Truth and narrative

“True story” is an oxymoron.

I phoned the Tax Credits helpline for advisers, and got nowhere. “You’re being very condensating,” said the man I was referred to, and after half an hour my brain was so cabbaged that I knew he meant something else, but did not know the word for it. Thank you, you don’t need to say it now, I worked it out for myself later.

In the nineties I knew a man, still the most boring man I have ever met. I can’t remember his name, but it ended in an í sound, a contemptuous diminutive, Nicky or Ricky or Donny or something- anyway, he got very drunk on whisky, and ever thereafter could not drink it. He found a sip nauseating. Dismissively contemptuous, Neil said he probably had had no head for it anyway, he got drunk on a couple of glasses.

I associated those stories. “Condensating” was the moment I got nowhere with the benefits authorities, that I could not take any more. I cannot bear it. I could not bear another such conversation, it nauseates me.

Another myth. Margaret saw me as Clare for the first time, and said, “It’s as if you are acting when you’re Stephen, just you when you’re Clare”. Aha, I am a woman really, I am right to transition. The story becomes my conclusive evidence that I am right, the judgment of another person which I cling to, and take out for reassurance from time to time. It is my self-image: I know who I am, and “you’re just you when you’re Clare” is part of it.

Then about a year ago, I took off my wig and put on my cycle helmet, appearing androgynous, but continued talking, and H said “You have this lovely male energy”. Her beliefs, her politics, or her individual judgment of me need have no bearing on me, but have had. I could if I wanted call that comment on Wednesday 2 March 2016 the decisive moment

where my lies came apart
where my truth was undermined

Several times I have picked on particular dates where all changed, changed utterly for me. H has changed my view of the world. I am not sure if I have ever been entirely sure that I am a woman- I joked “I don’t know, and neither does my psychiatrist”, and said “I’m both and neither and in between”. Her word “lovely” just makes the blade sharper.

Either it is liberating- yes, I am a man, I need no longer assert a falsehood that I am a woman- or terrifying and destructuring, and I try to piece together the shards of my framework, world map, understanding which lets me navigate the world. “I am a man, but transition was the best I could do,” I say. “Bad things happen to good people.”

Or I create a new narrative. “I am a trans woman”. I have the right to be this way.

Brexit and Trump, and possibly this year Fillon and AfD, change my comforting narrative, one which is probably yours too. It is a debased Whig version of history: just as the Battle of Bosworth Field in 1485 was a decisive moment of progress, which changed the way of doing politics in England from battles to individual murders, a clear improvement, so Obergefell v Hodges was a step into the light, which could not be reversed. A Tory version of history, that there are random events with no broader significance, is reasserted, so that Trump’s Muslim ban is not a pathetic attempt by the failing forces of reaction, but a random event of quite as much significance as Obergefell.

We need to change our stories. Since 2016, our stories have not been the Truth, but a comforting lie to help us get through the day without collapsing on the floor, screaming. The words “male energy” are a stake through their heart, as is the Muslim ban. “Do your duty, Republicans,” says the New York Times. “Prosecute him!” Trump meanwhile promises a new Muslim ban which will be less vulnerable to judicial scrutiny.

I have been reading of stories. Here’s Rachel Cusk in the NYT:

In psychoanalysis, events are reconstructed in the knowledge of their outcome: The therapeutic properties of narrative lie in its capacity to ascribe meaning to sufferings that at the time seemed to have no purpose. The liberal elite are in shock; they fall upon the notion of the victors’ regret as a palliative for their mental distress, but because the referendum result is irreversible, this narrative must adopt the form of tragedy.

And, writing of her mother

She didn’t care what she said, or rather, she exacted from words the licentious pleasures of misuse; in so doing, she took my weapon and broke it before my eyes. She made fun of me for the words I used, and I couldn’t respond by threatening her with death. I couldn’t say “I could kill you” because it wasn’t true, and in language I had staked everything on telling the truth. I have had that experience debating Creationists: I try to persuade, using truth, they simply assert their Beliefs. “It cannot be so, because of Genesis.” It was bad enough debating a blogger on the other side of the world- how much more terrifying, to face your own mother’s assertions?

