BARBELITH underground
 

Subcultural engagement for the 21st Century...
Barbelith is a new kind of community (find out more)...
You can login or register.


Underground > Head Shop >

Concerns regarding the lack of effectiveness of gender reassignment

  
  

Page: 12(3)456

 
 
*
23:26 / 29.10.05
Mister Disco, I'm sorry the thread has become upsetting for you. I hope you'll take whatever time you need away from it, so that you can return and give us the benefit of your perspective without distress.

I agree with you that there is something about the way doctor-patient relationships are usually constructed which breeds mistrust. I don't think it was purposely designed that way, because psychiatrists are better at doing what they need to do when there is trust. But I think there are some challenges inherent in the structure, and that improving this will take work on the part of trans people as well as psychiatrists. Largely that means listening to each other and being honest with one another. This is what happens on an individual level, when patients and therapists establish trust with one another, and I think it's what needs to happen on a community level for the relations between trans people and gender specialists to improve. There is no question of fault at the community level. Are there individual doctors who are incompetent, problematic, or arrogant to near the point of malice? Assuredly. Are there individual trans people excessively playing victim roles in online communities? I've certainly met one or two. But trans people are not to blame for these relationship issues, and psychiatrists are not to blame for these relationship issues, speaking in general terms. Instead, both communities have a responsibility to try to address these problems. Psychiatrists, because they are obligated to help and heal as effectively as they possibly can, and clearly this lack of trust is impeding that. Trans people, because if we don't take care of and advocate for our own, no one will. Blaming one another as groups, as you point out, is clearly not the way to achieve this.

I think the guidelines fail to be as flexible as they need to be to accomodate the wide range of individuals with a wide range of individual circumstances who need to transition. This is ameliorated somewhat by treating them as guidelines, but it seems like (and correct me if I'm wrong, Ganesh) when there is public money at stake they are treated as rules. I think part of the problem is that they are set forth as quantities— of time, of office visits, etc.— as opposed to goals. One trans person might live full time for a year and have many extensive therapy sessions, and not achieve as much progress in terms of self-reflection and analysis as someone else with six months of "most of the time" and a few sessions. People just move at different speeds. Maybe if there were a series of clear therapy goals which might be achieved in varying amounts of time, the system would work better for a wider range of people.

I'm not sure what these therapy goals might be, precisely, because I'm not sure about the different signs and profiles of people who might think they wanted to transition and later change their minds. Probably having consistently comfortable interactions in the role consistent with gender identity is the main point, and that could probably be broken down into smaller, more objectively identifiable steps. These could be presented more obviously as steps to make transition smoother, rather than tests, obstacles, or hoops to jump through. I think this would be a more process-oriented approach, and it might be more helpful to all concerned. However, I acknowledge it would consume more resources— there would have to be more and more frequent sessions, and it may well take some patients longer to reach the point of beginning hormones.

RLE is a hellish time for many people, and to me the problem is not that it exists at all but that, I think, there is often very little support available for people transitioning under the NHS protocols who are in the midst of RLE. This is clearly a problem of resources available, not negligence. But if there were a decent amount of support, from communities as well as the psychiatric providers, I think RLE would be more tolerable and less of a burden. I would still disagree with using it as a one-size-fits-all diagnostic test, but I don't think that's how it's being used, at least where I come from.
 
 
*
00:37 / 30.10.05
I was talking with Nesh via PM, and the outcome of that discussion is that I want to come down out of the ether and get a little more personal about where my feelings are regarding transness, and my relationships with therapists and to the SOC.

I feel really conflicted about gender therapy providers and the SOC. On the one hand, I was fortunate to have a very supportive and constructive experience in therapy. I didn't go into therapy feeling as if I knew what I wanted— I thought I wanted to transition, but I was afraid to admit that to myself, and I wanted someone— anyone, really— to tell me if it was right for me or not. Fortunately, my therapist was not the sort to simply say "You sound like a transsexual of some stripe, have some pills." Equally fortunately, she was not the sort to tell me right away that I wasn't a transsexual because I liked men and didn't like football and didn't unequivocally want a "fully functional" penis. So I'm aware that I'm speaking from privilege, and also from a place where I took a certain amount of time to decide, and that time was helpful to me. (I still don't know if that time qualifies as RLE or not.) I also know people who have transitioned and then detransitioned and were stuck not only with aftereffects of hormone therapy but with a gaping hole in place of the 'support' they'd previously had from other trans people who were so sure they were doing the right thing, and now regarded them as traitors or as inconvenient mistakes to be swept under the carpet. (Not universally, certainly, but there is enough of that going on that I worry about it as a trend.)

On the other hand, I am also acquainted with people struggling in the NHS system— intelligent, level-headed people, many of them, who nonetheless are in such distress over their treatment and their relationships with their psychiatrists that I worry about their well-being. I had some mistrust to work through to get to the supportive and egalitarian relationship I had with my psychologist, mistrust which wasn't her fault and wasn't my fault, it was just the nature of the doctor-patient interaction. I can see how if that mistrust hadn't been overcome the way it was (by my confession that I had a hard time trusting her and why, and her leveling with me in return about what questions were on her agenda), we would never have progressed beyond that point. I don't know what to think about the RLE as a requirement; it would probably help if I'd ever come to understand what exactly defines RLE. I can certainly see how for people who are fully capable of making their own decisions without any outside interference it seems like an insult. But I regard myself as a reasonably intelligent, sane individual, and I didn't think I was capable of making that decision on my own— it scared me, and it still scares me on occasion. I'm glad I was made to, but I'm also glad I had some support, and that I took the amount of time I did.

