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Kind Words - January '18

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Transsexual, Transgender, and Gender-Nonconforming Care - Questioning the Prevailing Orthodoxy

Posted 9/6/2017

Patient: I am a woman trapped in a man’s body and it makes me miserable.

Therapist: You have gender dysphoria.

Patient: Can you help me?

Therapist: Yes.

Patient: What do I do?

Therapist: Make an appointment with your GP for a referral to a Gender Identity Clinic (GIC). You’ll probably have to wait a year.

Patient: And in the meantime?

Therapist: Indulge yourself. Clothes. Make-up. Try living like a woman.

Patient: What about my wife?

Therapist: Ah. She’ll probably need to see a counsellor too.

Patient: What happens at GIC?

Therapist: They will tell you to live as a woman for a year, just to make sure, then give you hormones to make you more feminine, and surgery to make you female. You’ll probably want some vocal coaching too.

Patient: So I get to be a woman?

Therapist: You already are.

Patient: Really?

Therapist: Yes. Specifically, you are transgender, male to female, which makes you a trans-woman. You always have been. The sex you were assigned at birth is incompatible with your gender, which is female. It will take a while but once you have completed the process of transitioning physically to a woman’s body you will be at peace with yourself.

Patient: But I’d rather be a man.

Therapist: It doesn’t work like that. But don’t worry, you’ll be much happier as a woman.

Patient: Thank you. That’s such a relief. I feel better already.


That might be a shorthand version of a conversation which may take place over several sessions but the essential elements are common. As the World Professional Association for Transgender Health (WPATH) states in its Standards of Care (2011), “The overarching treatment goal is to help transsexual, transgender, and gender nonconforming individuals achieve long-term comfort in their gender identity expression.” Consequently, the whole transgender community, patients and professionals, inhabit a bubble where satisfying the gender is the only game in town. For all the liberal, accepting, accommodating attitudes which abound within the bubble, there is ultimately one route to happiness: satisfy the gender.


It was not always thus.


In 1949, surgeon David Cauldwell first used the term ‘transexual’ in his essay Psychopathia Transexualis to describe individuals whose sex assigned at birth was different from their gender identity. Cauldwell had no doubt where the problem lay.


“When an individual who is unfavorably affected psychologically determines to live and appear as a member of the sex to which he or she does not belong, such an individual is what may be called a psychopathic transexual. This means, simply, that one is mentally unhealthy and because of this the person desires to live as a member of the opposite sex.”


And if that wasn’t clear enough ...


“When an individual fails to mature according to his (or her) proper biological and sexological status, such an individual is psychologically (mentally) deficient. The psychological condition is in reality the disease.”


Cauldwell believed it was all a matter of upbringing, and noted that such problems were far more prevalent amongst the affluent because the poor had more pressing issues to worry about. In fact, Cauldwell’s famous Psychopathia Transexualis could adequately be characterised as a pompous account of an ham-fisted attempt to deal with a solitary female-to-male (FtM) transsexual, utterly undermined by Cauldwell’s own ignorance, prejudices and preoccupations. Reading it in 2016 one wonders what on Earth he thought he was doing. Nonetheless, Cauldwell was one of the leading sexologists of his time and this (outrageous!) article made him a pioneer in the understanding of transgender issues.


Cauldwell’s orthodoxy would not last for ever, however. Harry Benjamin MD did for it in 1953, and then finished the job in 1966 with publication of “The TRANSSEXUAL PHENOMENON”. He viewed any attempts at changing the mind of the transsexual as ‘futile’ and ‘useless as to cure’. Rather than paraphrase him I reproduce below his central denouncement of psychotherapy (beginning on pp53).


Psychotherapy in transsexualism

Psychotherapy with the aim of curing transsexualism, so that the patient will accept himself as a man, it must be repeated here, is a useless undertaking with present available methods. The mind of the transsexual cannot be changed in its false gender orientation. All attempts to this effect have failed.


Dr. Robert Laidlaw, chief psychiatrist at Roosevelt Hospital, New York, has studied a number of transsexuals and has come to the conclusion that "psychotherapy has nothing to offer to them," as far as any cure is concerned. In numerous conversations and in psychiatric reports, Dr. Laidlaw considered the transsexual's state "inaccessible to psychotherapy."


Dr. John Alden, a prominent psychiatrist in San Francisco, fully concurs with this opinion and has repeatedly stated so. Numerous other psychiatrists agree, to my own personal knowledge. (See psychiatric reports in Chapter 7.)


In my own practice, I have seen ten or more patients who have been in analysis for as long as three and more years without the slightest change in their transsexual attitude.


