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

The doctors

What should we want from doctors?

In creating DSM V, experts distinguished unusual behaviour from distress arising from that behaviour. A paraphilia is only a disorder if it causes suffering for the patient. The distress arises from the disjunction of what the person desires, and what s/he thinks s/he should desire. Unfortunately, the distinction has not always been observed: it was thought the distress arose from the desire, so the treatment was to change the desire. That was the basis of my own aversion therapy in 1992: the psychologist offered me a choice, and could have sought to make me more comfortable with the desire, but instead sought to increase my disgust, and change my desire to other channels. Better to seek to change desire than squash it. But desiring women is compatible with cross-dressing.

The issue as I see it now is not fitting how “Men” are supposed to be. Cross-dressing, cross-dreaming or identification is a way of coping with that, symptom not cause. Sexual arousal is incidental.

The Danish Girl makes the doctors monsters. One points radioactive sources at Lili’s genitals because science, and because he has this expensive equipment which must be used for something. One calls her schizophrenic and wants to lock her up. One performs the first SRS under medical conditions, but then implants a womb so that she dies from organ rejection. The Franken-doctor’s reputation would have been so great had the operation succeeded!

Doctors want to fiddle around and do something rather than leave well alone. Or- doctors seek to make the person better able to cope with life, but don’t always see the best way to do that. Surgery is better than trying to make the trans woman more Manly.

Self-acceptance is the cure. We come to enjoy our coping strategies rather than being ashamed. They become less compulsive, less isolating. I don’t know whether this is in the air or I am just more aware of it. T-Central’s latest share is a review of a book along those lines. I would highly recommend retiring from gender to anyone who is feeling like the spectrum or the binary doesn’t fit. Many people look at me strangely when I tell them, but the decreased pressure of having to perform a gender makes up for all the misunderstandings.

Would anyone want surgery if it were not the path to being acceptable to the general public? I don’t know. Seeking to pass as a woman is seeking to fit in with gendered society. That means hormones and hair removal is a surrender, compromising being me in order to fit in. Of course, everyone compromises to fit in, from speaking differently at work and in the pub, to following fashions rather than creating them.

Norethisterone

Should I be taking norethisterone? It is synthetic progesterone, and (if the difference between the green pills and the white pills means what I think it means) I take it twelve days in every 28. Why should a trans woman take hormones, anyway? What good do they do?

My friend is a retired doctor, as is her husband. I wanted to discuss my emotional lability, and the possibility of a hormonal effect on that, with a friend before the psychiatrist in November. She thought her husband would be more up to date on endocrinology. I thought, oh, do I have to? Telling a friend is one thing, telling yet another person that I have never met-

I cycled by country roads, luckily picking the right private farm road, and entered their beautiful house. The garden is glorious. I meet this man, and really do not want to. We shake hands. Over lunch I admire the art work- this 4′ high fish is welded together of bicycle parts- and having sensed my discomfort she suggests he go out of the room, she could consult him if she really needs to: yet such was his gentle charm that now I would like him present.

The whole problem is life passing me by (does everyone think that, or only most of the people most of the time?) while I sit at home with little motivation and no felt ability to earn money to support myself. And I feel so lonely yet want to hide away. But the smaller problem, which might be addressed by hormone adjustment, is my emotional lability. I would like to discuss this with you without bursting into tears. I would like to discuss Quaker problems with an overseer without crying or getting angry.

He says, there is not always a medical solution, and one of the GP’s roles is to protect patients from specialists. An endocrinologist will seek a hormonal solution, a psychiatrist a psychiatric one. Mmm, sometimes leave well alone is the best answer. I started the norethisterone after the endocrinologist saw blood results, and after the psychiatrist suggested testosterone for motivation.

Godward, an Offering to VenusHe says, the point of norethisterone in HRT is that oestradiol alone risks cancer of the lining of the womb, and norethisterone clears it out reducing that risk. So there should be no need in me. Now, I wonder, what of motivation, did the specialist know something he did not? Or not? One of his patients on norethisterone had been quite unreasonable emotionally- he happened to see it, she admitted it- and on this sample size of one he was wary of it. Though proper peer reviewed studies may be no more reliable.

There you go. One possible thing worth trying. Not an answer, even though hormones affect mood: premenstrual syndrome is not merely a male chauvinist myth, and I feel, well, premenstrual. I could try and see if I felt more labile when taking the green pills.

We discussed my wider issues. On defences, he noticed that when I seemed to be coming to an important point, I would digress into a long story.