Thus saith the LORD.

There is no answer to that. Tim built an impenetrable wall of language to shield him from- the truth? Or just, my understanding of the World? The defeated liberal is abashed, so less confidently assertive.

Anna Blundy, in a completely different essay- a short column not a hefty work like Rachel Cusk’s- also addressed making sense of truth with words. Language distances us from our real thoughts and feelings in an almost defensive way (the fact that it makes us feel better to have named something, perhaps is even indicative of that)… we’re trying to repackage something into a digestible form that will make the symptom of the sufferer more bearable.

Surely it is better to face the unvarnished truth? This essay says that news broadcasts and advertising alike end up telling stories… the mastery of danger, the satisfaction of desires and the ultimate restoration of morality. But here, an effort is made to lead people to believe that the story accurately depicts people and events. As a result, all end up profoundly falsifying what they portray, once again mixing faithful and manipulated images, and fact and fiction in seamless ways so that it can be hard to tell where one ends and the other begins. The attack is mitigated by the fact that the essay itself has a similarly comforting structure, where the restoration of morality is us all becoming more sceptical about the media.

It is not at all reassuring to say that I can’t bear another phone conversation with the benefits authorities. I could say, well I had hundreds before, many of them successful, or simply that I should eschew predictions of the future, which may just be paranoia, and concentrate on the actual task. I know what the task involves. Fear of what bad things will happen and how I will respond when I fail just get in the way.

This is my two thousandth post, on a blog about me, truth, trans, the world, and everything that interests me. I do it to be read, and achieve less of that than I would like. Joanna wrote a short post recommending one of mine, and I am grateful for the recommendation, because my post got more than three times the views from it, than 75% of my posts get from all sources. This is my least worthwhile goal, to see that I have had more views. Writing of Donald Trump stretches my writing, but gets fewer views, as most of my readers come from a Trans site, so I restrict my choice of subjects to get more views. Posting daily gets more views. I get a tiny dopamine hit when I see my page-view numbers have increased- nearly 198,000 views in five and a half years.

I might be better to write longer essays. I could develop an ability to analyse an idea in greater depth. This is not that: I have quoted undigested screeds from three essays and some of my own thoughts on truth, rather than explained the essays, created a satisfying narrative argument in my own words, and polished it. Writing around 500 words a day is good practice, but I want to edit and structure something more satisfying than these short pieces. I have published just one 2000 word article. I love Rachel Cusk’s essay- how I would love to write something like that!

I blog to tease out my understanding, as well. It is psychoanalysis for me, repackaging reality into that digestible form. So I have written how transition or surgery was the best thing I could have done, and the worst, in separate pieces, and wonder how to unite them.

St Clare

Research on trans

A combination of hormone therapy and surgery improves gender dysphoria and other areas of psychosocial functioning. So says WPATH, the World Professional Association for Transgender Health. You would think they should know, and would back up their assertion with evidence; you would be right.

A study may consider patients through the treatment process, or assess patients after treatment. Because the researchers are making the assessment at all times, a prospective study is more reliable. A prospective study of 325 patients reported in 2005 that psychological function improved after therapy, as did body-satisfaction. Surgery alleviated gender dysphoria, and fewer than 2% expressed regret after therapy.

I went to the study abstract. It is even more positive: After treatment the group was no longer gender dysphoric. F-M and “homosexual” (ie, F-M attracted to women, M-F attracted to men) functioned better than non-homosexual and M-F. Two non-homosexual M-F people expressed regrets. Clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance, says the abstract, who may require more therapeutic guidance.

That is, people need support throughout the treatment process. It is not a mere medical matter of administering hormones and surgery, but psychotherapy. Perhaps psychotherapy without gatekeeping or assessment for hormones: a claim of gender dysphoria should be sufficient to get hormones.

Surgery has continually improved, and there has been a steady increase in satisfaction with its outcomes, especially after the Standards of Care were published. Johns Hopkins University medical school ceased to provide treatment after its study found no improvement after treatment; but that study was in 1979. Even in 1981, before the Standards of Care, in a retrospective study of 283 MtFs 71% reported improved social and emotional adjustment.

