from Little Britain. Too many straight women looked like they might be lesbians, and I wanted to be the only gay in the village!

To go back to my five men and a toilet, I don't have a problem with men disposing of their genitals, but it does not make them women, in the same way that shoving a bit of vacuum hose down your 501s does not make you a man.

Guardian Unlimited © Guardian Newspapers Limited 2005

http://www.guardian.co.uk/gender/story/0,,1134263,00.html

and the 'apoligy':

http://www.guardian.co.uk/comment/story/0,,1147891,00.html
 
 
the virgin queen
12:59 / 30.11.05
Also perhaps worth pointing out, Virgin Queen, that your recommendation of further reading material (to the author of the article in question) might be viewed as more credible if you yourself had taken time to read the thread first.

--as I said in my first post I havn't read the thread. Just off to do it...
 
 
Ganesh
13:08 / 30.11.05
Cross-posted. Will be interested in your opinions, Virgin Queen, when you're up to speed. We started off talking about the Guardian article, but it's become a more generalised discussion of trans experiences within different healthcare systems, and what should be the way to proceed.
 
 
the virgin queen
13:08 / 30.11.05
I'll get round to reading this soon...

Who's observed those rates, then? And what's actually meant by "failure" here? Are you talking about those who disappear from follow-up, those who actively complain, those who detransition, those who express regret?

---it's anacdotal observations (from what I can gather) rather than proper statistical studies and i've heard the figure quoted by quite a few medics (spit snarl sneer.) As I said there has not been a large study done of the population althow there *is* a study which is being done here in Scotland that I'm eagerly awaiting the results of (but they've been delayed so often that I fear I may reture before the analisis of the data is complete )

By 'failour' I ment those who regret what they've done not (as the study the Guardian did) those who 'go stelth that is deside to 'pass' (interesting word to use but that's another discusion) as female and disapere from the comunity. For menny that is a sign of 'sucess' rather than of failour.

While I'm having a look at the rest of the thread I'll look out some of the other hatchet jobs the Guardian's done on Gender Varient people (some of which have disapered from the web site.)
 
 
the virgin queen
13:13 / 30.11.05
but it's become a more generalised discussion of trans experiences within different healthcare systems, and what should be the way to proceed.

---don't get me started on the bloody medics! Bunch of gender normitive fachist...I'll not finish that statment as it would end in a string of expleteves.

If any other effective treatment can be found great but so far there hasn't.
 
 
ONLY NICE THINGS
13:24 / 30.11.05
I'll get round to reading this soon...

Please do the people who have posted at length to this thread the basic courtesy of reading what they have written in order to avoid repeating things that were debunked or discussed at length already. This is entry-level good manners, Virgin Queen - the time it takes you to read the thread will be less than the time it has so far taken you to post to it, and it will make your contributions more useful and profitable.

You may also want to take a look at this thread, which discusses the Bindel article you quoted above in more detail.
 
 
the virgin queen
13:24 / 30.11.05
just something from reading the first page of this thread:

I think what's needed is counceling for people *after* surgery.

Menny people think that, if the get x or y done then their life will be complete and then find out otherwise. The Gender clinic in Glasgow offers counceling but I am not sure if you can acess it after surgery (I seem to remember that being a complaint some people where having with the service.)
 
 
ONLY NICE THINGS
13:30 / 30.11.05
I'll assume that's a crosspost - that is, that you wrote it before I posted mine. Rather than posting every response you have while reading the thread, why not write them down? That way, if they are addressed by other people or more is added that you would like to respond to, you can add to it before you post. We'll all still be here when you get back, and it will make for a smoother ride for everyone.
 
 
ONLY NICE THINGS
16:12 / 30.11.05
Incidentally, Fausto-Sterling and Butler in particular feature in this lengthy and remarkably bad-tempered discussion of the epicene pronoun here, and there's some quite fun stuff on gender construction in this very short thread here.
 
 
David Batty
09:31 / 01.12.05
I'd request that this thread stays focused on transgender healthcare & that any other issues - e.g. raised regarding transgender theory/politics - are relevant to that central topic. As the Mods have already highlighted there are several separate & quite in depth threads on more general trans issues.

Virgin Queen I suggest that if you're going to lecture me you not only read this thread but also all the articles I wrote on trans healthcare last year - links to most of which are available in this thread. In particular I'd direct you to the Guardian Weekend feature 'Mistaken Identity'.