I feel valued. I feel cared for. It was lovely, talking of my stuff to sympathetic hearers for two hours.

 

Medical model

I was styled by SophieWhat do doctors do, exactly? They cure physical illness, but with disability it is more complex- they help patients conform to an ideal as well as possible. Synaesthesia seems at best a distraction, but many synaesthetes like their peculiarity and seek no cure. Messiaen used it in his music, producing colours only he could see but sounds many enjoy. Mental illness is cultural with medical responses: what level of boisterousness is classed as manic? Plastic surgery is given for preference, even where there is no physical or mental need of it.

Trans women could fit three separate categories here. I am a woman, so my deformed, enlarged clitoris is reduced, to look like any other woman’s. I am mentally ill, with the chronic delusion that I am female, so unusually the doctors help me conform to my delusion in the hope it will make me function better. Or I am well, but want to alter my body so should have plastic surgery if I want it.

I was styled by Sophie 1I say the sickness is in society and not in me. I am effeminate and unmasculine, and this is a bad thing- or at least I hear enough messages that it is bad, for me to be distressed at how feminine I am. You might think society is more accepting than that, but a friend recently expressed to me his distress at being thought unmanly. He thought the solution was to become more manly, rather than to find people who would accept him as he is- like the two of us who heard him, at that moment. Perhaps he will change, and see the solution as self-acceptance; and perhaps he will veer between these two paths, uncomfortable on both.

Whether I am a man or not, I am more comfortable dressed feminine calling myself Clare. If others were completely happy with feminine men, I would not need to, and perhaps never would have. I might have retained my gonads. This fashion blog, where I got the pictures, thinks that is OK now. I notice evidence otherwise.

We don’t fit in, so get sent to Doctors, who have to do something. How to alleviate distress? “Therapy” to make me more Manly does not exist, though some treatments might get me suppressing my nature, to my harm. I don’t think I am mentally ill, but within the normal range of feminine to masculine. Are there ways to thicken my skin, get me able to tolerate messages I should be more masculine, that I am wrong in some way? What we have in Britain is a path where those who persist in expressing ourselves female are allowed to have hormones and plastic surgery to help us better approximate a female appearance; or deal with the issues in our own way, without the treatments. In Iran, where homosexuality is seen as wicked but transition permitted, some people who would function as gay men here get gender reassignment.

I needed to accept my femininity. Without the cultural judgment that such femininity is womanly, a psychiatrist might have seen that self-acceptance was the way to alleviate my distress, without the need for transition.

But transition is the path the doctors prescribe. They like to do what all the other doctors do. That is the Hunter v Hanley test of medical negligence- did s/he do something different?

Big data

File:Google’s First Production Server.jpgWhether I should opt out from the NHS health data sharing scheme is an emotional not a rational decision. I opted out.

I see the point of it. GP and hospital records go to the Health and Social Care Information Centre in Leeds, where they may be analysed to see what health provision works best. “Free text”- what the GP notes about symptoms- would not be sent to HSCIC. Diagnoses, test results and prescriptions would be.

I thought the data would be used for research, but the “Clinical Practice Research Datalink” already gives information to researchers.

My email archive gives a complete record of me, in my real name. Someone has a record of all I have bought at the supermarket in the last three years, and is able to sell that information. My data is out there already. Then again, my GP said she wished they could opt out all their patients, rather than have us opt out individually. She has concerns about the data protection. I have concerns about large Government computer systems, which have made a mess of every new benefit for the last twenty years. But, mainly, I don’t trust them, so I opt out.

Mmm. Do Buzzfeed quizzes record your responses for advertising? What about personality tests?

——————–

I am lying in bed feeling powerlessness and terror, after two things on facebook which remind me of two separate-

I went to the GP to ask about counselling, as recommended by the psychiatrist, and my “while I’m here” was about breathlessness cycling. I have no crushing pain in the centre of my chest, I just get out of breath cycling where I had cycled quite happily last year. She said, well, exercise more, you have exercised less in the winter weather.

File:Charles De Wolf Brownell - Tree and Sailboat, Lyme, Connecticut.jpgSo, yesterday, this started a thought in me: my way is to withdraw. Cycling up that hill, get a bit breathless: stop cycling and moan about it. Then I thought, no, my way is to get the bit between my teeth and battle on despite multiple discouragements, to the end. Like then.
-But that was last century.
(Thoughts of reverting go through my mind. Don’t go there.)

One friend is dying of cancer, palliative care only, one will stay in hospital tonight for tests and fears cancer. Life is a slow tragedy with one end. So-

More exercise could do me good, spiritually: that moment minute or hour when I push on though I want to stop.

