8. How to treat?
At some stage, a number of those who experience ongoing and intense autogynephilia present themselves at psychiatrists' offices and gender clinics, requesting assessment for a sex change.
Assessing psychiatrists, as things stand at present, usually do not base their decisions to treat patients on levels of autogynephilia, but on whether a change will be in the patient's best interests overall.
More enlightened practitioners will sensitively present the available alternatives discussed in Chapter 7 (eg. gay, bi or hetero androgyny / gender-bending, transgenderism, crossdressing, etc).
Popular opinion regarding treatment
The above-mentioned approaches are humane, compassionate and practical, given the depth and longevity of many patients' autogynephilic feelings. However, such an enlightened approach flies in the face of common community attitudes, which are not always known for wisdom or compassion. The community at large, for the most part, tends to split loosely into three camps:
- Phobics believe that transsexualism is never right and
that no assessing psychiatrist should ever recommend hormone treatment
or surgery. Often these people hold fundamentalist religious beliefs and maintain
that those seeking gender reassignment should either be given intensive cognitive
treatment, be healed through faith in God, or rejected and punished for their
Another type of phobic is the redneck type which can be male or female; their (often) low levels of education being reflected in their high levels of fear of the unknown and unfamiliar. Some phobics feel threatened by gender-transgressors due to fear of their own unexpressed bisexuality. Others are simply misinformed by negative images of transsexualism presented in the populist media.
Phobics are usually strongly supportive of patriarchy. Yet ironically, another form of phobic is the feminist ideologue, who believes that sex and gender are inseparable, and as such engage in their own form of dogmatic fundamentalism.
- Pragmatists have little or no interest in trans-issues and therefore judge transpeople by conventional standards. That is, they tend to make strong distinctions between feminine and masculine types, often responding especially badly to those with a "genderfuck" approach. Many will be fairly tolerant of transsexuals who "pass" (if they find out) but ridicule those who don't. The pragmatic layperson's logic generally tends to go like this: "I can only understand it if she is exactly like a woman".
- Accepters are probably the smallest group (surveys seen by the author would indicate under 20%), often referred to as "the latte left", "the chattering class" or "left wing intelligentsia" by the tabloid press. These people have strong beliefs regarding human rights and may even gain pleasure in meeting those in minority groups because it gives them the opportunity to express their tolerant attitudes and satisfy their curiosity. Accepters will usually strongly in favor of women's rights and racial tolerance.
It should be said that there is much room for overlap between the groups, and the above is only intended as a rough guide.
Phobics and Pragmatists will suspect the motives of transsexuals who look, sound and and come across as unmistakably male. They think "Who on earth does this person think he/it is?". As such, there would be a strong majority of support in the community at large for non-surgical treatment of such autogynephilic individuals, a viewpoint almost invariably reached without regard to transsexual candidates' full circumstances.
Those who debunk the validity of sex change surgery as a matter of principle tend to share a single attribute: an almost complete lack of knowledge of the subject of transsexualism, usually making off-the-cuff motherhood statements based on simplistic belief systems. It could be argued that even former transsexuals who later claim that their sex change was invalid know little or nothing of transsexualism. By definition, they are not genuine transsexuals and have never experienced what transsexuals who are happy with their change (the vast majority) have experienced.
Plato's famous quote, "As empty vessels make the loudest sound, so they that have the least wit are the greatest blabbers", would appear to apply most neatly to most debates in regard to transsexualism.
Some offshoots of religious organizations engage in reversion therapy. Given that, as stated in Part 4, trauma results in permanent changes to the brain, resulting in a permanent hair-trigger reaction to the primary trauma stressor (in this case, emasculation), such approaches seem doomed to failure in all but the mildest cases.
An exception is the former crossdresser/transsexual who engages in vociferous anti-trans activism; anti-transsexualism becomes their raison d'etre.