These issues are very much larger than me, and while they're not getting solved people are suffering— in some cases intolerably so. So if my discomfort with using the word "torture" in this context seems to make light of that suffering, I want to assure you it wasn't my intention.

So, Mr. Disco, that's my background and where I'm coming from. All this worries me very much, and it's much more comfortable and safe for me to engage with it on an intellectual level where I can keep it at a distance and brainstorm solutions and imagine that is productive. But it's precisely because it worries me so much that I want to find a way to close this gap between trans people and gender therapists. I don't think it's productive to do that by blaming the psychiatrists and it certainly doesn't help when people blame the trans people.

Sorry for two long posts in a row.
 
 
elene
12:10 / 30.10.05
Hello id, mr disco,

I don't live in England at the moment, and would in any case hope to avoid the
NHS while dealing with this matter, so I'm not directly involved.

It seems to me that people faced with the problem of starting the RLT before HRT
and, for those that need it, facial depilation have serious problems managing the
transition alone. That might easily lead to both a sense of helplessness and
concomitant frustration when faced with a slow-moving diagnostician, and to
the caregiver questioning the patient's ability to manage life to his or her own
satisfaction after transition.

I can't imagine the condition almost any male above the age of twenty-five must
be in to attempt to live as a woman without HRT and beard reduction. I'm certain
though it's neither a rational nor healthy condition.

That the typically m2f transsexual seems to be a long-term cross-dresser who
suddenly needs SRS right now (or she'll die), surely can't help either. That this
is what the caregivers have been induced to expect is even worse. Many
transsexuals seem to present a hysterical stereotype as their reality. Lack of
both a clear motivation and the ability to manage the situation alone can surely
be expected to lead to extended testing and probing for indicators of the final
outcome. The clinically expected motivation being a strong sense of identity
with a class to which one by definition does not (yet) belong must also make
diagnosis difficult to verify.

This response is motivated by my own recent experience seeking a psychiatrist's
letter that, together with an already completed deed poll, will allow me to
finally change my passport to match reality. She has a very good reputation, I've
high hopes this will not take long, nor be excessively invasive. My first visit
though began with her asking me "so, als was fühlst du dich," well, what do you
feel yourself to be?

Although I've done everything else alone, can live full-time without anyone's
help and know exactly both what I am and what I want, I must stumble through a
system of illusions I don't have to a destination that doesn't require them. I
blame transsexuals for that, and for helping construct and submitting to a
system that elevates the sick and incapable, and above all for placing
their ability to pass a gynaecological examination as female above there ability
to do their job as a woman.

It wasn't clear to me just how strongly I feel about this until now. Sorry if
it's excessive or irrelevant.
 
 
*
16:10 / 30.10.05
I don't think it's ever really registered to me before now that there are requirements before hair removal in the NHS. Ganesh, could you address what those are briefly?

I think perhaps the way ahead is for NHS gender clinics to establish closer links with voluntary agencies, so that, even if they cannot themselves offer intensive support, they can at least point their patients in the direction of organisations or individuals who can. One potential difficulty here might be finding supportive-but-'neutral' communities who don't themselves have an agenda...

I agree, in that something I have heard commonly reported by trans women on the other board I frequent, some of whom are crossdressers rather than transitioning types, is that some support groups have the problem of heavily pressuring their members to transition, and to transition quickly. Even when that pressure is not overt, applause and congratulations directed at trans women who are making steps towards transitioning can leave a crossdresser who is otherwise satisfied staying a crossdresser feeling she is less valued in the group. It takes a skilled and sensitive facilitator to include them in praise and support when they don't seem to the other group members to be making any "progress."

I believe many eventually do better when they've embarked on full-time transition than when they're fearfully limbering up to it.

I can't speak to this necessarily, except to say that I suspect you are correct in that there is probably for most a period of relief and relaxation once the initial plunge is taken. But in my experience as time goes on and one still has difficulty living in one's desired role because of lack of passing ability, it proves wearing. It is wearing for me and I live in the San Francisco Bay Area, in a queer household, and have a supportive school environment (and will have a supportive work environment or none at all, since I've been out with potential employers as I look for work). I'm also on HRT and have been for more than six months. I still am not commonly read as male, and it does cause me some distress, even with all of these advantages. I can't imagine how trans people in Ft. Worth or Kennebunkport keep themselves together for a year, except that it's generally easier to pass in a place where people think that transsexuals are something that only happens to other people in big sinful cities.

Pallas Athene, I've been avoiding addressing your post until now because I'm not sure I understand your meaning. You seem to be suggesting that trans people who have to go the NHS route due to lack of the funds and privileges which you and I enjoy, are necessarily in a less mentally healthy condition to begin with, since they can't manage it "on their own"? If that is what you're suggesting, I think I take exception. I think in many individuals a little bit of self-doubt is a healthy thing, and knowing when to seek help is generally good. And in any case those whose financial situation forces them to rely on the NHS rather than spending a great deal of money going the private route may or may not feel they "need" the help of the psychiatrists to make their decisions. They may in fact feel exactly as you do, that they know just what they are and what they want, only without the financial means to transition on their own. Please let me know if I've misunderstood you.
 