———————

-Too low for a racer, too high for a tourer, not much use to anyone really, said the man looking at my bicycle gears. In about 1988. I remembered it, and thought, I am the kind of person who remembers small slights for decades, and tortures herself with them. Then I thought, character revealed in one comment- why was he cycling Lands End to John O’Groats alone, again? Perfect memory for a writer. Being positive takes effort.

Am I the only one who sees others posting things like “stay away from drama and negativity” and worries it is all about me?

I have acquired a meditation stool. So I will still be uncomfortable, bored, distracted or confronted by bits of myself I don’t like in meditation, but my feet won’t go to sleep.

The geese form pairs and fly low, circling over the river, honking constantly, for the joys of Spring.

Breast screening

breast screening 1I had my breasts squeezed, pinched and photographed today.

Women aged 50-70 are invited for screening every three years, and some women aged 47-49 are invited as part of a study of screening older and younger women. I am an atypical subject for such a study, but, well, why not?

That was what the letter said, though the leaflet says something different: from 2012 the screening programme will be extended to women 47-73, this was decided in 2007 and is now being rolled out. Whatever.

How do I feel about medics touching me? My GP, who has a lovely manner, offered to show me how to examine myself, and I fled: the thought of taking my top off and being touched upset me. I stiffened- if she had touched my clothed arm it would have bothered me.

In 2003 Tim, my friendly Endocrinologist, referred me to a gynaecologist whom I saw three times. He was really really lovely. Just nice. I told him how uncomfortable and difficult I found dilation, and wept. I wanted to talk without crying but could not: I could get the words out if I sobbed in between. Then crying opened me: I could feel my hurt and talk, and he was gentle and understanding.

I saw a surgeon when I was considering implants. I thought I could just be examined, but felt shy when it came to it. He offered a female chaperone, and though I had thought I would not need this, I was glad of it. Sitting with my top off- I can’t respond quite as rationally as I might otherwise.

I cycled a mile to the mobile trailer at the outpatients’ clinic. A woman entered me on the system: hello, how are you? How are you? Oh, not many ladies ask that, I’m fine, she said. I sit in a breast screening 2cubicle where I was invited to take off my bra- indeed I would not like a communal waiting space. There are old magazines.

I go into the end room where the Mammographer asks me to take off my top, and shows me the machine. I remember Josie telling how her breast was squeezed between two cold metal plates- but that was last century, this machine uses plastic. Without intending, I go into a half-trance, so that she can place me as she wishes. I go quite passive. I do not want to make eye contact. She takes some time arranging me just so- it is worse, she says, when people try to cooperate. It pinches. It is uncomfortable, though no worse than seeing the dentist. I will get results, she says, in two weeks.

Some women will have treatment for a condition which would never have caused them problems. 3% of women will have the serious worry of needing further tests, but not needing treatment. Lives get saved by early diagnosis.

I asked if she could show me how to examine myself, but she is not trained to do so. I should ask my GP’s practice nurse. What a job, doing that all day.

Being polite

RAF portrait small file

kilt portrait croppedUp to London, then up to Edinburgh, all in one week. I had no conversations on the train, at all, which disappointed me. I cut cheese for lunch on Tuesday 12th, and the man next to me gave me a wet-wipe to clean my penknife. “Be prepared is my motto”, he said. Well- I lifted the knife. He had thought of getting one, but they are £19. Several people helped me with my heavy case, going south.

I wrote that on my last leg, then a man sat opposite, and we chatted. He is a chemical engineer from Ohio. His daughter is 13, and wants to be a writer: at the moment she is devouring books, hundreds of pages a day. He adopted a child belonging to a neighbour, and the child thereby avoided a life of crime. Despite this, I found his talk boring, perhaps for lack of affect.

I had wondered why I had not been subjected to a medical for my ESA yet- but I saw the GP on Monday, and she told me that it was time to put some structure in my life. Then, perhaps my face fell, perhaps it was my bereavement, she gave me another three months. Stopping being on the sick does not put structure in my life, it makes me sign on every two weeks, and possibly get sanctioned. Possibly SEMA expect GPs to put us off the sick, rather than doing it themselves.

I got the 9.20 bus, and my sister picked me up at Waverley at 4.10. As I thought, we were polite to each other. That evening, we could have talked but I was finishing off my draft minutes for AM. Then we could have talked, but she was watching soaps. So, rather than getting drunk, and weeping together, and sharing our feelings, we were polite, and went to bed around ten.