I wondered if the reference to “observational” studies meant that outcomes were discerned by the researchers, rather than reported by the subjects. That does not appear to be the case: an observational study is one where the researcher cannot randomise assigning the subjects to a control group or a treatment group. Patients would not participate in a study where they could be refused treatment, and researchers could not be unaware which patients had received treatment and which had not, so a randomised controlled trial is impossible as well as unethical. In a review of studies conducted between 1961 and 1991, involving over two thousand patients, 86% were assessed by researchers as stable or improved in “global functioning”. 14% were worse, but who could know how they would have progressed without treatment?

We live in society, where we do not fit. We transition whether we receive hormones and surgery or not, though many are encouraged to transition by medical support. The real control would be a society where diversity was welcomed as the gift it is.

Treatment is justified, and is improving. Doctors providing treatment act ethically. You can entrust yourself to their care.

gwen-john-the-convalescent

 

Inspiration

Where, in the late 1970s, would you get the idea of cross-dressing from, anyway? Dick Emery, perhaps:

Or there was an orgy scene in I Claudius, where the bra of the fleeing coquette is seen to be stuffed.

Where did I get the idea of cross-dressing from? I just wanted to, so I did. Arousal, compulsion, shame followed almost immediately-  not in my memory of the first time I did it, but ever thereafter. I knew no-one must know I did this awful thing, but then people keep sexual matters private. The people I saw in women’s clothes were women.

Here’s Johan Zoffany, The Last Supper.

john-zoffany-the-last-supper-detail

Zoffany, like most artists, used real people as models for his Last Supper. St John, leaning on Jesus’ left shoulder, is WC Blackwell, police sergeant of Calcutta, a cross-dresser who would round up criminals while dressed as a woman. Very fetching she looks, too. At different times, there are different levels of acceptance, and sometimes we can be brazen. You hear about other people who do it: I read two articles in the Mensa magazine by Christine-Jane Wilson, and got in touch. Her magazine published my poem, but we never met. But we do it spontaneously, before we get the idea from others.

Rachel the Trans Philosopher wondered how she knows she is trans. She does not have direct knowledge that she is female, contrary to The Script, “I knew I was a girl from the age of five”. She infers she is trans from her desire to transition and her delight in proceeding with it. Either it’s circular: I have the desires, therefore I am trans, therefore the desires are right for me; or it is “I can do what I like”: I need no excuse to follow these desires. I judge them harmless.

I don’t think I would have transitioned without the example of other people.

I read of a man executed by drowning in the Nor’ Loch, where Princes St Gardens are now, for bestiality. It was done at 4am, because he told his trial that he got the idea from a previous execution. It has never appealed to me, but I condemn it less than others might because of my own inexplicable desires.

Explanations tend to be descriptions- I express female because I want to, with no justification for the desire, because it needs none; or rationalisations- I am in some way a woman, which sounds good until someone asks what that could mean. We may tell ourselves stories about it because they are the stories we have heard, or we make up our own, but we start cross-dressing spontaneously, because that is what we want to do.

Issues around gender

I am reading the World Professional Association for Transgender Health standards of care. There are overlapping issues around transgender.

First, there is the cultural concept of how a man should be, and the character of the person who does not fit that concept. Then, there is the enforcement on the person of the cultural concept, by family and peers. Then, there is the amount to which that person tries to hide difference, even from themselves, and the distress arising from the difference. Some people will not be bothered that others apparently object to their gender presentation, some will take it to heart. Transitioning is one solution to problems arising from these issues.

WPATH say Being Transsexual, Transgender, or Gender Nonconforming Is a Matter of Diversity, Not Pathology. Well, yes. Doctors might get involved because of the distress, or because the person wanted medical help with transition, but not to make the person conform to gendered expectations. We suffer stigma, so abuse and neglect from family and society, which can cause anxiety and depression.

WPATH say Treatment is available to assist people with such distress to explore their gender identity and find a gender role that is comfortable for them …What helps one person alleviate gender dysphoria might be very different from what helps another person. I feel treatment should also be available for the person who does not present with distress, because they have decided to transition. Aversion is an emotional response- “I find my genitals unpleasant”- but people might show dignity, and not wish to express that emotion as distress. However the diagnosis in DSM is gender dysphoria, or distress.