 
Disco is My Class War
16:34 / 30.10.05
Having thought about this all day, I can return to the thread feeling far less defensive and mad than yesterday. This stuff is incredibly complex. It's also very personal, so difficult to talk about with emotional distance.

My feelings about SOC's and publicly funded trans healthcare are as follows: there needs to be another option than the SOC model, with surgery/hormones pending psychiatric approval and management, OR, a discourse around cosmetic surgery, choice, with the resulting difficulty in getting healthcare publicly funded. How is it possible to articulate the premise that transitioning is not a choice (at least, for a lot of people it's not) but to also respect an individual's autonomy? Oddly, this is also the difference between welfare state ideology, where the state 'manages' biopolitical forms like healthcare, and a liberal 'free market' ideology where individual choice is valorised. Neither really works here.

As well, I am a little wary about solutions that involve individual responsibility. Part of the problem with standards of care, either as guidelines or rules, is that the sexological categories that are used -- are still being used! -- don't seem to reflect the diversity of experience. For example, this, from upthread a ways:

Out of interest, is this being discussed mainly by FtMs, MtFs or pretty much equally? I ask because I'm aware that there seems to exist a taboo of sorts among the latter on openly discussing this sort of thing - at least (and not terribly surprisingly) with NHS gatekeepers. I've occasionally had the suspicion that someone's arrived at the decision to transition via a sort of 'exuberant/euphoric genderplay' (or even transvestic) background but that this has, over time, evolved into a strong desire for hormonal/surgical transition; when asked, they're almost always loathe to talk about it. I suspect there's a worry that such digressions from the accepted narrative might result in demotion to 'secondary transsexual' status - but perhaps I'm just being cynical.

I think this probably happens often. And given Benjamin's categories of 'secondary', 'primary', transsexual, transvestite, it's entirely rational tht someone might feel hesistant to relate that experience of making the decision. But the question needs to be asked: is 'euphoria' at the discovery of different gender inside oneself really untrustworthy? A pretty large proportion of the FTM's I know who figured out their gender stuff through drag kinging. Many of these are people who will probably always feel themselves to be 'in between' male and female; but many of them still want to go through with chest surgery and/or hormones. Everyone I know who's taken this route is perfectly happy after hormones and surgery; a couple have phased back the hormones, but I wouldn't call what they experience 'regret'. It's more a constant modulation of what people feel comfortable with.

And similar to id entity, my experience of the "Real Life Test" felt like an artificial, imposed concept that wasn't particularly relevant to my transition. The psychiatrist seemed to think my RLT had begun when I changed my name; but some people were using male pronouns long before that, and some people still slip up with pronouns three years later. Legally I'm in some weird limbo where I can't change my birth certificate until surgery, and various administrative bodies don't really know where I'm at, or have ridiculously ambivalent categories. At the dole office, when I was on unemployment benefits, they changed my title to Mr but couldn't change my gender. My driver's licence is the other way round: my gender is male, but letters from them are adressed to Ms (insert full male name). I pass a lot more than I used to, but still not all the time.

I am also very into 'official' healthcare providers liaising with groups that don't have an agenda. But 'without an agenda' is not easy.... Here, the community groups that exist are very polarised in terms of working wth the gender clinic. One group has the official support of the clinic. The woman who runs it used to hang out on the e-list of the group I'm part of and flame anyone who was critical of the clinic; finally we had to revoke her membership.

In terms of the group I'm part of, as a moderator I consider it my responsibility to provide reliable information without judging people's decisions. So, we tell people where to find trans-friendly doctors and we tell them how to apply to the gender clinc, if that's what they want. But I also tell people to attempt to protect themselves emotionally when they have appointments at the clinic. Some seem to get through okay; others need to know that when they feel head-fucked in an appointment, due to the psychiatrist's unprofessionalism, that a) it's not their fault and b) they're not alone.

Mostly those who feel most vulnerable, and who end up subject to the most difficulty, are those who are really young, who don't have parental or family support, who aren't financially stable and who don't have a stable occupation or 'lifepath' they're following. A 19 year old friend of mine is going under male pronouns everywhere but with his parents, but he still lives at home. He finished high school last year and didn't get into any courses; he's also been injured since January, so couldn't work. His mother constantly harasses him for having short hair, shaming the family with his masculinity; he hasn't come out to them because he thinks it's likely they'll kick him out. Australia's draconian youth welfare laws means he can't get the dole unless he works fulltime for a year. Anyhow, he wants to start T, and the gender clinic advised that he come out to his parents before he does that. Maybe it's better for him to sort out his life first, before starting physical transition, but he feels stuck in an unwinnable situation. He can't get work, therefore can't move out of home, therefore doesn't feel safe coming out to his parents, therefore can't start T. The whole circular situation is driving him deeper into depression. Meanwhile the gender clinic's psychiatrists (he has to see two) don't seem to offer any meaningful support for these problems: they just give him more hoops to jump through. Luckily he just got a job -- as a pizza-maker, paying shit wages, but possibly enough to be independent. So the situation will resolve itself. But this detente has lasted nine months. Compared to his case, mine is child's play.
 
 
Disco is My Class War
16:45 / 30.10.05
Oh, and I fully support id entity's call for groups that don't have an agenda to applaud or push people to transition. After I'd been on ftm mailing lists for about a year, it became boring when everyone was called upon to whoop and congratulate people on every step they took in the hormones/surgery direction. Particularly when these same people would exhibit many other emotional problems that simply weren't addressed as important, or were assumed to disappear once transition had been completed.
 
 
elene
17:18 / 30.10.05
Hello Ganesh,

if it works for one that's fine, there is no problem, but if it doesn't
then it's a very considerable problem of the sort one does not leave to
others to manage.
 