Returning to the topic. The Royal College of Pyschiatrists was due to publish draft UK standards of care in the summer that take account of the differences between the UK healthcare system and the US healthcare system. I suspect these have been delayed until after the GMC inquiry into Russell Reid. But what realistic modifications to the Harry Benjamin guidelines would doctors & patients like to see - taking pressures on NHS resources into account? E.g. many trans activists would like to see an increase in the length of patient appointments and their frequency during the real life test - is this possible given the tiny number of psychiatrists/psychologists working in this field?

If Reid is struck off - or, as is rumoured on the internet, retires - next year, where does that leave private provision of transgender healthcare in the UK? Does the NHS have the capacity to pick up his patient list - and if not, or if his patients are determined not to seek treatment at Charing Cross GID, what is the predicted fallout?
 
 
David Batty
10:39 / 01.12.05
Yes I was aware of this I wonder how transgender psychiatrists are going to react to a GP setting himself up as a one stop transsexual health shop? & is a year of general psychiatric training sufficient to deal with the inticacies of this field? No doubt he will attract clients purely on his trans status but it's a jump to say because he's been through transition that he's any more insight into other patients.
 
 
Goodness Gracious Meme
15:10 / 01.12.05
Thought this might be of interest to readers of this thread.

Brighton and Hove PCT and Spectrum, (Brighton LGBT community forum), funded a report into the 'Medical and Related Needs of Transgender People in Brighton and Hove'.

Summary here

Full report here

Makes for interesting reading.
 
 
Ganesh
16:24 / 01.12.05
Yeah, here's where we began talking about it.
 
 
*
18:35 / 01.12.05
Thanks, Ganesh, for that clear and useful description of the NHS situation from your perspective. Seems like if we're (everyone) actually going to get anywhere, we (trans folk) need to understand the realities of working with the NHS system, just as psychiatrists need to understand the realities of living as a trans person.
 
 
elene
06:48 / 02.12.05
what realistic modifications to the Harry Benjamin guidelines would doctors & patients like to see - taking pressures on NHS resources into account?

I want the freedom to change myself as I see fit, thanks. I accept the NHS's financial constraints, but if I can find the money myself, I want the freedom to use it. I want the psychiatrists out of my life, and the GPs and surgeons responsible only for their own competence - not mine. Is that realistic, David?

Ellen
 
 
the virgin queen
14:41 / 02.12.05
Firstly may I apoligise for some of the things I said before on this thread.

The 'gender normitive fachist' thing was, I'll freely admit, a *bit* OTT but...consider the historical perspective for a mioment: early gender clinics refused to treat anyone unless they would make an atractive hetrosexual woman; in the 1980's Lou Sulivan was campaigning for the right of FtM's to identify as Gay men (they where being refused treatment before this.) Today i hear again and again of people being treated poorly if they do not do just what the clinitian wants (our local one much prefers women to wear skirts and gives, as has been noticed by the local suport Group, preferensal treatment to gender normitive patients - to the point of prefering hetrosexuality and giving such people treatmewnt far quicker than others.)

I wonder weither my, or any other Gender Varient person's voice, is entirly welcome on this thread. I do not mean that anyone here is engaging in overtly discriminatory behaviour but consider some of the things said here: that there is a similarity between Gender Varient people's naritive of discpovery (I'll raise that issue at another point) and mental illness (I am not referencing the post on this page but one earlier); Gender Varient people complain all the time about the service; Gender Varient people are gender normalists ect, ect. Given how much this invaladates my subject-position then how can my views be as valid as those of other people posting here.

Anyway regardless here are some of my thoughts about how treatment should progress...

1. Removal from the list of psychiatric disorders

2. Removal or rather relocation of Gender Clinics from psychiatric setings and into the wider comunity (such does happen: the Galsgow Clinic is in a comunity setting.)

3. The diagnostic criteria in the Standerds of care are meaningless now. In an age where anyone can have a look at them online and suport groups (quite rightly) tell you how you can get treatment quicker by saying what is expected of you (a corse, BTW that I refused to take) then what point is there in the diagnostic criteria set forth? It's a game, a little pantomine and in the wrong hands it can become a huniliating ritual that individuals are forced to inact for the entertasnment of clinitians.

To quote elene:

I want the freedom to change myself as I see fit, thanks. I accept the NHS's financial constraints, but if I can find the money myself, I want the freedom to use it. I want the psychiatrists out of my life, and the GPs and surgeons responsible only for their own competence - not mine.

--the idea that underpins much of the discusion of gender and much of the discusion on this thread is that I and people like me are incompident of making a valade choice considering our own health and our own bodies and that is frankly offensive. I'm not a child, I'm an adult who has read all I can find on the risks of treatment, who has tried to find alternitve ways of constructing an identity and has not found one. Indeed I have discoverd my identit ywhich i wish the clinitians to help me realise: that of a female bodied Femme.

