Transsexual Analysis: 8. How to treat?

Transsexual Analysis

Nature vs nurture: humans are diverse  |   Diversity in society  |   Woman in a man's body?  |   Trauma can shape us  |   Emasculation trauma

Trauma and sexuality  |   Perversion or lifestyle choice?  |   How to treat?  |   Superficiality  |   Problems and reversion  |   In summary

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:

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.

Anti-trans activists

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.

Assessment safeguards

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.

Risk assessment

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.

Unrealistic expectations

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:

By contrast, most transwomen were brought up with typical male expectations of, and tutoring in, independence and enterprise, advantages too many girls women still do not enjoy. Boys are told to be tough, to be logical, to make and fix things around the house, to not cry, to excel at sports, to date girls. Regardless of how successful, or welcome, those lessons were, the experience is still different.

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:

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.

Professional responsibilities

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:

Late onset transsexuals (LOTs)

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.

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