 
Ganesh
17:19 / 30.10.05
Sure - but one could manage the problem in a number of ways, without oneself becoming irrational or psychologically 'unhealthy'. That was my point.
 
 
elene
18:10 / 30.10.05
These various solutions are not apparent to me, Ganesh. Not caring to pass,
passing only by lamplight, being young enough or simply naturally feminine
enough to pass without difficulty or so old that there’s not real difference
anyway are attributes of different groups from that I intended. I’m sorry if
that was not clear. That said I may still be wrong, too rooted in my own
assessment of my options. My only aim is to live life as best I can as a
woman.
 
 
elene
19:57 / 30.10.05
Sorry id entity,

I ran straight into Ganesh's post when I looked in before and didn't get around
to the others 'till now.

While there certainly are people who have to do everything the NHS tells them
I am convinced that's a small faction of those who do. SRS is of course a huge
expense, it is for me too by the way, but hormones are not and neither is
enough laser hair removal to get by very well. With these RLT is just living
your life with possibly major and urgent sexual problems remaining to be solved
but the rest in your own hands. I think most who don't do these easy things
'till the psychiatrist tells them they can aren't really convinced they ought
to. They'd like to be told they should. That's OK too, except that empowers
a system that gets in my way - I don't like it that I must see a psychiatrist
to allow me to change my name to match my apparent sex.

You can say I'm wrong, they're all really, really poor, but I won't believe
you. I know that's not so.
 
 
elene
20:25 / 30.10.05
Ah, but they’re hardly complaining about being told they can potentially
improve their quality of life in these ways, or indeed about their not
using the opportunity because they can’t leave the fags. The one’s who
need to feel very safe are no doubt right though.
 
 
elene
20:50 / 30.10.05
I'm sorry Ganesh, this is too complicated for me. Good night.
 
 
Ganesh
20:52 / 30.10.05
*shrugs*

G'night.
 
 
*
22:26 / 30.10.05
SRS is of course a huge expense, it is for me too by the way, but hormones are not and neither is enough laser hair removal to get by very well.

Well, that's all relative. For me right now paying for my own hormones is a burden, and if I had to combine that with laser hair removal I'd have to find some other way to make rent. We don't have national health care, but fortunately there's a low-cost trans clinic.

You can say I'm wrong, they're all really, really poor, but I won't believe you. I know that's not so.

I'm not saying you're wrong and that they're all really, really poor. I'm saying that you may be failing to consider that some people may be "really, really poor" (or in extreme financial circumstances, as I'd rather express it).

I'm sorry the conversation has become too complicated for you; for my part I'm still not sure I understand your arguments, so perhaps we're just talking at cross-purposes. I'm still interested in what you have to say, but I think I find myself disagreeing.

I think there's an understanding that Benjamin's categories are, to a certain extent, fluid. They're approximations, shorthand. Pretty much any system that sets out to describe aspects of human behaviour is.

That understanding may be the prevalent one in the field of gender psychiatry, but most laypeople, including the trans people the categories attempt to approximate, don't realize that they're supposed to understand it that way. Then we tend to believe that any psychiatrist who makes reference to those models views them as absolutes, and if we don't fit the models, our treatment will suffer. I know this isn't necessarily the case, and at the root there's probably a lack of understanding about the way psychiatrists use these models. But still, it might be good to remember that when someone says "I believe the autogynephilia vs. true transsexualism model has some validity" and means "I think this model tells us something useful some of the time, in some cases," it can be heard as "I think this model explains why transsexualism exists in all cases, and any anomalous results can be chalked up to dishonesty or delusion." Does this mistake represent a less-than-nuanced view of psychiatric professionals? Certainly. But it's what we have to work with, in the absence of better information. I hope that better information will be forthcoming.

On the other hand, there are people who advance the theories as absolutes, and claim that anyone who doesn't fit their theories is lying. At least some of them are trans people themselves. I really believe that the "two types" model doesn't even begin to cover the complexity of the trans people I have observed. Although I have known of a few trans women who fit one of the two types proposed by this model, and some of whom self-identify using the model, I would say the majority of trans women I've talked to don't fit this model. This is why on the basis of my experience I question its utility. I certainly don't believe it should be held to fit everyone who desires to transition. I'm alarmed when I encounter people who try to explain my behavior in a way which is radically inconsistent with how I experience it, when this explanation is expected to have repercussions about how I will be allowed or should be allowed to live my life. I think my alarm is familiar to those who are "supposed" to fit somewhere in the two types model, and don't.

I can't help wondering whether a) some people start themselves as hormones at least partly as a substitute for this period of psychotherapist-facilitated exploration/reflection, and b) whether the prospect of seeing a therapist, as you did, would be generally welcomed or seen as just another 'hoop'.

Well, I can't speak to proposition a), except to mention that for awhile hormone therapy was used by some therapists as a diagnostic tool and perhaps some trans people still view it that way. I think how seeing a therapist is received, though, depends largely on how it's presented and on individual biases. If it's offered as an option, with the understanding that it's there for support and not for evaluative purposes, I think some will take that option. It sounds like GICs with limited resources could benefit from networking with other gender therapists, perhaps those who are, tempermentally or in terms of professional qualifications, better suited to offering support than to making diagnoses.
 
 
elene
06:20 / 31.10.05
Good morning Ganesh, id,

Ganesh, your last comment left me with the feeling that I must re-read the
entire thread and amend my comments accordingly. That's too much effort
and I won't do it. I regret expressing my anger here. Please wipe my
comments as they're only a distraction.