I'm going to stop now as this post has probbebly given you lot more than enough to start on

I'll discuss (if it's felt relevent) how Clinitians act in the process of constructing an aceptable genderd identity and how fear of their power stifles debate and diffrence and, in the end, makes it almost imposible for someone from outside the comunity to realy know what's happening within it (or perhaps I'm wrong...)

oops! Sorry I ment to say I'd discuss those things next if you thougught them relevent...
 
 
ONLY NICE THINGS
15:24 / 02.12.05
I'd like to come back to some of these points later, but there is, I thionk, a pressing issue here about whether gender variant people are being made unwelcome here. I believe that maybe half a dozen gender variant members of Barbelith have contributed to this thread, or rather half a dozen members of Barbelith who have identified as in some way gender variant. Those who are reading - could you possibly, if you feel so inclined, share with us whether you feel that this thread has been unwelcoming to your perspectives, and what might change to make it more welcoming. Ideally, we would have a space here where transpeople and other gender variant people could feel able to speak freely without feeling unwelcome, and pretty much everyone could also do so without fear of being insulted either personally or as members of a particular group.
 
 
ONLY NICE THINGS
15:58 / 02.12.05
And back on topic:

3. The diagnostic criteria in the Standerds of care are meaningless now. In an age where anyone can have a look at them online and suport groups (quite rightly) tell you how you can get treatment quicker by saying what is expected of you (a corse, BTW that I refused to take) then what point is there in the diagnostic criteria set forth? It's a game, a little pantomine and in the wrong hands it can become a huniliating ritual that individuals are forced to inact for the entertasnment of clinitians.


OK... my first question on this - would be the extent to which these criteria are criteria for being able to access gender realignment surgery and to what extent they are criteria for being able to access funded gender realignment surgery. That is, whereas your first two proposals are propositions for action, this one is a statement - the diagnostic criteria are no longer a useful way of determining who should receive GRS (presumably on the NHS or by NHS referral). So, if we assume that not everybody can receive GRS, or at least not everyone can receive GRS without paying for it and/or at the precise moment that they conclude that they require it, what are the criteria for priority?
 
 
*
16:31 / 02.12.05
I wonder weither my, or any other Gender Varient person's voice, is entirly welcome on this thread. I do not mean that anyone here is engaging in overtly discriminatory behaviour but consider some of the things said here: that there is a similarity between Gender Varient people's naritive of discpovery (I'll raise that issue at another point) and mental illness (I am not referencing the post on this page but one earlier); Gender Varient people complain all the time about the service; Gender Varient people are gender normalists ect, ect. Given how much this invaladates my subject-position then how can my views be as valid as those of other people posting here.

As a gay and genderqueer trans man, I assure you you are not the only "gender variant" person posting here. Yes, I have found this thread challenging at times, but I've also found it really enlightening. Since I'm not from the UK, I try not to be overbearing about the UK health system, but to present things as I understand them from within the US system. I feel I know Ganesh and Haus well in the context of the board, Mr Batty less so but we've certainly had some interaction, and I trust them all to take my views seriously.

Some would claim that doctors need only react to the requests/demands of their trans patients, on the grounds that transsexualism is "self-diagnosing". The same, however, might equally be said of schizophrenia ('I have a radio transmitter in my head, you need to remove it')... Would a truly "patient-centred management approach" mean acceding to all these requests?

I do not think that transsexualism is entirely and in all cases self-diagnosing— certainly I needed a goodly amount of time and a supportive therapist to talk to before I figured out my own situation— but I do think you're oversimplifying the issue a bit for the sake of your analogy here, Ganesh. For instance, operations to remove non-existent radio transmitters are not a part of the protocols for care of schizophrenic people, whereas medical transition is at least sometimes indicated for transsexual people. Transsexual people are not diagnosing ourselves with non-existent illnesses— typically, when we come into a clinic and say "I am transsexual" we are using the language we know how, and the language we expect you to understand, to explain that we feel a disconnect between our physical gendered bodies and our internal gender identities or preferred gender role. (Yes, I know that certain people may well see this as identical to "diagnosing ourselves with nonexistent illnesses"; I hope that doesn't become relevant to this thread.) I can see that it would be more useful to you to have us explain our feelings and not simply how they tend to be categorized. Maybe the category needs to be taken apart and re-examined a bit.