The next night I watched her daughter, who continues her Architecture course, design a building by CAD, loving the way she manipulated it. She creates disabled access, and the principle is that the disabled person’s experience of the building should be the same as that of the able person. No going round the back for disabled access. I looked through Dad’s photographs, and my nephew looked too.

And- I just passed them to him. We did not discuss them. I did not point anything out to him. So while I resented how polite and flat of affect we were, as I predicted, here was I at least taking my part in creating that. I don’t know whether we could have expressed real feeling. It could be worse, fighting and blaming each other would be worse than mere politeness. We refer to when I will next be in Edinburgh, but I do not know if I will ever see them again.

The funeral was beautiful. We started in St Vincent’s church, where Dad worshipped for years, and where the presbyter Rodney, 87, was his good friend. Rodney celebrated the Eucharist, and preached, then preached again at the crematorium.

It had been suggested that I not share the funeral car with Dad’s wife, but I did, and six of us drove in a silent dream up the hill through new town and old town. Beautiful city. Past the Liberton hospital, which is a happy memory for me.

The crematorium is being renovated, so we had the smaller chapel, which seats fifty: we had people standing at the back. Rodney spoke of Eternal life, the life with God, more than once saying “Which Alec is now experiencing” and I thought, I do not believe in that; but his voice is beautiful. The family wore black, which I had not thought to do, and Dad’s wife asked me to the line at the end, greeting everyone, which surprised me. Form’s sake, or sympathy, I do not know. Bomber Command Association and dancers and walkers and Piskies and friends: none I really recognised.

Next day, my sister went back to work and her daughter lay in bed as I scanned those photos. I had nothing to say to her, hardly even meaningless expressions of good will.

Charing Cross

KlimtMy business in London was not The Solution, but it may do some good, eventually.

-It is rare for us to see someone at your stage in transition. Why are you here?

-About two years ago, my GP, knowing that one stays on HRT for a limited time, stopped my hormones, and my emotions went wild, I was shouting and weeping in the office and in the car. I went back on them within six weeks, and back on the full dose within six months, but my lability continued. At the time, I asked to see an endocrinologist here, to see if there was something to do with hormones- there are no double-blind studies, but you get to know your patients- and finding myself at last referred to a gender psychiatrist, I am here to see what good we can do together.

-OK.
He is concerned that I will think the way he uses the consultation a waste of time, but I am in his hands. Insisting on my own way of using the time cannot be better than merely co-operating. He takes a history.

-What is your earliest memory related to transgender?

This one confuses me, because it is not a five-year-old’s memory, but a 47 year-old’s. I know we reconstruct memories every time we consider them, and twist them for our own satisfaction, but- I envied my sister’s party dress. It was yellow velvet.

Apart from that, I did not fit The Script- know there is something wrong aged 2, know I am a girl by aged 5.
-If they are honest, a lot of people do not fit that, he says.
I self-identified as a fetishistic transvestite. And, here cutting my long story short, when I was 35 even though I was terrified of transitioning and thought I would be sacked and ostracised for it, I knew it was what I had to do.

-How did you feel about the changes of puberty?
-Growing body hair really pleased me. I wanted to fit in, then, I was ashamed at how slight my arms were.

Giving my history reminds me that I had several times off with depression while in Oldham, the longest six weeks. My emotional problems were before I came off the oestradiol.

He suggests it would be good for me to talk about these things, so suggests counselling, at his clinic in London as local counsellors can get hung up on the gender issue. OK. He sends me to the phlebotomist, and thinks it would be useful for me to see an endocrinologist there. He makes me another appointment with himself: May is the earliest possible.

There, I see a woman aged 19, who is diffident with the receptionist, one hour early, and who huddles in the corner staring down at her phone, the picture of our extreme meekness; and an older woman, with a male voice, helping a trans man with registering as the man cannot manage the forms. She explains to him, possibly inaccurately. Having nothing better to do in London, I take the train home, and phone Jayne to meet for coffee. She tells me all about the hassle of organising a lunch for a group of which she is now vice-chair. I would have told her of the GIC had she asked.

The next visit to Charing Cross GIC is here.

Aging

OLYMPUS DIGITAL CAMERAOn the train, the young woman is overflowing with happiness: last night, she met a school friend she had not seen for eighteen years, and now she has a date. We giggled together at the announcement that tickets sold on Easyjet planes are not valid on this service, and then as we passed the First Capital Connect stopping-service, we giggled again. “Easyjet passengers!”