Id, I'm simply furious that I must allow someone to mess with my brain in
order to change my name. I unfairly blame people who find this tolerable
rather than circumnavigating the system as I ought to. I know it's wrong.

It's not easy to avoid the state in the matter of obtaining an appropriate
passport.

It is messing with my brain. I don't "feel" I am anything other than what I
am and I've no desire to fit myself in (to the transsexual world). There's
almost nothing I'd do this for. Almost - I feel like Pavlov's dog.

So this is all anger and headsick and doesn't belong here. That wasn't clear
to me when I wrote my first post though.
 
 
*
06:42 / 31.10.05
Pallas, what you're saying is more clear to me now, and as I mentioned several posts back, it's probably a good idea for us to get out of theory and actually talk about how these things affect us personally, now and again. So I value what you've said, and more so now that you've more definitely framed it in terms of your personal experiences rather than theory. Thanks for just expressing your anger and there's certainly space for it here.

That said, I hope sometime you will take the time to reread the thread and think about it in a wider sense, not to amend your posts or to change your mind, but to think about how the system affects people who are in different circumstances than yours. You might then return with good ideas for changing the system in a way which would help both people in situations similar to yours and people in different circumstances as well.
 
 
Ganesh
07:13 / 31.10.05
Pallas, your comments are more than merely a distraction. I can completely accept your own position and how you feel about it. All I'm saying is, be wary of generalising what makes sense to you to everyone seeking to change their sex. Different people have different priorities.
 
 
David Batty
09:46 / 31.10.05
I wanted to go back to id entity's point about the attitude of (at least) a vocal minority in the TS community towards regretters. I'm in total agreement, there should be room for people to discuss their doubts & regrets without being labelled traitors.

I can understand why certain lobbyists are so vehement in their condemnation of high profile regretters because, as they see it, such stories undermine the fight for public acceptance. But the assumption that regretters - & particularly 'reverters' - are either attention seekers or just idiots is at best patronising and at worst highly offensive. (& such accusations do not help to create an atmosphere where people in transition feel they can openly & honestly discuss their doubts & anxieties.)

All those I interviewed had complex identities, medical/life histories - conditions ranging from bipolar disorder to personality disorders - plus traumatic life events such as bereavement, adoption, & sexual & physical abuse. (The failure to discuss childhood sexual abuse during psychiatric assessment was particularly disturbing given it is known that victims often loathe their genitalia as a result of their trauma.)

Their experiences of transition raised concern about the quality of the psychiatric assessments they received & the peer pressure not to reveal information which might slow down their transition. Only two of the regretters I spoke to were anti-TS, but they all justifiably objected to the personal abuse they received from some in the TS community.
 
 
*
18:32 / 04.11.05
Concerns about support for people who have started transition and decided not to continue have impelled some people in that situation to create this group. And I've also been approached off of other groups I'm on by one or two people expressing that this is their experience— spaces which are "safe" for transitioning people often don't feel safe for people who tried or considered that route and decided it wasn't right for them.

On the one hand, some people who decide transition isn't right for them extrapolate their situation unfairly to others, and decide that all trans people need to be prevented from transitioning for their own protection. However, trans people who choose to transition have no right to try to silence this population. We can try to protect our access to the medical care we see as necessary in other ways.
 
 
*
03:50 / 05.11.05
Well, it could just be that trans people who aren't making sweeping generalizations are, ah, quieter. Self-selecting population— the ones who aren't under the impression that they know everything about the topic consider that fact reasonably obvious and don't make a big production about it.

On the other hand, this might be a problem which faces many marginal communities in the earlyish stages of their organization. We are being represented primarily by outsiders. It is natural that those of us who are insiders feel some need to take control of that representation. There's a power struggle right now to determine which portion of the group will control the largest share of our representation, rather than an understanding that we can only ever speak for ourselves as individuals, not for the entire community. Largely this may be the result of constructing a common identity around a diagnosis.

There's a popular conception of medical diagnosis as a set of signs and symptoms which are consistent, or at least reasonably consistent, across the board, and certainly some kind of consistency in the criteria is necessary for diagnosing anything. The trouble is, there's no firm agreement yet on what constitutes the crucial and consistent signs and symptoms of transsexualism. In some circles, large swaths of a person's personality may be assigned to their transness, and I think in large part it may be this failure to differentiate personality traits from the "syndrome" which causes some trans people to make reflexive judgments: "I don't dress/act/feel like that, so that person isn't a real transsexual." (Or in some cases, "...so maybe I'm not a real transsexual?")

As for judging doctors on the basis of generalities, the most common thing I hear from trans folk over here is "Well, some psychiatrists understand trans issues and some don't." Granted, it's assumed that a psychiatrist who understands trans issues is going to give advice that trans patients agree with. But maybe the fact that it would be impossible to divide up the country's gender specialists into two poles, given the number and diversity of them, prevents fan clubs and anti-fan clubs from forming the way they seem to have around the Reid-Charing Cross split.

