Transnormativity

How can a man live as a woman, or a woman live as a man? When gender stereotypes are enforced like moral laws, with disgust, contempt, derision, anger, resentment and violence fencing round how a man or woman can be, how can we express our true selves? Some strong or fortunate individuals might live like that- Elagabalus the Roman Emperor proclaiming herself Empress, or WC Blackwell the police sergeant of Calcutta, rounding up suspects while wearing women’s clothes- but most of us might pretend to be straight. Humans fit in to society, like bees or termites fulfilling a role. In the shadows, discreetly, some who cannot do otherwise express ourselves.

The psy professions- psychiatry, psychology, psychoanalysis and psychotherapy- find us, and because we do not conform we are called mentally ill. Scientists classify the extent and causes of our deviance,  to construct an understanding so we might be predicted and controlled, and devise treatments to return us to normality. In the 19th century, women were seen as mentally ill if either too feminine or not feminine enough.

Eugenics, the idea that the white race was superior and could be improved through selective breeding or degenerate if inferior people produced children, influenced the ideas of how humans should be. The male “invert” Lili Elbe could become an exemplar of vigorous European womanhood through genital operations, and the implantation of uterus and ovaries which killed her.

Gender variance was legitimised, made almost normal, by bodily transformation. We cannot know whether people would desire genital operations but for that fugitive hope of acceptance. Some doctors worked with trans people’s desire for operations, some were revolted by the idea of mutilating healthy bodies. Psy professionals found trans women could not be assimilated to an ideal of normal masculinity.

Transnormativity evolved: a concept of a “real transsexual” who might be suffered to exist on the edge of society, tolerated though not valued. This was constructed by psy and medical professionals. From press reports and other trans people, we learned the narratives the professionals required, and said what was expected of us. In order to keep control, the medical Standards of Care required knowledge “independent of the patient’s verbal claim” that the characteristics of defined acceptable transsexuality applied. From 1981, the Standards of Care required the psychiatrist diagnosing to be a specialist in gender therapy.

At the same time, intersex people had operations as babies to normalise genitalia and provide a role, either boy or girl. “It’s easier to make a hole than a pole” joked my mother’s midwifery tutor. You can’t “dress it in a kilt and call it Frances”. Gay men suffered aversion therapy and hormone treatment to suppress “homosexual” desire or attempt to create heterosexual desire.

Heterosexual people, conforming to gender stereotypes, were idealised and others had to conform to that as much as possible. Trans people sought the treatment, the psychiatric assessment, years of real life test, and surgery, to avoid the social violence enforcing conformity. It was important to pass as the other sex.

Affirmative treatment, accepting our desires, will not set us free while the wider society and trans groups preserve transnormative ideas. We remain presented with limited choices- treatment and acceptance is for the “real transsexual” who wants surgery. If there is a wider acceptance of gender variance, rather than specific treatment paths, people will find better what is right for them. Gender variance is beautiful. Complexity is beautiful. Unfortunately conformists find others’ non-conformity threatening, and seek to prevent it.

I got much of this from the paper Transnormativity in the psy disciplines, at least one of whose authors is trans. Of course then I spun it and riffed off it following my own concerns.

DSM V Gender dysphoria

What do you need, to get a diagnosis of gender dysphoria? This is the Diagnostic and Statistical Manual of the American Psychiatric Association definition of gender dysphoria:

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two of the following:

1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics).

2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).

3. a strong desire for the primary and/or secondary sex characteristics of the other gender.

4. a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).

5. a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).

6. a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

Under “Diagnostic features” it notes that “There must also be evidence of distress about this incongruence. Experienced gender may include alternative gender identities beyond binary stereotypes… Adults feel uncomfortable being regarded by others, or functioning in society, as members of their assigned gender.”

Medicine is practical. Doctors don’t make people conform to a particular ideal Wellness, but help us continue to function. This definition is focused on the patients, and what we believe, desire and experience.

You don’t need to desire to change sex characteristics. Secondary sex characteristics include facial hair, or the lack of it, so a desire to change that, rather than gonads or genitals, is enough. So the attempt of some gender critical feminists to distinguish between transsexuals (acceptable) and transgender (not) is not backed up by the APA.

Alternative gender identities: the diagnosis recognises non-binary people. It does not state that the appropriate treatment will be hormones or body alteration, but at least recognises they exist. Private doctors may be more keen to give the patient what they want, so recommend surgery or hormones.