One might seek respite in the qualification that it is a useless undertaking “with present available methods” and hope that some new method might help. Benjamin was not unaware of hypnosis and, indeed, approved its use in the treatment of transvestism saying (pp51),


“There are instances, however, when transvestism may be a great handicap for the patient and he would then be ready to undergo treatment with the hope of being cured of his strange and embarrassing compulsion. He may be in love with a girl whom he wants to marry and who would not tolerate transvestism. He may be disturbed and annoyed with himself or feel that his job is endangered. Or his family may have found out and may urge him to seek psychiatric help. Psychotherapy, possibly with hypnosis, would then be the method of choice, and if the patient persists long enough in an honest wish to be cured ("honest" at least in his conscious mind), success may be attained.”


But Benjamin was absolutely adamant that psychotherapy had no curative role to play in the treatment of transsexuals. Their only hope for happiness lay in hormones and surgery. And that, I fear, is from whence today’s orthodoxy derives. Hence the WPATH advocates provision of care “that affirms patients’ gender identities”. “Psychotherapy is not intended to alter a person’s gender identity.” “Typically, the overarching treatment goal is to help transsexual, transgender, and gender nonconforming individuals achieve long-term comfort in their gender identity expression.” That’s the prevailing dogma; today’s orthodoxy. Anything else is ‘unethical’. That probably shares its basis with the distaste for ‘correcting’ homosexuality. Homosexuals who want to be straight are told there is nothing wrong with homosexuality and, rather than trying to become straight they should learn to embrace their homosexuality. Equally, there is nothing wrong with wanting a body to match your mind so go for it, don’t fight it.


There is, of course, nothing wrong neither with homosexuality nor transsexuality. Both are biological. But neither is there anything wrong with dark hair but people are still allowed to be blonde if they choose – and dark hair is just as biological. Transgender therapy options have become politicised and it is all pro-mind, anti-body because the body doesn’t have a voice.


Richard Ekins (of Colraine and Ulster University’s Transgender Research Unit and Archive) observed that ‘contemporary western transsexuals are as much the product of Harry Benjamin as contemporary psychoanalysts are the product of Sigmund Freud’. I’m not exactly sure what he meant by that as he seems to compare patients (transsexuals) with therapists (Freud). If he meant that the Benjaminian care of transsexuals today is as outdated as the Freudian care of anyone, then I am inclined to agree. This is not mere wishful thinking, as the WPATH SoC also states that (pp8)


“Often with the help of psychotherapy, some individuals integrate their trans- or cross-gender feelings into the gender role they were assigned at birth and do not feel the need to feminize or masculinize their body.”


Benjamin, it seems, was wrong.


And yet the care of transsexuals remains firmly rooted in the Benjaminian paradigm. The prevailing orthodoxy changed from Cauldwell to Benjamin and is, I think, at least due a reappraisal. Unfortunately, anyone qualified to speak on the subject is likely to inhabit Benjamin’s bubble and might be less than entirely objective.  Everyone else is unqualified to speak. That may explain why we are still wedded to Benjamin.


When it comes to deciding how to help someone whose sex and gender are incompatible the health care community seems to have an institutional blind-spot where trans-gender (as opposed to trans-sex) should be. From the very outset people are described, not according to their situation, but their destination. Why is it that someone who has a male body and a female mind (MBFM) is described as ‘Male TO Female’, or ‘trans-woman’? The implication of both is that female/woman is the appropriate and inevitable destination. The very definition of ‘transsexual’ is a person “Having changed, or being in the process of changing, physical sex”. ‘Trans-‘, itself, is not the Latin prefix meaning ‘across’ (‘across-woman’?) but an abbreviation or inference of ‘transition’ and the transition in question is a physical one. It is the body which must go from male to female; the mind is there already.


Where is the nomenclature for the MBFM who wishes to change their mind (‘trans-gender’, or so it should be), and have a male (or more male) gender identity to go with their male body? Where is their encouragement? Where are their psychotherapists? Where is their validation? One of the SoC authors told me that the integration of trans-gender feelings into one’s birth-assigned sex was something that could “Only emerge out of long term therapy and reflection”, but could not be the therapeutic objective. And yet “the overarching treatment goal is to help transsexual, transgender, and gender nonconforming individuals achieve long-term comfort in their gender identity expression”. That is not even-handed. That is biased and prejudicial.


I am not the first to ask such questions, or be curious about what some see as the transgender community’s ideological straightjacket. The typical response seems to be an assumption that anyone with the temerity to question the supremacy of the Benjaminian paradigm must be transphobic. Of course, individuals and organizations who are transphobic will ask awkward questions. That does not mean, however, that everyone asking difficult questions is transphobic but the fear of being branded as such is a real disincentive.