In this case, the person will frequently refer to his former days of cross-presentation and often there will be pictures of himself cross-presented on public display. Such people often seek as much media exposure as possible, again, with obligatory cross-presentation images and talk about wearing women's clothing. This is essentially the same dynamic seen in the crossdresser who carries pictures of his crossdressed self in his wallet; he simply cannot let go.
Thus, anti-trans activists can still satisfy their cross-gender needs, most likely an autogynephilic desire to be publicly emasculated / humiliated.
As such, their approach could be thought of as parasitic, in that it satisfies their own needs while attempting to deny those of others, and lacking a medical background, risks causing considerable damage to any naive or desperate persons who come to them for help.
Because of the variability of transsexuals, existing in any combination of
femininity, masculinity, androphilia, gynephilia or autogynephilia, they can
be notoriously difficult to assess accurately.
While there is a 1 - 2 year real life test prior to approval being given for surgery, how can a doctor really be sure how a patient will feel in 3, 5, 10 or even 20 years' time? The author has observed one writer to a web forum who declared her intention to revert back to the male role an extraordinary 20 years after transition.
Many laypersons intuit a certain air on "invalidity" around sex changes, with its unscientific "woman trapped in male body" claims and transsexuals' own history of conforming slavishly to female stereotypes. On the other hand, the hardline "it's never right" attitude of conservative psychiatrists, reformed transsexuals and fundamentalists rings similarly hollow.
Some may believe that an emasculation trauma model pathologizes autogynephilic transsexuals. In a sense it does, but only in the context that one of the most common and highly effective "cures" for such trauma is gender reassignment.
Given the permanency of strong autogynephilic needs, any attempt at alternative
cures would appear counter-productive unless patients are so disturbed by their
feelings that their lives become dysfunctional. The issue becomes, what is the
best manner for such a person to express or deal with his/her autogynephilia?
The last thing a deeply gender dysphoric person (or any person with life difficulties) needs is "treatment" at the hands of an ideologue. Treatment of transsexuals by ideology was proven to be ineffective at best, and dangerously damaging at worst, some decades ago.
It is arguable whether advancements in behavioral therapy in recent years are capable of being appreciably more effective than the failed methods of the past. This is not to say that cognitive therapy should not be considered or attempted, but hormonal and surgical interventions should never be disregarded out of hand.
To refuse to consider all options, disregarding the extreme intensity of some sex change applicants' needs, is to invite the return of "backyard jobs" - self-mutilation, suicide and extreme marginalization. In this sense, transsexual issues parallel those surrounding abortions. In both issues, a failure to empathize to any extent with the people seeking treatment can result in disastrous waste. In both cases, those with limited or no knowledge of the issues seek to tell individuals what they should be doing with their lives and bodies.
In the heavily overpopulated world in which we live, surely the time is long overdue to discard primitive belief systems based on our "populate or perish" instincts?
It could be argued that the recent swing towards conservatism and fundamentalist religious belief systems is a backlash against a rapidly changing world and may well be a prelude to further social advancement, as per the usual "two steps forward, one step back" pattern of growth.
While this is not the forum to discuss sociology in detail, the basic point is that applicants for gender reassignment pose no threat to the species or the fabric of society and they deserve a fair hearing, even if this flies in the face of (poorly informed) majority opinion.
As mentioned earlier, certain types of feminist ideology is also anti-transsexual. Proponents of this viewpoint assert that transsexuals misguidedly, perhaps naively, believe that sex and gender are purely physical issues, and ignore the psychological aspects of our being.
While this may be true in some cases, this viewpoint undersells the many transsexuals who are acutely aware of this fact, often to a greater degree than most. Some transsexuals would argue that it is the wider public's view that sex and gender are purely physical that makes the surgery so essential. That is, to not have surgery would invite non-recognition of their changed gender status and their psychological femininity. This attitude is clearly encapsulated in a newspaper headline observed by the author, "If it's got tackle, then it's a bloke".