The evidence of “distress” is a fudge. Many of us are not distressed by our gender, but by society’s (perceived) response to it. I know I am a woman, but other people rejecting that distresses me. And, I decided that to be distressed by others’ responses gave them too much power over me. I accept that some people think I am a man. I am not going to waste any energy trying to persuade them otherwise, and I am not going to get upset about it. And, being seen as a woman is not necessary for friendship or politeness: they could see me as a transwoman but think that’s OK.

Yet, if you are not distressed, you are not ill. Being trans is not an illness, it is just a way people are. That means the diagnosis would change to something like gender incongruence in the proposed ICD, as it is only necessary for psychiatrists to intervene if someone wants genital surgery. You might like the backing of a psychiatrist- yes, I really am like this, I am a trans woman- but that is more the province of social scientists than of doctors.

The conviction that one has the feelings and reactions of the other gender does not fit me either. I am a gender critical feminist. I don’t think either gender is so limited, and the feelings of both are the same. I believe the reactions are culturally conditioned rather than innate. I believe my feelings and reactions fit the feminine stereotype far better than the masculine.

The convictions need to have lasted six months for diagnosis. There is no need for The Script, a claim that the feelings have lasted since childhood. But the longer the feelings have lasted, the more likely it is that they will persist, so treatment is less risky.

DSM V estimates prevalence at 0.005% to 0.014% in natal males and 0.002-0.003% in natal females. Other estimates go from 0.1-1%.

It’s all a botched job. It is trying to create a working definition for a varied human phenomenon, and people may try to fit that definition to get what we want.

Don’t have GRS

Personal stories of why people wanted genital surgery, and why they regret it.

The way transgender is understood in Anglo-American culture, in the theory and practice of law and medicine and in the way trans people understand ourselves (until it’s too late) puts overwhelming pressure on trans women to have genital surgery which is not in our interests. When we regret hormone treatment and surgery, there is pressure on us not to say that in public. I regret surgery, so I have an interest in this- to save others from my mistake, as I cannot rectify it- but I am not alone, evidence of regret is suppressed and evidence of satisfaction exaggerated.

The circumstances of MtF and FtM around motives for surgery are completely different.

The diagnostic criteria for gender dysphoria in the DSM and gender incongruence in the proposed ICD-11 both require a strong desire to be rid of primary and secondary sex characteristics and to have the characteristics of the opposite sex. The Equality Act protects people who want their sex reassigned, or have had their sex reassigned, though the heading is “gender reassignment”.

At the time I changed my name and went full time, I was ambivalent about surgery, but a year later I passionately wanted it. Why would you want surgery? I believe I wanted it at the time because I wanted social acceptance, or possibly to accept myself. Where a person male by genes gonads and genitals wants to dress as a woman, there were two categories they could fit- transvestite and transsexual. The transvestite is considered to be a sexual fetishist, which I found unattractive, but the transsexual had a medical condition, which I found more congenial. I felt my personality was feminine, a concept which now I consider meaningless.

If there were more acceptable categories, protected against discrimination by law, not involving surgery, perhaps I would not have wanted surgery. Medicine tends to categorise health problems which require the intervention of doctors to cure, but possibly we could reconceptualise gender dysphoria. Gender incongruence type 1 is a desire to live in the role of the opposite sex. The treatment is to live in the role of the opposite sex, using an appropriate name and clothes. Gender incongruence type 2, a distinct condition which may or may not co-exist with type 1, is a desire for hormones. Type 3 is a desire for surgery. Type 4 is a desire to subvert gender, by not fitting any particular gender role, and the treatment is to be allowed to present as you want, male, female, androgynous.

There should be the freedom to present as you want anyway, without the need for medical affirmation, but I did not feel free and medical affirmation, or a category defined by doctors, might have helped me accept myself. The health problem would be shame and distress rather than cross-gender behaviour, and the treatment to alleviate the shame and distress rather than to change the behaviour. As the medical model is about desiring cross-sex characteristics, the GICs can’t cope with non-binary people. They still demand change of name, as Charing Cross did when I first went there in 2001.

I would have said, I want surgery because I am transsexual. I am a woman and my penis distresses me (it did). In the bath I want bubble-bath to hide it (I did). I now feel I wanted surgery to be classed as transsexual and so to be socially acceptable, as demonstrated by the available legal and medical categories. If there had been different types of gender incongruence recognised by medicine and protected by law, I might not have wanted surgery or hormones.

Transsexual support groups enforced the desire for surgery because it differentiated us, the real TSs with a medical condition, from all the weirdos and perverts, just as law, medicine and the wider culture did.

Hormones can reduce fertility, possibly permanently. I wanted to reduce my sex drive because my attractions shamed me. Self-acceptance would have been a better way.