Find a role comfortable for the patient- transition is only one of several possibilities.

The standards of care are based on European and North American experience, and there is a wide diversity in cultural construction of gender around the world. Doctors elsewhere should apply the principles of the SOC being sensitive to the local culture and to patients’ needs. These principles include the following: Exhibit respect for patients with nonconforming gender identities (do not pathologize differences in gender identity or expression); provide care (or refer to knowledgeable colleagues) that affirms patients’ gender identities and reduces the distress of gender dysphoria, when present; become knowledgeable about the health care needs of transsexual, transgender, and gender nonconforming people, including the benefits and risks of treatment options for gender dysphoria; match the treatment approach to the specific needs of patients, particularly their goals for gender expression and need for relief from gender dysphoria; facilitate access to appropriate care; seek patients’ informed consent before providing treatment; offer continuity of care; and be prepared to support and advocate for patients within their families and communities (schools, workplaces, and other settings).

gwen-john-dorelia-in-a-black-dress

Psychotherapy for trans people

Is therapy completely worthless, or might it have some use?

Reparative therapy has always failed, because of how it envisages health, and what it attempts to do. Aversion therapy attempted to make the victim associate their desires with pain, fear, discomfort and misery. If the therapist, claiming that the person needs to control their desires, to fit in with normal society, prevented the person from acting on their desires, that would be a “success”.

For me, any organism seeks out its own health and good. Just as a broken bone knits together, so the mind turns towards what will fulfil it. People are different, with different gifts, and that fulfilment is different for each. The individual does not cross-dress because she is disgusting, and wants to be disgusting, as my mother said, but as the best way she knows of approaching health. The question would be, why does she cross-dress? What does it achieve for her?

The aim would not be to prevent the person dressing, but to find options for her. Is there another way of proceeding, which she prefers? The choice would still be the patient’s. Barry wrote of a person who transitioned role and was going to have surgery, but then reverted and found a partner.

You might favour transition if you imagine that men should be a certain way, women should be a different way. If men are generally more “masculine” whether this comes from nature or nurture or social construct, you may be more comfortable expressing yourself as a woman. Even if you don’t believe these restrictions are appropriate, you might observe that they exist, and feel you will be more accepted after transition.

Intensive psychotherapy would find your wounds and scars. What are you repressing? What shames you, what do you fear in yourself? We are a social species, and trans women in particular are intensely pro-social. We are made in the image of God, loving, creative, powerful, beautiful. What do you want from life? Again, the question is not “Why are you so broken that you contemplate transition?” It is “Who are you?” I have addressed this question after transition, as everyone must, some time.

norah-neilson-gray-little-brother

The effects of hormones

Taking oestrogen reduces your blood pressure. Or not.

There was a study published in 2015 of 23 trans women and 34 trans men commencing hormone treatment, measuring blood pressure, BMI, lipids and sex hormone levels at the start of treatment and six months after. Trans men continued menstruating throughout the time. The trans women’s blood pressure reduced from 130 to 120.

When a doctor takes my blood pressure I become tense, and they tell me this may give a falsely high result. Trans women beginning treatment are likely to relax. They are on their way, so their stress will reduce. So blood pressure reduces. These people are undergoing such an extreme life change that it is impossible to isolate one possible cause of change of blood pressure. “The study had insufficient power to detect other associations,” the summary says, and I wonder, decades after doctors started giving us hormones, that so little has been done to find what they do to us.

I wanted to read the article Priorities for Transgender Medical and Health Care Research, but it will be published on 1 April.

From 2007, there is an NHS leaflet, addressed to both trans men and women. The aim of hormone therapy is to make you feel more at ease with yourself, both physically and psychologically. That is, the fact of taking hormones, whatever effect they have physically, affirms your transition so makes you feel better. Some people find that they get sufficient relief from taking hormones so that they do not need to change their gender role or have surgery. I had decided to transition: I am transsexual, therefore I will transition to expressing female. A more fluid way of proceeding, trying things out, would have been better. I railroaded myself.