Despite their disparity, all brands of anti-transsexual ideologues share one thing in common: lack of empathy for transsexuals and their life situations. Any psychiatrist who strictly subscribes to the above ideologies is not suitable for any role that involves treatment of transsexuals because they will be unable to appropriately relate to their transsexual patients and could put their own ideologies ahead of their patients' welfare.
It is inevitable that a small minority of unsuitable sex change candidates
will "slip through the net" and come to regret what is, essentially, irreversible
surgery and/or hormone treatment. However, we must accept that risk is a
reality of life. No activity in life, and certainly no treatment, is failsafe.
Almost all professional and/or corporate activities incorporate risk management principles into their planning processes, a tacit acknowledgement that perfection is simply not possible.
Transsexual assessment is no different, hence the 1 to 2-year "real life test".
In practical terms, this period is often longer because of the time it takes
for pre-op transsexuals save up for the surgery.
The risk of misdiagnosed sex change applicants being adversely affected by social and hormonal gender changes they undertake, with or without surgery, must be balanced against the risks created by not treating applicants; suicide, self-mutilation, debilitating depression, with accompanying loss of productivity are typical results of poor or non treatment.
Nonetheless, assessments can still be improved by way of more sophisticated
models. The "woman trapped in a male body" cliche has quite simply become an
impediment to realistic assessment. Any such statement made by a gender change
applicant should act as a trigger for the assessing psychiatrist to further
explore the patient's issues; it demonstrates either a disconnectedness with
reality and/or a desire to gloss over the issues.
Other cliches which should be removed from the trans-treatment lexicon are, "I am a woman" or "I will become a woman" when the word "woman" is spoken with naive conviction, as opposed to being used as short-hand for realistic self-images such as "a woman-like person" or a "woman for all practical means and purposes".
As previously discussed, an M2F transsexual not only cannot be a woman (any more than a F2M can be a man), but has never felt quite like a woman or thought quite like a woman.
A highly feminine applicant may think in feminine ways - that is, in ways more similar to most women than that of their male peers - but that is not quite the same, as any woman will tell you. Some of the obvious differences between the experiences of transsexuals and those of genetic females are:
- Transsexuals were not brought up with the expectation of becoming a mother.
- They are rarely taught the arts of "proper" feminine presentation, homecrafts and behavior in their youth.
- They were not shaped by estrogen during puberty, with budding breasts, widening hips and the onset of periods.
- They were, at best, honorary members of "the girls club" in their childhood and teens, with their subtle games of acceptance and exclusion.
- They have not known the frustration of being over-protected sexually by their parents to safeguard against pregnancy, especially by fathers.
- They have not experienced those unique mother-daughter, father-daughter and sister-sister bonds.
- They have not experienced the pain and, sometimes, madness of the monthlies.
- They have not been pregnant, nor felt the expectation, hope or fear of becoming pregnant.
- They have not given birth or been a mother.
- Prior to changing over they have never been patronized by men as "useless" or "dumb" women.
While it is impossible for a male to feel quite like a woman or vice versa, this does not render their cross-gender invalid. Nor does it mean they cannot benefit by making the change. However, it does mean that those needs need to be realistically defined.
Realistic claims and expectations
Despite the above, transwomen can still become women in the world for all practical means and purposes. Feminine transwomen can be so much like normal women that the difference is not important in the greater scheme of things, at least for those without an ideological axe to grind. The only real exception in this regard is relationship issues, where a male partner may feel threatened by the potential stigma of being with a transwoman.
Transwomen may not be quite like genetic women, however normal female diversity is their ally. That is, we do not expect all women to be the same, so if a transwoman looks, speaks and smells enough like a woman and basically "vibes" like a woman, then it is perfectly possible for them to lead a fairly normal woman's life.
Less feminine transsexuals, too, can also find relief in making the change
and, knowing that "passing" is a lost cause, many still manage to
carve satisfying and effective niches for themselves in life.