On another note, what kind of "ownership" do you think the trans community as a whole needs to take of people who have decided that transitioning was a mistake? Given that some of these people no longer identify as trans at all, if they ever did? I agree that nonjudgmental support is required of us, but I don't agree that the trans community needs to "own" them in the sense of "take responsibility for." (Other definitions could be advanced which are more seriously problematic, but raising those would be facetious since I know that's not what you meant.)

(It's also worth pointing out that not every individual who stops transitioning/identifying as trans does so due to the feeling that transitioning in the first place was a mistake. For some people it seems as if it was something which had real benefit for them for a period of time, and now it doesn't, and they're managing the aftereffects as best they can.)
 
 
David Batty
10:07 / 10.11.05
Some of the 'regretters' I interviewed last year felt that they had not been made aware there were other options open to them than full transition with SRS. One felt it would have been preferable to 'partially transition' - breast augmentation without genital surgery. Others talked about how they'd felt trapped within the confines of their biological gender only to find themselves feeling similarly restricted by their 'acquired' gender.

There was a feeling that the response of both doctors and the TS community to gender dysphoria was black and white. With the cop out argument that Society wasn't ready for people living as a third gender so transition was the only option. So some people with gender dysphoria felt pressured into transitioning only to find it did not reflect their 'non-conformist' gender identity.

Something I noted was differences in class and location. Strict/traditional notions of gender were more common among patients from working class backgrounds outside of urban areas. They held quite startlingly stereotypical ideas of masculinity and femininity, which did not seem an ideal starting point for transition. It was worrying that these notions had apparently gone unchallenged during transition. Perhaps some cases of regret could be avoided if patients are helped to see that their biological gender roles are not as restrictive as they perceive.
 
 
David Batty
12:30 / 10.11.05
Well I think such cases lead into a debate about what is transsexualism & consideration that it is not the same thing as gender dysphoria. Then, is it fair to only fund treatment for gender dysphoric individuals who are transsexual?
 
 
David Batty
12:37 / 10.11.05
& I'm not saying that a 'partial transition' would have been the best option for that case - just that there may be cause to assess other outcomes for gender dsyphoric patients.
 
 
Ganesh
12:49 / 10.11.05
Yes, sure, there are other avenues for treating gender dysphoria - but breast augmentation in a biological male with no strong desire to become permanently female generally wouldn't be one of them.

I take your point about the need to spend time exploring gender with individuals who have very rigid, traditional ideas of masculinity and femininity, rather than simply offering the RLE/SRS or nowt. In an ideal world, gender clinics would be in a position to provide much more by way of psychotherapy in this direction.
 
 
Ganesh
12:53 / 10.11.05
Then, is it fair to only fund treatment for gender dysphoric individuals who are transsexual?

No, but it's arguably fair, within a framework of limited resources, to restrict surgical treatment to individuals who are transsexual. At the present time, anyway.
 
 
David Batty
13:07 / 10.11.05
Point taken - but what I'm trying to get across here is there's a real dearth of research on other treatment options. Largely because it has just been accepted there is only one course of treatment, despite the lack of evidence to corroborate its long-term effectiveness. However, the chances of a body like the National Institute of Clinical Excellence devoting time and resources to GID are very low. & groups such as PFC have made it clear they would vocally oppose any attempt to compare SRS with alternative approaches.

So do you think it's possible to be transsexual and not want the genitalia that conforms with the gender you identify as? Remember the main case study in my Weekend feature has no genitalia, & doesn't particularly want a third set constructed, but firmly considers herself transsexual (and a woman).
 
 
*
14:54 / 10.11.05
I think this is particularly relevant to FTM situations, since a lot of us prefer not to have our genitals messed with, and feel comfortable being men and living as men with genitals which are not standard male genitals. I think there is a problem with defining our target genders based on genital configuration, since as you pointed out David it probably contributes to a number of people who have a real need for some intervention but would regret genital surgery both having regrets about the extent to which they took transition and wasting the NHS's money.

In some circles it's being reasoned that transsexualism manifests differently for different individuals, and so the appropriate treatment may vary. I would think, logistically, that if the NHS discovers that twenty percent of the patients they treat for transsexualism don't need the most expensive part of the standard treatment, even though they do need some treatment, they would rejoice at realizing they could help people and save money if they make the treatment plan more flexible.

I'm remembering now a story told by a friend of mine, of someone he knows well who transitioned with state funding in France I believe. He didn't particularly feel the need for genital surgery, but whether it was state policy or just the individual doctor, he was tracked into getting a phalloplasty in order to transition legally. He's now having severe complications from the surgery, which means more surgery and more expense.

Ganesh, I'll get back to your earlier post in awhile; I just wanted to let you know I'm not ignoring it.
 
 
Ganesh
16:28 / 10.11.05
So do you think it's possible to be transsexual and not want the genitalia that conforms with the gender you identify as?

Yes, I do: many FtMs are in this position, partly because phalloplasty's not terribly evolved as a surgical procedure and therefore not an especially enticing option, and partly because their dissatisfaction with their gender tends to be focussed more on breasts than on genitalia.

(Naturally, I'm generalising here.)

I'm not sure, however, that it's possible to be strongly MtF transsexual and be perfectly happy with a penis and testicles. As with anything else, though, I'm sure there's a spectrum of severity of dysphoria, with some finding it easier than others to live with unwelcome genitalia.
 
 
Ganesh
16:45 / 10.11.05
I would think, logistically, that if the NHS discovers that twenty percent of the patients they treat for transsexualism don't need the most expensive part of the standard treatment, even though they do need some treatment, they would rejoice at realizing they could help people and save money if they make the treatment plan more flexible.