Hormones will affect your appearance, but you need to be realistic (the leaflet says). Fat may be redistributed, hair loss may reduce though probably not significantly reverse, facial hair may be easier to electrolyse, you may grow breasts though that might take years- ten years, in my case. You may have blood clots in brain, heart or veins: a woman I met in Thailand had a stroke a few months later. You should stop smoking, which increases risk: I was told you could not have hormones until you stopped.

If you start to feel better this is a good sign that you are having the right treatment. However, I railroaded myself. I committed to the whole thing. Moving forward on that track made me feel better, because I thought I had the solution, waiting at the end of the track.

You may find erection and orgasm harder to achieve. You may become infertile: it is not known when. You may become less interested in sex. This was a good thing for me, as I was so thoroughly ashamed of it, but I might have found better ways of living with it.

It is unethical and impossible to conduct a study comparing transition with other modes of treatment. People wait for years to see an NHS psychiatrist, and have definite ideas of what treatment we want. From Lili Elbe onwards, doctors have seemed delighted to have a subject they could try things out on, rather than merely wanting to find the best way to help, which might be to do nothing.

“You will need to take hormones for the rest of your life.” I was told I had to, to avoid the risk of osteoporosis.

Study: Effects of Cross-Sex Hormone Treatment on Transgender Women and Men.

Patient leaflet– A guide to hormone therapy for trans people, pdf.

norah-neilson-gray-self-portrait-1918

The pink fog

Do not transition. Self-respect is a human right. Transition is too great a price to pay for self-respect.

Transition is a way to get self-respect, and so is tempting. You have never felt you are a real man. You feel less. You try to make a man of yourself, and always feel inadequate. You have the shameful secret that you cross-dress.

But what if you are trans? Then, Being a Man would be obviously wrong for you. You could express yourself in a way which fits your personality. You would be free. You would have The Answer- you know why you have never fitted in, and what you can do about it. The delight you feel when contemplating transition and the misery you feel at presenting male is confirmation. Having a long and difficult journey to reach freedom, every step you take on it delights you. You are in the pink fog, a wonderful term I got from my friend Joanna Santos, whose whole post is worth reading: Dreaming about the aspects you think you would relish about being a woman can lead you into a deep pink fog which can sometimes confuse things.

You ask yourself if other theories fit. Autogynephilia, perhaps: “Men trapped in men’s bodies”. No. I don’t think Renee Richards entirely cuts it either- “a lifelong committed transvestite”. Some object to the term transvestite, coined by psychologists and formerly used as a diagnosis of a disorder. “Cross-dresser” was coined by the community. Cross-dressing is a harmless way of reducing stress. If it arouses you sexually, that is nothing to be ashamed of: the clothes are lovely, and humans get horny at all sorts of things. Yet that is not all you are. You are not a failed man with a disgusting habit, and the habit does not define you. It is a harmless habit, though. It need not be all your life.

My other theory is that you are a “beta male“. You don’t fit “alpha” models of masculinity, but beta is the upgrade! You have ways of being which are a blessing to a community. You are soft, gentle, peaceful. You are empathetic and conciliatory, and like to fit in- this is a blessing, but has been distorted, to cause you to try to be a Real Man.

If you have been shamed by not being a Real Man, transition is a way to self-acceptance and self-understanding; however if you have been shamed, that is a psychic wound which can distort how you see the world and yourself. You went along with it for a time. You tried to make a man of yourself. You could not, and your shame increased, but you could not because it was not right for you. Find a therapist who can help you appreciate your own beauty. If you find someone who will love you for yourself, rather than for a false image of you, that will help.

I believe there are trans women who will be fulfilled by transition. I would never want to cut off the path to transition. But it is not the best way for everyone who starts it, and you may face discrimination and hostility.

Rather than a real life test, where you must change your name and agree never to present male again, I would recommend a period of exploration, to include extensive psychotherapy. You could present female or male, and you could try to express your feminine side while presenting male. What do you want?