Below are some of the more valid scripts for seeking a sex change:
- My personal qualities and attributes (physical and/or mental) are better suited to a feminine life than to a male one. I have felt uncomfortable and/or miserable in all of the male roles I have attempted to fulfil and I believe that I would function better in all aspects of life, and experience less rejection, as a woman.
- I will make a better woman than a man and will have a better chance of attracting the sort of partner I desire as a woman.
- I dislike being a man and being a man upsets me. I would prefer to be a woman and wish I had been born a girl.
- My male genitals are of limited use because I have desires to be sexually receptive but not to be in the active role, so I have little to lose.
- People don't recognize my feminine mentality or treat me in a way that feels right to me when I am in the male role because they see me through the lens of my male identity, so if I change my physical presense then people will simply take me "as is".
- I am worn out with the endless focus on cross-gender issues and/or the difficulties I face in swapping over and just wish be "one" - to reconcile my dual-identities and "just get on with life".
- I am sick of the obsession of it all - the waste of time and energy, the selfishness and self-absorption, the deceits, the subterfuge and the fears.
These are all valid and realistic issues and some, if not addressed, can be crippling and play havoc with a person's self-esteem and general productiveness in life.
In a patriarchal society that devalues femininity, a male seriously lacking in stereotypical masculine traits could be regarded as having a social disability because his social and sexual functionality is so limited.
Psychiatrists and other professionals not only have a responsibility to their patients but also to the community at large.
If a therapist believes that giving a patient "the go-ahead" for surgery will help her be a more useful, better functioning and more productive citizen, then it is hard to argue with the validity of that decision, especially if it later proves to be the right one. This approach places the importance of spirit, or mind, over that of the body.
Pioneer in gender dysphoria studies, Dr Harry Benjamin, was quoted as saying that if you cannot change the mind to fit the body, then change the body to fit the mind. Religious types may comfort themselves with Jesus' words: "If your right eye causes you to sin, pluck it out and cast it from you; for it is more profitable for you that one of your members perish, than for your whole body to be cast into hell".
In this context, the "sin" can be seen as a person being unable to lead a productive and happy life because s/he is too caught up on a maelstrom of inadequacy or dysphoria, "hard-wired" from childhood. Jesus' words could be seen as an affirmation of the of mind/psyche/soul over the body. This stands in stark contrast with the materialistic values of modern society.
Nonetheless, many gender swap applicants do have a change of heart during the real life test, a strong affirmation of RLT's effectiveness as an assessment tool. Some applicants' transsexual (ie. autogynephilic) desires may have been temporarily exacerbated by major events in their lives - marriage or career failure, or some other traumatic event. Once again, trauma can play a key role.
Some "failed" candidates suffer from psychiatric problems such as narcissistic, borderline or psychotic personality disorders, schizophrenia or, rarely, multiple personality disorder.
Again, issues must be explored thoroughly, with the guiding principle being:
"Will the change be to this person's, and society's, long-term benefit?"
Exploring the issues
Freed of the baggage of ideology and cliches, psychiatrists are more able to
practically help their patients to explore the genuine reasons behind
their wish to change over. This may or may not result in a rethink on the patient's
part. A psychiatrist's role here is not to push for a certain result
but to help the patient realistically explore their issues, to mediate facilitatively
rather than transformatively.
Surprisingly, there seems to be almost no discussion - either in the medical or trans communities - about the relativity of emasculation trauma and its role in transgender expression. In fact, the way contemporary medicos and TSs themselves appear to have missed the obvious link between autogynephilia and emasculation trauma is extraordinary.
Dr Ray Blanchard, while providing us with some useful ideas, has unfortunately
done so without sensitivity or an apparent desire to understand the deeper nature
and roots of transsexualism. His overly black-and-white, "snap-out-of-it-and-face-the-truth"
approach has pushed transsexuals and TS applicants with autogynephilic backgrounds
towards even deeper denial and self-delusion as they dig in to defend the validity
of their life positions.