That's one way of looking at it. In practice, I suspect this viewpoint would be seen as problematic, because

a) it might logically be concluded that those who're happy with male genitalia (and I'm talking specifically about MtFs here, because at least 50% of FtMs don't go for "the most expensive part") are not strongly transsexual, but want to alter themselves physically to appear feminine or androgynous for other (fetishistic, transvestic, even criminal) reasons; I'm not sure these reasons would be considered a clinical need,

and

b) there are related medicolegal issues around the long-term prescribing of high-dose oestrogens in biological males. Transsexualism is viewed as more of a clinical need than, say, the desire not to have to shave one's body hair. If an NHS doctor were to start someone on oestrogens for the latter reason, and that individual were to develop thrombosis and die as a result, the doctor's clinical judgement (balancing of risk:benefit) would likely be called into question. An NHS doctor prescribing high-dose oestrogens in someone with no intention of ever undergoing SRS (or at least orchidectomy) would essentially be accepting (some degree of medicolegal) responsibility for a lifelong risk of that person developing thrombotic complications - as opposed to the shorter window of risk when there's a surgical 'end-point' (a much lower dose is required post-operatively).

I think these are the main reasons it's not simply viewed as 'not going all the way = cheaper'.
 
 
*
19:05 / 10.11.05
What about those MTFs (and there are several of my acquaintance) who desire orchiectomy only?

The objections you pose, Ganesh, are certainly to be considered. But I find the belief that all MTF transsexuals must desire complete genital surgery to be problematic, and counter to my experience with many trans women. I think there are lots of reasons why trans women may choose not to undergo genital surgery, or to prefer orchiectomy over vaginoplasty. If a penis isn't necessary for a person to be a man, then why would presence of one automatically prevent someone from being a perfectly successful woman?
 
 
Ganesh
20:10 / 10.11.05
I don't think those rules are absolutely hard and fast: there'll always be exceptions or special circumstances. MtFs wanting orchidectomy only would at least not require indefinite long-term oestrogens. I suspect they'd have to convince several psychiatrists that their reasons for wanting to hang onto their penis weren't primarily fetishistic, though. This is because a) strongly fetishistic elements tend toward a poorer prognosis, and b) fetishism isn't, generally speaking, considered sufficient reason for the NHS to fund surgery.
 
 
elene
07:44 / 11.11.05
strongly fetishistic elements tend toward a poorer prognosis
Why do you think that, Ganesh? I had the impression the prognosis for autogynephilic transsexuals was unusually good, and surely nothing fits between autogynephilia and fetish? It must also be very strong if it's to serve as sufficient - and quite possibly the strongest - motivation for SRS. Now it's clear that you mean a fetish one needs a functioning penis to satisfy, but in that case anti-androgens should provide a good diagnostic tool. This would suggest that money could be saved and that some people need not throw caution to the four winds in order to better fit in and be a lot happier.
 
 
Disco is My Class War
13:41 / 11.11.05
Part of the problem with this discussion, especially with the way that it keeps being brought back to a question of whether someone is 'strongly transsexual' or not, is that 'transsexualism' itself is simply not a viable, particularly accurate concept for assessing the relative necessity or urgency of someone's desire to have a different body. The gender scale at work here is also at fault: trannies don't line up on a linear scale from 'just a little bit cross-dressy' to 'very strongly transsexual'. Need/desire and urgency to change the body works on all kinds of trajectories. Until we stop thinking of gender as binary and start theorising it as a multiplicity of signs, sensations, relations between experience of body and sociality, we're prevented from acknowledging that even 'true transsexuals' have very specific configurations of needs, feelings, wants -- which never, of necessity, simply and straight-forwardly progress along a male-female axis, where physical anatomy matches up with the mind. It's just not that simple. Decisions about surgery are pragmatic, for one. What can you afford? What's viable? What can you afford to hope for, and if you can't hope for it, what can you negotiate with your body to keep 'intact' and re-signify somehow?

Ganesh, I find it quite interesting that when, for instance, you might think about BDSM (and here I'm reflecting on past threads you've contributed to) you probably think about it as a multiplicity of different sensations, foci, desires, premised on the multiplicity of different kinds of pain, restraint, kineaesthetic sensations and styles of 'play', right? No top is just a top; he's a particular kind of top, with particular kinks. The same goes for gender. This is why diagnoses of transsexualism, with a solution of all-or-nothing hormones and surgery, don't work and never will. It's why no matter how many times you say, "Transwomen who are happy with their penises aren't 'strongly transsexual'", there will still be many, many transwomen living perfectly happily, or maybe not happily but in a negotiated way, with their original genitals still intact. Taking hormones; indeed, far more likely to get hormones on the street and risking HIV infection, precarious access to hormones, because psychiatrists refuse to acknowledge their kind exists.

Thinking about this in terms of 'special circumstances' doesn't work, either. When I think of the number of transwomen I know haven't had vaginoplasty, I am not thinking of an exceptional few. This is why even the conceptual framework Ganesh is working in, where there are guidelines but not hard or fast rules, doesn't necessarily work either. 'Guidelines' are just as hegemonic, in my opinion, as hard and fast rules. They still operate to gate-keep, and they still operate within a system that reifies binary gender.