Surgery is irreversible. I mourn being mutilated, and the pain is keener because it was my choice. That choice was socially constrained, and I am moving from self-blame to rage against those constraints.

A great deal of research reports high degrees of satisfaction with treatment, and low rates of regret of surgery. I am unsure why. Possibly it involves people surveyed shortly after surgery, when I and others experienced euphoria; possibly people feel shame about our regrets. I certainly do. People are unwilling to score below Neutral in a satisfaction survey, marginal people are less likely to complain of bad treatment, and while we might open up to a qualitative researcher we might not on a survey. In my case, I have been loath to speak out because I don’t fit the accepted understanding of trans women, and might spoil it for those wanting surgery now; and I want to maintain links to trans groups. Though Johns Hopkins stopped doing GRS as they decided it did no good.

 ♥♥♥

Sylvia Morgan undertook qualitative research, trying to find difficult to reach trans people rather than using the customary routes of gender clinics and trans support groups. Post-op, most people lose touch with those sources and that might be a reason why some research reports such high satisfaction rates. Four out of thirteen post-op trans people expressed regret. That is a huge figure.

People report long waiting times to see gender clinics, and long waiting times for surgery referral once there- perhaps seven years. A friend waited longer. Another friend said the psychiatrist kept challenging her desire, saying that it won’t grow back once it’s cut off, as if she did not realise that. Of Dr Morgan’s research subjects, Lady G who wanted penetrative sex had to wait many years because she had to work in male role, as a lorry driver, and the protocols demanded the “real life test”. She also refused to fit the stereotype of a “woman trapped in a man’s body”- “I don’t know how women feel. I just know how I feel. I’m definitely not trapped. All I want is the wee operation down there.” She passes as a woman, unlike most of the MtF research subjects, and has a strong sense of being one.

Kylie, though, felt hurried. She was not sure how she felt and questioned the conclusion of her first half-hour consultation that she had “insight” and an “excellent understanding” of the transition process.

People used The Script, saying they felt trapped in the wrong body, felt they were not of their assigned gender from very young. “People play the game to get what they want.” Dr Morgan reports that discussions in support groups are dominated by medical procedures and visits to the GIC, and I observe that on facebook, with regular delight at getting surgery or despair at the delay. It is a way of getting status in the groups, that you are seeking surgery. Four said they had never considered medical procedures before joining support groups.

Phoenix felt pushed through a process. She had said she did not particularly want surgery, but had it three years after her first referral to the GIC. She drifted through the process and does not know how she got where she is, post-op.

Vida first went to the GIC in March 2010, and had surgery in October 2012, having pushed for it. She was processed quickly because she demanded progress. There appears to be little consistency in procedures and protocols. Waiting times appeared arbitrary. One psychiatrist was described by many participants as condescending, patronising, clock-watching. Trans women felt disrespected, as I did.

We want medical recognition in order to get legal recognition, so we have surgery as that is what the medical model requires. The participants wanted a vagina in order to “feel fully female”, rather than for what one would do with it: gynephile trans women still go to surgeons who can give depth. The psychiatrists generally did not attempt to dissuade them. (We would hate it if they did, denouncing them as cruel gatekeepers.) Yet the surgery is a symbol of being a woman or truly transsexual, rather than a choice because of what the penis and testicles can do, or the neo-vagina can do.

Dr James Bellringer, who does NHS vaginoplasties, said the backlogs were “spiraling out of control”. In 2013/14 they received over three hundred referrals yet did 180 operations. “The nature of gender surgery is that the vast majority of these referred patients will go on to GRS,” he said.

Iain, a gender queer trans man, thought better of it. The effects are irreversible… there’s so much that can go wrong… it sounds like a world of pain and struggle and scarring and infection.

Oestrogen is a symbol too. Subjects perceived it as enhancing emotions and gentleness, but one reported that her powers of concentration were a lot worse, another that she was considerably weaker, making her job more difficult.

As hormones and surgery are primarily symbolic, that one is really trans, entitled to legal recognition, others as well as I feel euphoria after finally having surgery. But then Carina reported that reality hit her like a big sack of potatoes. Surgery does not mean social acceptance, necessarily, and the body has to heal its effects. The neovagina is in effect a wound, so you have to fight the healing process with dilation.

Vida felt recovery took two years, and had further depression ten years after surgery, “because there is no aftercare or support”. Dolores said she had not understood how difficult and time-consuming dilation would be: “A lot of girls just don’t bother with the dildo, they just let the vagina close up”. Lily agreed. “Nothing really prepares you for what happens afterwards.” I think when some people go for the gender reassignment there is a hope for changing your life, starting a new life, but then it’s still just you with your same problems, and after the surgery you have more to worry about… Some of them just give up, they stop dressing in female clothes and everything.