On another note... thought experiment. Ganesh: How would your feelings change if the NHS somehow discovered an easy and ethical way to triple the funds they allocate towards SRS procedures? Would you change how many cases you recommended for hormones/surgery, and if so along what guidelines? Virgin Queen: How would your feelings change if you were in charge of deciding which five cases out of twenty all along the trans spectrum were to be funded that year? How would you prioritize the need? What guidelines would you suggest?

I wouldn't recommend such a thought experiment if I weren't willing to take part in it, but I will wait for your responses first.
 
 
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17:43 / 02.12.05
So, if we assume that not everybody can receive GRS, or at least not everyone can receive GRS without paying for it and/or at the precise moment that they conclude that they require it, what are the criteria for priority?

1) Need, to be discussed more thoroughly later.

2) Likelihood that each step of transition considered will ease the person's distress (with the awareness that some steps of transition necessitate others, which will also have to be considered; I undertook hormone therapy with the understanding that it eventually (probably) necessitated a hysterectomy, which I otherwise might not have seen as a need.)

3) Ruling out other methods of dealing with the distress, which may involve simply asking the trans person what other avenues they've attempted.

4) Inability to pay for care under the private model, practically speaking. (I don't think someone has to be below the poverty line to be unable to pay for care in the private sector, seeing how prohibitively expensive it can be. I do feel that people who can pay for care should, in order to let those with financial need access the system which exists for their benefit.)

I think the following should most emphatically NOT be criteria:

1) Perceived adherence or lack thereof to gender stereotypes.

2) Sexual orientation or preference, including kinkiness.

3) In some cases, I think the above criteria are snuck in under the label of deciding whether someone's male or female persona is "viable." I think relevant issues of determining whether someone can live happily as female or male can be addressed under need/likelihood of redress, without a separate criterion for "viability"— which to me seems vague enough to be open to entirely unintentional abuse.

4) Ideally, no one should ever have to get to the point where their need is so great that they are considering suicide. The problem should be dealt with before then. While I have no idea if psychiatrists actually use this as a criterion, the occasional trans person has used suicidal ideation in my presence as a peg in the transer-than-thou game, which makes me wonder. People should not have to consider suicide before their transition needs are considered seriously.

I am waffling on presence of mental health issues which don't significantly impair the decision-making ability of the trans person. I know people whose transition was indefinitely delayed because of depression, when I think positive steps toward transition would have at least helped alleviate some of the depression. On the other hand, people who are depressed may feel self-destructive, and this may lead them to consider options they normally wouldn't.

On need:
I'm going to propose a model which will be seriously flawed, but which will maybe provoke some thought in a useful direction. To wit: There are several factors which contribute to need and which might be measurable components of it— intensity of distress about one's body, intensity of distress about one's social role, duration of distress about one's body, duration of distress about one's social role. "Needs assessment" is distinct from diagnosis in that it doesn't necessarily assume an "illness," but rather a problem to be addressed. Needs assessment may be performed through inventories, and should be carried out over a period of time to add the factor of duration. Intensity will probably always fluctuate somewhat over duration. I have the instinct, though, that someone for whom the intensity fluctuates wildly will be more likely to experience regret at some point.

Now, I'm imagining a health clinic where an initial needs assessment is done, with periodic follow-up assessments while the person lives in the role of the gender they identify as, as far as possible. The time period for this is understood to vary. Support needs to be provided during this time, even if it's peer support or through a social worker rather than a psychiatrist. The emphasis is on prioritizing needs, not making diagnoses. Each step of transition is considered separately as far as health concerns allow; for instance, orchiectomy may be the only surgery desired by a trans woman, or a trans man may choose chest surgery but not testosterone, at least for the time being. Funding will always be tight. In the US, a clinic like this would be applying for foundation grants and private donations to supplement government funding, and trans people who come to the clinic will probably have a pay-what-you-can system (which ideally is kept completely separate from their care— the doctors should never know what the person is able to pay, only registration, and registration has no say over the course of their care). I don't say that outside fundraising is necessarily any good, because it frequently leads to dubious corporate sponsorship practices, but it exists precisely because the government here does not fund necessary services for everyone. It sounds like the NHS in the UK is also not able to fund necessary services for everyone, although they do a much better job than the US (absenceofa) system. Maybe some outside fundraising would help? Is that even an option?

Please help me by pointing out the problems with my model, both those I know about and those I have overlooked.
 
 
elene
10:44 / 03.12.05
Assuming you can find the money and GPs/surgeons willing and suitably personally insured to prescribe for/operate upon you, then yes. That's realistic.