(And yes, I'm implying that one day, even taxpayer-funded Charing Cross GC will have to deal with the fact that sex/gender are not binary but multiple, context-dependent and specific. I know saying this may be discounted as impractical, but once upon a time it was thought impractical to believe the earth was round.)
 
 
David Batty
14:32 / 11.11.05
I don't think the issue of binary concepts of gender is limited to the doctors. Some of the most stereotypical & outdated attidudes about gender roles and identity I have ever come across were from (pre & post-op) transsexuals. This, I think, is partly related to 'passing' - & the pecking order within the community based on how well you 'pass'. Many of the TS lobby groups campaigns have been so focused on the right to SRS (as quickly as possible) that there's been scant debate of other options.

You may find some medics open to options other than full SRS. But a) they may think society will oppose other treatments & b) recognise that the NHS is highly unlikely to even consider them. There'll need to be a substantial evidence base to support alternatives to SRS - & given the lack of interest in doing such studies from both doctors & the community (& the outright hostility from some activists), it's likely to be a long time before other treatments are developed, let alone provided.
 
 
*
19:33 / 11.11.05
MD, thanks for articulating so well in your first paragraph what I was having trouble putting words to. I wanted very much to explain that degree of reassignment desired != degree to which reassignment is desired (or replace desired with required, as needed).

I think David also makes a good point, that the trans community is in many ways self-policing and self-censoring as well as having to deal with outside agencies, some of which are helpful most of the time, some of which are helpful none of the time, but most of which fall somewhere in between.

I had decided to keep those involved in this discussion apprised of my ongoing experiences with harm reduction-based state care. This week I had my second appointment, where I had a psychosocial evaluation administered by a LCSW and some lab work. The psychosocial evaluation was not particularly strenuous, and seemed like it was designed to evaluate me for any additional psychological concerns rather than establishing a diagnosis of GID, although I was asked the usual "At what age did you begin identifying as the gender you identify as now? How do you know?" type questions. I found the LCSW personable and approachable, but it's a bit too early for me to start asking her questions about the overall success rate of the clinic. I don't know how many people ask for HRT there and are turned down, but last time we spoke she did intimate that if it weren't for the fact that I've already been in care and had a prescription for T before, my age (I'm 25) might concern the doctors, as it's a little on the young side of their patient demographic.

And to respond to the post by Ganesh earlier which I cruelly neglected:

I know roughly what you mean, I think, but could you clarify a little what's meant by representation in this context? Do you mean the medicos usually trotted out to give an opinion when trans issues are discussed?

I meant a wide swath of media representations which include those medicos, Jerry Springer shows, court cases, tranny jokes, Sheila Jeffreys, angry ex-partners, well-meaning "allies", documentaries... all that contributes to the image a non-transsexual person who has never knowingly met a transsexual person might have when they think of words like "transsexual." Many groups have more control over their representation, as described this way, than trans people have over ours, and I think that contributes to a sense of being assailed. One reaction might be to create a black-and-white us-and-them portrayal of the situation which can be easily digested by the meeja; I don't think it's the right approach but I can understand how some might react that way.

Technically, there is, in terms of ICD/DSM definitions but, as I think you're pointing out, the fact that these diagnostic criteria are interpreted and applied by (and to) individual human beings means there's always going to be a degree of individual interpretation.

Not only that, but the validity of those definitions is debated by many psychiatric professionals with a wide spectrum of opinions on the subject.

I suspect that this is a factor of the US's private healthcare system as opposed to our NHS. Without the latter, the bipolar system you describe presumably wouldn't exist, because there would be those gender psychiatrists whose philosophies tally with those of (the majority of) their trans patients, and those who go out of business. Personally, I think looking at the UK's specialists as cleaving to one of two defined camps is a little simplistic.

Agreed.

I don't mean "own" in the literal sense of "take responsibility for", but I do think there needs to be less reliance upon the circular 'if they decided it was a mistake, they weren't trans in the first place' logic used by all parties. At the very least, there should be acknowledgement that these individuals' accounts cut across the not-infrequent proposition that transsexualism is a 'self-diagnosing condition'. Individuals who regret transitioning to the extent that they subsequently 'detransition' may no longer consider themselves trans, but the fact remains that they (and presumably the doctors who worked with them) once did. I think that needs to be factored into the mix to a greater extent ie. not simply supporting those people but accepting their narratives as a valid part of the 'trans experience' (yes, I know) and encouraging examination of those narratives. What little I've read/heard of discussion of Charles Kane et al is rather more suggestive of an attempt to dismiss, disown or marginalise them.

By fortunate coincidence, in the last two weeks this debate has opened up in some of the trans spaces I inhabit online. Specifically I'm thinking of one which skews young, well-educated, and self-critical. There has been some suspicion regarding the possible motivations of a person who no longer identifies as transgender for seeking the acknowledgment and support of the trans community, along with fears that they might demand access to trans-exclusive spaces. The majority of people who spoke, however, voiced their concerns that people who once identified as trans and now no longer do, or who are detransitioning or retransitioning, don't have sufficient support. The issue of how their needs overlap with those of trans people arose as well. I hope others spread this debate to other spaces.

Incidentally, just as I was acutely feeling that some kind of online networking for people who de- or retransition would be helpful, and lamenting that it was no place of mine to create one, one was announced. Despite being limited to those most likely to benefit from it, its membership has grown dramatically in the two weeks since it was begun. Given this, face-to-face support groups should, and are likely to, follow.
 
  

Page: 12(3)456

 
  
Add Your Reply