Who are you, really?

berthe-morisot-jeune-fille-au-bal

Labiaplasty

It is not necessary to have a vaginoplasty, unless you wish to be penetrated. The alternative is a labiaplasty.

When I was considering the operation, we called this the “cosmetic op”, as if vaginoplasty was not also cosmetic surgery. Surgeons competed to create the orifice- should they use penile skin, or scrotal? What about hair removal? How deep would they go? Dr Suporn of Chonburi, Thailand regularly achieved seven inches. A friend was angry at her psychiatrist for recommending orchiectomy more than a year before vaginoplasty, because she felt this caused her penile skin to shrink so that she could only get one inch. Then, colo-vaginoplasty is the option.

The neovagina needs to be dilated. There are no rules. I spent four hours a day with a stent in me, which I found painful and debilitating, and which was not enough. The body does not naturally cleanse the orifice, so you need to wash it out, and it can be smelly. I was told not to have my anus penetrated sexually, as that could breach the wall of my vagina. If you do not want to be penetrated, it may not be worth it. Yes, you may want to be penetrated later, but if you are not interested in a relationship with a man, consider labiaplasty.

Here there is a small orifice, about an inch deep, and labia are created from penile skin, which is more sensitive. Most or all of the glans can be retained, so that you may still be sexually aroused, and stimulated. You can make love.

You will no longer be able to swive. You will not penetrate another. And you cannot lie back and be ridden in the same way as you might have before. And, before, you could lie back and be stimulated- the glans has only changed position a few inches. It is worth considering what you gain.

I found my desire to be passive and receptive in lovemaking mindblowing and distressing. I knew that as a Real Man I should be active. It seemed to be what women wanted. A line from radio comedy- a woman asks derisively, “You want me on top, waggling my hips up and down?”- stays with me, as archetypal female contempt for someone less than a man. Well, now I can’t swive, though I could use fingers or tongue on another. Either operation frees me from that Manly role, though perhaps finding the right partner or accepting my desire might have freed me in a better way. Sex with another was unpleasant, and I did not see how it might be better. And when I was passive, and a woman played with me, I found it humiliating.

I did not consider “the cosmetic op” a serious option, seeing it as less than vaginoplasty, as what an older person might choose, or someone with health difficulties restricting the time they should spend under anaesthetic. I wanted to resemble a woman as much as possible. If there is an option, think what might be good about it, however ridiculous it seems.

The other alternatives are orchiectomy, retaining the penis, and no operation at all.

What do you want?
Why do you want that?
How might it be achieved?

gwen-john-self-portrait-1899

Trans and homophobia

When I realised I was lonely and I wanted a relationship that’s what got me thinking well, I don’t want to be with a man, so the other option is to be with a woman. I thought I can’t be with a woman as I am because it just feels wrong. I saw a documentary on TV and I didn’t realise that women could transition into men so it was from that and realising how unhappy I’ve been all my life, that’s what I wanted to do.

Oh God, I thought, that’s just what gay people who want to drop the T from LGB say we are: it is internalised homophobia. I can only love a woman if I am a man. Being a lesbian “Just feels wrong”. I was bothered to hear this on Radio 4, Ovid in changing times. It also had an old interview with Jan Morris:

-Is it not the height of arrogance to assume that, having your penis taken off you can say “I am now a woman”?
-I have not said that. I am a person who felt self to be of feminine gender so adjust body to fit my inner feelings.

Later we hear her say, I was in a difficult situation, not certain of myself, I tried to be more one or the other. Now I know just what I am, I’m in the middle, really, I’m a bit of each. It’s a comfortable place to be.

We adjust what we say about ourselves, to fit what others will accept. I don’t know about “comfort”. Possibly rather she felt reconciled to the journey, she was not resenting or fighting it. Though I loved her for this:

-Are you ever able to stand up and see an element of absurdity?
-No. I think it is beautiful.

Of course I am absurd. We retain the concept of “normal”, even if we recognise that Diversity is a good thing, and I am certainly not that. I wanted something which many would call ridiculous, and I cannot justify except that I wanted it, because it was the way I could best express who I am. Emotion is absurd, and therefore people are absurd. But I resent on her behalf that allegation of a lack of insight- “Are you ever able”. What arrogance in the interviewer, to suppose that one could only transition if one didn’t understand.