I do not mean that every MBFM should want to be a man; far from it: simply that they do not all want to be women, yet scant regard is given to those who don’t. I imagine this might be due to a sense that validation of MBFMs wishing to be men could possibly complicate, confuse or undermine efforts to support those who wish to be women. Perhaps it is easier, for all concerned with pursuing a male to female transition, if there is no alternative. But it should not be the case that the well-being of MBFMs wishing to change their mind rather than their body, and be men, need be sacrificed for the sake of the majority (I suppose) who wish to be women.


In any case, does the mind or the body really have to change? Where MBFMs experience anxiety, depression and suicidal thoughts they are likely to be diagnosed with gender dysphoria. They are not happy, it is said, because their self-identified gender does not accord with the sex assigned at birth; i.e., they have a female mind but a male body. I suspect much of the discomfort is caused by the conjunction, ‘but’, which discomfort might have been lessened had it been ‘and’. I do not know – and I’m not sure anyone does – to what extent the dysphoria is a consequence of an innate conflict between form and feeling or, alternatively, a product of the pressure and effort to pretend to be otherwise. Thus, if one were able to grow up having a male body and a female mind and not having to pretend otherwise, how much relative dysphoria would be experienced? My guess is, less.


The Cri de Coeur is always “I am a woman trapped in a man’s body” but never, “I am a man stuck with a woman’s mind”. I suppose that is because the mind has a voice, and the body doesn’t. I wonder what the body would say if it could talk. Would it, perhaps, echo the sentiments of sexologist David Cauldwell who, advising a young woman who wanted surgery to be a man, said “It would be criminal for any surgeon to mutilate a pair of healthy breasts and it would be just as criminal for a surgeon to castrate a woman with no disease of the ovaries or related glands and without any condition wherein castration might be beneficial.” At the time, certainly, Cauldwell would have considered the removal of heathy male genitalia as equally ‘criminal’, and today we do not encourage people who request amputation of healthy limbs – because they believe it will make them feel better – blithely. Indeed, Angelina Jolie’s decision to have prophylactic mastectomies was not greeted with unqualified approval, notwithstanding her family propensity for breast cancer.



Post-operatively, does the trans-woman have a Female Body to complement their Female Mind. Yes, is the prevailing wisdom. But do they really? Are their ears or feet or elbows different? Or their heart or kidneys or spine? Is it not the case that they still have a male body but with some female modifications? No doubt, for some, that will be an improvement and may address any gender dysphoria. It comes at a price, however, not simply in terms of the financial costs but (and this rarely gets mentioned) other dysphoria which may come as a result of changes in one’s milieu. Dhejne et al’s 2011 paper, Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery concluded, “Even though surgery and hormonal therapy alleviates gender dysphoria, it is apparently not sufficient to remedy the high rates of morbidity and mortality found among transsexual persons.” Trans-women risk a similar set of adjustments in their orbit as do men (particularly) suffering economic misfortune. They can lose their wife, their children, their home, their job and often find themselves anxious, depressed and having suicidal ideation. Plus ça change ...  And, of course, the annals of cosmetic surgery are littered with people who wanted bigger breasts because then they would be happy, only to find that bigger breasts did not make them happy. Just as weight loss doesn’t necessarily lead to happiness, neither does cosmetic surgery.


I dare say that all the patients and health care professionals in the transgender community will assert that the risks and downsides of transition are well known and equally well catered-for in the counselling offered to everyone who transitions. Even so it happens, necessarily, in the context of the Benjaminian bubble. It must do because, as we know from the WPATH SoC, “Psychotherapy is not intended to alter a person’s gender identity”. Sometimes, it should be.


There are MBFBs who are men stuck with a female mind. They wish to change their mind to Male, and keep their Male body. (Their spouses, and children, would prefer that too.) Despite Harry Benjamin, “with the help of psychotherapy, some individuals integrate their trans- or cross-gender feelings into the gender role they were assigned at birth and do not feel the need to feminize or masculinize their body.” It can be done.


It must be understood that the acceptable therapeutic alternative to gender dysphoria cannot be a different type of dysphoria. People who wish to change their birth-assigned body-form must be respected, supported and assisted. The same respect, support and assistance must be available to people who wish to change their birth-assigned gender. ‘Identity’ does not comprise gender alone. Sex-identity is as significant as gender-identity and, ultimately, identity is more than the sum of sex and gender. Transition is a valid option for those who cannot escape dysphoria any other way, but it should not be the only game in town.


The Cauldwell paradigm was wrong. The Benjamin paradigm is flawed. A new paradigm is required which has physical transition as an option, but not the sole objective.


Barry Thain


NB. I have focused on MBFMs but the same principles apply to Female Body Male Minds (FBMM).


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