Mmm. Young. 18 years since school. Hmmmm…

H is noticing aging, having just passed a Life Event: her 50th birthday. She celebrated, and she considers life, and doors closing. She notices that she does not recover from a pulled muscle as quickly as she would. My nephew broke his leg very badly, so that it was shorter than the other: he endured further treatment to lengthen the shorter leg, over about a year. I watched him walking, taking precise care to keep his pelvis level, and we walk through Regent’s Park in the sunshine mimicking this shorter-leg walking. I only notice her limp because of the noise her backpack makes.

S has also been thinking of aging, and of aches and pains, which frighten her.
-My father used to hang out in this café with other old Jews.
-Do you feel the need to hang out with [slight pause, concerned- should I say “Jewish people”?] other Jews?

“Some of my best friends are Jews”, she says, which makes me guffaw. She recognises the irony. She has the Synagogue choir, and various friends, and that is enough, really.

I do not “know what she feels”. I only have my own experience: being slightly alien, and wanting to honour that as well as to fit in and be normal and rub along with everyone, rather than retreating to a small group of particular like-minded folk. Just like everyone, I suppose.

F has been very ill, and her GP did not spot it in time. She explains precisely what it is, and how it may be cured. She went to him, and he checked one level which was abnormally low, and said he would want to see how it was in a week. The next week she could hardly walk, and the level was a quarter what it ought to be. She could see him protecting his back: her control makes the anger more frightening.

She drove herself to casualty, and was there six hours among the drunks and the suicide attempts, and then she saw a doctor, and as soon as she saw him she realised he was a Healer, and everything would be alright. Mmm. Some doctors are healers, some are scientists with no empathy at all.

I got irritated with her ascribing it to aging. If an ill is “because I am getting older”, then it can only get worse. If an ill is something going wrong, then it may be fixed.

Ted had cheese puns. What cheese gets a bear down from a tree? Come on, bear!!!

We went to the rose garden and smelled the roses. Some smelled of not much, but one or two were heavenly, and for a glorious moment knocked everything else out of my mind.

Bad treatment

https://i0.wp.com/upload.wikimedia.org/wikipedia/commons/6/64/Araneus_diadematus_2005-08-18_01.jpgI might not have survived NHS treatment of my gender dysphoria, had that private route not been available, which the General Medical Council now seeks to close down.

In 1998, I saw a consultant who wrote to my GP, “Mr Languish is not transsexual”. He is clearly wrong, in hindsight: I have been transitioned ten years. He put back my transition at least three years, and that harmed me. Could he really not have spotted that I am trans, had he not been unduly prejudiced against the possibility?

In 2001, I saw a gender psychiatrist. This was 8 months after my GP’s referral, which is an abnormally short delay. He made no diagnosis of gender dysphoria, and told me that I could not get hormones until after I had changed my name: that is, after I had taken the plunge, gone full time as female.

Separately from those decisions, the consultation made me so upset that I could not bear to see him again, and went private.

I wanted reassurance that I could make a go of transition, and support in doing so: voice training, facial hair removal, hormones. He gave me nothing. So I went to Russell Reid, who gave hormones, I found a speech therapist and electrologist, and transitioned. Of these doctors, it was Reid who was investigated and found guilty of serious professional misconduct. He retired.

He sold his practice to Richard Curtis, who now is also up before the GMC with similar complaints.

Far more people are hurt by refusal of treatment than by wrong treatment. But the ones hurt by refusal don’t matter. They are only trannies, after all. The important thing for the doctors is to avoid anyone for whom the treatment is wrong, getting it. And for the media: “tranny refused treatment” is not a story, probably not a real tranny anyway- but cutting the breasts off someone who later objects is a hugely salacious story. Any psychiatrist should be capable of diagnosing my condition: it is easily described. But we must be referred to gender psychiatrists.

I do not know why people revert. I was capable of making my own decision, I knew I would be permanently changed and infertile, and I had no psychosis or other condition which might make me falsely believe I was trans. So Dr Dalrymple told me. I did not know I could make a go of it but I knew I had to try. The two questions:

Am I transsexual?
Will I be happier if I transition?

may have the answers yes- no. If you revert, there may be huge pressure to find reasons why transition was wrong in the first place.

One I know who could not afford to go private transitioned before me, and may have her operation this year, ten years later. No. That is not shocking at all. It is only strange in that she is actually getting her operation.

I hate the salacious, prurient Telegraph article, especially in giving Curtis’ former name and the area he lives in; but it reveals he is “non-homosexual“. One of my lot.