Not so, Ganesh. If he needs to be insured against a malpractice suit on the basis of his having failed to assess my psychological condition correctly then I was never in control in the first place. I want to own my mistakes.

This might just be Germany in action but I’m now doing RLT with all my documents still fixed to my old name. I could change my name (on my passport, that is) to “Mad Dog” tomorrow but not to Ellen. That’s just wrong.

Are m2f transsexuals people who hate their penis and want a penectomy? When I was 16 I thought that’s what transsexuals were. I told my psychiatrist I’ve nothing against my penis and she was shocked. Now, I’ve been on HRT for years, which she knows, and my penis is certainly not everyman’s penis. I’m very happy with it, but I doubt many men would be. I would like it reformed into a vagina, that's true, but I’d certainly not want to be left with no feelings down there after an OP. So it's complicated, and full of risk. How is one to catch all the nuances on this issue in an intelligent and not wilfully misleading response? No, transsexuals hate their penis and want to be real women, she says (more or less). She asked whether I was a transsexual. I said I’ve no idea what a transsexual is – which might be true - and no interest in being one at all - which is. I think we made some progress after that but (some of) you people have some very odd ideas. This is going to be an incredibly slow and painful process, and if I can’t even change my name (on my passport, which I do need) without going through all of this then the situation is clearly not as I would have it.

Sorry, but I’m not being treated as a competent adult, and this is being treated as an illness not an option.
 
 
elene
15:41 / 03.12.05
it's perfectly possible that Charles Kane said exactly the same thing. And he's by no means the only one.

And? And anyway Kane's talking about being diagnosed with something. I'm not.

removing 'illness status' from the gender diagnoses would, I suspect, lead to their being viewed as lifestyle choices instead - which would then have interesting repercussions in terms of what the UK Government would and wouldn't agree to fund.

So, because some people need this very badly but can't afford it I must accept that I am mentally ill?
 
 
ONLY NICE THINGS
15:51 / 03.12.05
Possibly that illness is the easiest way to present your need for a solution in a way that frees the national health service to pay for it.

Condition - gender dysmorphia
Treatment - gender realignment.

That may come down to what is more important - gender realignment, or the terms under which gender realignment is made available/subisidised. These are no doubt both valuable things to consider in terms of their impacts.
 
 
elene
16:38 / 03.12.05
That may come down to what is more important - gender realignment, or the terms under which gender realignment is made available/subisidised.

You're right of course. And if everything were handled pragmatically that'd be just fine by me too. The notion there’s a thing called a transsexual is not pragmatic though.
 
 
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17:54 / 03.12.05
Ganesh, I will respond more fully to your earlier posts probably tomorrow, but I wanted to thank you for your insights, and recommend this to your attention in case I hadn't remembered to do it earlier:

As the DSM prepares the next update, I urge the authors to consider that the cross-gender behavior typical of gender variant people is neither a sexual disorder nor a gender identity disorder. Rather it is an anxiety disorder secondary to physical and sociological gender expression deprivation. Rather than referring to the cluster of behaviors as “Transsexualism” or “Gender Identity Disorder” I propose as I have elsewhere (25), that the condition be refereed to as Gender Expression Deprivation Anxiety Disorder (GEDAD).

Advantages in the terminology:

• GEDAD tacitly recognizes that gender expression is a critical element in all that makes us human.

• GEDAD tacitly recognizes that gender expression is a dictate of birth. It is not negotiable.

• GEDAD tacitly acknowledges that gender expression-- as defined by the individual-- is vital to good psychological health.

• GEDAD moves the locus of attention from the sexological to the psychological.

• Unlike GID, GEDAD does not connote disorder or confusion in someone presenting with gender issues. This should take away using the DSM to foster religious/political objections to gender role transition as part of the treatment plan.

• GEDAD describes what the presenting individual is actually experiencing.

• GEDAD can be posted in a directory of disorders allowing National Health Service or insurance coverage without the negativity Gender Identity Disorder currently incurs.

• GEDAD does not differentiate between adults, adolescence, children, MTFs, FTMs, Intersex, androphilic or autogynephilic gender variant people.

Reviews of the treatment outcomes of cases wherein an individual’s secondary sexual characteristics have been changed to comply with their innate sense of gender identity and the subsequent success of the individual’s life has shown that it is long past time for clinicians to accept that this is not a problem of confused identity but a problem of gender expression deprivation.
—Anne Vitale

I don't think it's perfect either, but I thought considering Dr. Vitale's proposal might add something to this thread, which I think is growing in some very interesting directions.
 
  

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