Why wouldn't transsexuals deny their autogynephilic feelings when faced with the invalidating presentation of his ideas by his successor, Dr Bailey? Autogynephilic people often need to be reassured that there is nothing wrong with autogynephilia, and that it does not necessarily mean they are unfeminine, apart from its problems of self focus - where arousal (be it sexual or emotional) is associated with the self rather than with others, which can be alienating and depressing.
Further, the sexual aspect of autogynephilia generally gives way to emotional
attachment, the result being that the common stark definitions which are based
on sexual arousal cease to apply, providing those who have moved on from a fetishistic
past with an easy "out", as evidenced in numerous transsexual forums.
Some autogynephiles may benefit by channeling their self-oriented drives into more productive, other-centered, areas. Patients need help in examining the roots of their early emasculation feelings to give these feelings an identity, something with which they can grapple. To this end it may be possible to transfer autogynephilic desires, at least in part, to human-human contacts in some cases. For example, psychiatrists may subtly suggest to a sex change applicant with, say, crossdressing attachments that to be made love to by a man can also be thought of as an "emasculating" experience. This may help to move the focus further from the self and facilitate personal development.
Importantly, "emasculating experience" in this context refers to an autogynephile's view of emasculation as a child, because this is nearly always the driving force of autogynephilia. In adulthood, autogynephilic people may well develop mature, cosmopolitan attitudes towards sex with men, but still retain the sense of childhood taboo. This approach will be especially useful with autogynephiles with repressed attraction to those of the same genetic sex.
Such an approach needs to be handled with more subtlety than common approaches used, such as "Couldn't you try being gay?" or "You could always try anal sex", which are at best tokenistic and lazy, at worst, unempathetic and undermine the therapist-patient relationship.
Most budding transsexuals will bristle if a psychiatrist does not properly acknowledge the difference between gender dysphoria and homosexuality. This reaction could be the fact that homosexuality and transsexualism have a number of significant dynamic differences, despite certain similarities; it could also be due to internalized homophobia.
In the end, Gender Identity Disorder and autogynephilia are not disorders as such, but the result of friction between innate characterists due to simple human diversity and societal norms.
Early-onset transsexuals (EOTs)
Early-onset (up to early 20s) and late-onset TSs face certain unique issues:
- Having been exposed to the masculinising effects of testosterone for a shorter period, EOTs are more likely to "pass" and be therefore more capable of living a normal woman's life. This can at times create a sometimes-false impression that they are more "real" that late onset TSs.
- In cases where the person is extremely androgynous physically and feminine mentally, EOTs can essentially be seen as having a social disability, always being targeted for abuse or ridicule, being rejected in many social circles, and being unable to attract the kinds of partners they desire, and the pain experienced in their teens may drive some self-aware individuals towards requesting the role change.
- EOTs almost always experience less denial of their feminine aspects than LOTs, so they tend to be less affected by psychopathologic conditions that are caused by sustained denial over long periods LOTs. However, without considerable parental and/or peer support (which is more the exception than the rule) they may suffer trauma-related conditions in relation the bullying, violence and ostracism. Self eeteem issues and overcompensatory narcissism can result.
- EOTs have less life experience and are usually less established in life than LOTs at the time of transition, so they are at greater risk of "going off the rails", falling into drugs and/or prostitution. They are therefore more in greater need of parental or other adult support.
- Young people are necessarily more unstable than older people, and usually have had less time to ruminate on the issues, and less able to analyze their issues clearly. In some cases, they may be capable of living happy lives as gay men if they can find a suitable partner (bearing in mind that most hyper-feminine boys grow up to be gay men, not transsexuals).
- Some young TSs may simply be late developers and, without medical intervention, may grow into normal-range masculine physicality over time.