I think I am beautiful.

But that line, being with a woman just felt wrong as he was. He talked of envying his male cousin’s anatomy in the bath, as a child, and how being a girl had been bad enough but puberty was awful; so there are two narratives here. It strikes me he is trying to justify his change, to create as many arguments as he can, and that is one. And gay people would say of course a woman can be with a woman. It is not “wrong”. I would agree- but this trans man said it was wrong for him.

If a gay person objected to trans on that ground, they are denying our existence, our ability to see our nature and make our choices. Phobic? Right back at you.

It does not help that his voice sounded female. Not everyone’s voice breaks properly on T. There is a trans man sound which some men have, a roughened alto, but his was completely female-sounding. The excerpt was without context, beyond that he was 39 at the time: I have no idea where he was on his transition journey.

Narrator: Not every change works out. We are always striving after what is forbidden, Ovid wrote, and coveting what is denied us.

Gender Incongruence of Adolescence and Adulthood

Would you rather be diagnosed with “Gender Incongruence” than “Transsexualism”? The International Classification of Diseases, which is worldwide unlike DSM which is for the USA only, is being revised. It may influence the DSM. Rather than being classified as a “psychiatric disorder” GD, or GI, might be placed in a separate chapter for “Sexual and gender related health”.

How you frame a diagnosis affects what people think of it, and what you do about it. If it is a psychiatric diagnosis, is it merely that psychiatrists are most qualified to make it, or does it stigmatise you? I believe I am a woman, or at least I want to express myself as a woman, and perhaps alter my body. The medical help I want is hormones and surgery, and counselling support to manage that change successfully and comfortably. Together, these alleviate my distress. From the point of view of fourteen years after transition, I want people to have assessment to find whether anything underlies that distress and desire, and to explore less dramatic options for alleviating distress, but from the point of view of immediately before transition I had made up my mind, and would call that assessment “gatekeeping”, which is oppressive. We know what we need. Give it to us.

Should distress (or “dysphoria”) be part of the diagnostic criteria? Well, that is a way to take away stigma from sexual fetishes. Getting aroused by high heeled shoes or whatever is perfectly healthy, and not a diagnosis for a classification of diseases. Only distress might justify medical intervention- not to make the patient normal by taking away the desire or arousal, but to alleviate the distress. That is an imperfect analogy for us. Doctor, I am not distressed at all by wanting to transition, only by society’s norms that I should not, and because of how difficult it is. I am not mentally ill. Medical intervention is justified because I am gender incongruent.

Making distress irrelevant, and focussing on the need for hormones and surgery, makes other outcomes apart from transition seem less appropriate. Then I would have found that liberating; now I find it disturbing.

Is a psychiatric or other medical diagnosis a stigma? I don’t think diagnosis is more of a stigma than being trans itself is. Cis people realise doctors are involved: if they accept me, they accept that; and if they do not accept me, that makes it no worse. The diagnosis might reduce stigma- if I transition, people might think I was being unwise, but having a doctor go along with it might reassure them.

We experience discrimination. I don’t feel adjustment of the narratives we use to explain ourselves will alter that, much: I do my best. This is what I want to do. This is who I am is the necessary basic narrative- if you can’t say that, no narrative will reassure you except temporarily; if that does not let others empathise and accept you no other narrative will.

I am pleased that I suggested “incongruence” as a diagnosis in 2012, and that the ICD is now catching up. What I want for our kind is:

from society- acceptance, however we choose to dress or present
from doctors- discussion of all the options, understanding of all the pitfalls of “work male, play female” and support to do that if chosen; and making us take full responsibility for hormones and surgery so giving them to us if we ask. A Real Life Test- you can be rewarded by hormones and surgery if you express female for a year and Never Lapse- is completely the wrong answer. Instead we should be encouraged and supported to play and explore.

Medical treatment needs paid for. We need our medical treatment, including surgery, quite as much as any other person needs medical treatment. Single payers or insurers should pay for it.

marie-bracquemond-under-the-lamp