- EOTs sometimes struggle during the real life test, feeling frustrated at not being able to act out on their sexual feelings (without complications), lacking the experience to understand that one year is not such a long time in the greater scheme of things.
Late onset transsexuals (LOTs)
- Due to the long-term effects of testosterone, LOTs tend to be less likely to "pass" than EOTs. A number are too masculine in appearance to ever hope to lead a normal life as a woman. This can create depression and suicide risks.
- Some late-onset, autogynephilic transsexuals provide difficult-to-prove reports of their past history, such as childhood femininity and same sex attraction in order to make their transsexualism appear more valid. In some cases their attraction to men is more of an extension of emasculation needs than a desire for the men themselves.
- The additional life and career experience of LOTs means they can more readily deal with the costs of transition, especially in areas with strong anti-discrimination protections. However, transition for LOTs may involve significant risks and losses (eg. career, family, social networks), again presenting a significant depression risk.
- A homophobic social climate may contribute to their dissatisfaction with the male role. In some cases, moving to a more cosmopolitan locale may make it possible for a LOT to make an acceptable life as a gay male or "out" crossdresser.
- Similarly, internalized homophobia may be present, making the choice to be a woman more attractive than being a gay man or crossdresser.
- Some may, after a long period or struggling with trans-issues, suffer from established personality disorders and mental illness.
- Another potential souce of depression can occur when the person realizes that the friendships and relationships they have formed were conditional on their pretending to be someone they are not.
Trauma therapy for autogynephiles
Again, the word "emasculation", as used in the above context, refers to the remnant "child" portion of the personality that drives autogynephilic desire, not necessarily current feelings. By the same token, small and sensitive boys who felt inadequate as children can grow to be strapping, competitive and impressive men who later marry and have children. Nonetheless, strong autogynephilia based on childhood trauma may still be present.
If the trauma is great, the individual's self image may not have adjusted to his new physicality and/or mentality. As with any trauma victim, treatment takes patience; it can take some time for trauma patients to face their feelings and their realities head on.
Regularly reassuring sex change applicants that explorations of childhood issues are not a threat to their assessment, but simply a way of helping them enjoy better relations with others (and themselves), may encourage them to open up.
This is one reason why it is essential to not dismiss gender-swap applicants
on autogynephilia alone. Sincere assessing psychiatrists sometimes find
this conflict of interest between their dual roles of helper and gatekeeper
to be frustrating and an impediment to proper treatment.
It is therefore important that possible feelings of emasculation in formative years - and the current triggers and reactions to those triggers - are properly investigated. Trauma patients generally suffer gnawing, faceless fears. If these fears can be rendered tangible, then patients can start feeling them as an adult rather than experiencing the sensations they felt as children when the triggering crises had actually occurred.
Once an autogynephilic person faces his/her demons, then cognitive and behavioral
approaches such as P-A-C
(transactional analysis) and game
theory may help consolidate the therapy. Again, the aim is to heal, not
to judge. Good results in this regard can be achieved regardless of the outcome
of the assessment.
"Passing" the test
If, one to two years of real-life test has been completed and a thorough investigation of
the applicant's possible emasculation issues have been conducted, and the applicant
appears to be balanced with adequate social support systems, and she still
wishes to push ahead with the change, then it is hard to argue that the wish
to change over is invalid.
If that is the case, you will very likely (taking into account risk management principles) be left with a mix of what is politically-incorrectly termed "true transsexuals"; that is, males who are more feminine in body and mind than the vast majority of other males. There will also be some individuals who may still appear to be masculine in mind and/or body but whose autogynephilia is so "hard-wired" that comfortable life in the original gender role is impossible, being impervious to medication and/or cognitive treatment.
If the latter group are otherwise realistic and balanced (using any other
recovering trauma patient as a guide), then one would expect that surgery or
hormone treatment should help them become happier and better people and citizens.
And that is what treatment is really all about, rather than deciding who would "make a good woman" or not, or trying to enforce simplistic ideologies.