Sally hoped surgery would give her psychological relief and social acceptance, but it brought neither. She had had profound ongoing depression since transition. Trans support group organisers told me not to talk about my personal problems, not to talk about being depressed since my surgery.

People determined to get the surgery are kept in the dark and fed on bullshit. Nine out of 28 participants had attempted suicide, some more than once.

While people are taking hormones and having surgery for validation as a true trans person rather than for the actual results treatment will provide, there will be inappropriate treatment, and social pressure to have treatment. I know what the desire for the operation feels like. I felt it. Now, I feel betrayed.

 ♥♥♥

When T-Central linked to this post, Calie wrote, The last two T-Central featured posts were based on very successful transitions. One from Halle, who has transitioned, and the other from The Transgentle Wife, the spouse of one who has transitioned.

This post is from Clare Flourish who has regrets. It is important to read both sides.

I will add that I know many who have transitioned and are happy and I know some who are not. In all cases, it seems that the lack of love in the life of those with regrets, or the lack of a job, is often the case.

Clare mentioned in a comment to her post that there is pressure to physically transition. I have seen this and know several who gave in to that pressure. Some are happy. Some are not. Clare is one of my favorite bloggers. She is just lovely in her pictures and I do hope things will turn around for her.

I am grateful for the link and kind words, but I am glad I transitioned. It was how I found myself. I feel transition could mean something different, that it does not need the monolithic full-time + hormones + surgery. I feel people should be encouraged to find those parts of transition which work for them, without imagining they must come as a package.

Some of the comments below go into these issues in depth.

Trans children II

Which would you prefer? To be always noticeable as a trans woman, to be subject at any time to others’ prejudices, but to be fertile and able to father a child, or to be indistinguishable from any other woman, albeit one without a womb, but sterile? Can you decide, aged even 18, whether you will want children at some time?

It is possible to defer puberty until a child makes the decision whether to transition permanently, and then give cross-sex hormones. Many adult trans women would like to have been so treated. Passing matters. We flourish better if we are not constantly worried about other’s real or imagined prejudices. You can adopt, or foster. Clever things might be done with stem cells: ordinary skin cells may be converted into stem cells.

Any use of cross-sex hormones, even with a natural puberty, might affect fertility. Never using cross-sex hormones might make passing more difficult.

Doctors do not make people “well”. They have a number of treatments which might improve a person’s condition. They do plastic surgery where there is no medical need. I do not believe in a discrete group which is transsexual, which will clearly benefit from transition. Our circumstances and our resilience affect whether we can make a go of life, and whether that should be as male or female. I can imagine a regret of either course. A doctor might want their patient to fight for puberty-blockers, so that the doctor could not be blamed later for loss of fertility.

An adult knows it will not grow back.

The Royal College of Psychiatrists position paper acknowledges the need for better evidence on the outcomes of pre-pubertal children who present as transgender or gender-diverse, whether or not they enter treatment. Until that evidence is available, the College believes that a watch and wait policy, which does not place any pressure on children to live or behave in accordance with their sex assigned at birth or to move rapidly to gender transition, may be an appropriate course of action when young people first present.

That says nothing. “First present”- what about after? It gives discretion to the doctor involved, to suppress puberty if they decide it is appropriate. Doctors might want a wide range of options, but not to be blamed for any of them. I do not blame doctors for the treatment which I wanted, and want them generally free of blame- it means that others can choose what I chose. If we blamed the doctors for wrongful treatment, we make their gatekeeping more onerous on those who follow us. We have to make these decisions for ourselves.

The mood of the paper is limiting treatment. “Better evidence on outcomes”- we fear this means, no puberty blockers. Parents and children can be particularly keen on puberty blockers.

I like the idea of the child following their own desires. Let them find what way suits them. I would like children to be able to experience both presentations side by side- to be able to go to school as boy or girl as they wished on the day. The RCP will not say that: The Department of Health and Social Care and the Department for Education should ensure all schools provide appropriate staff training and have clear policies that support transgender children. These include tackling bullying, effective safeguarding, parental concerns, and practical considerations (such as appropriate language, use of toilets and changing rooms, and uniforms). They make no suggestion what that policy might be.

We want the best for children- and not in some ideal world but the world they must navigate, now and throughout life. That I regret a decision does not mean that I would be happier had I decided the other way. Life will be hard on gender diverse people whatever choices we make. Life is difficult for everybody.

Conversion therapy

What is conversion therapy? For gay people, it attempts to stop them acting on sexual attraction, or even to create other sex attraction. For trans people, it is less clear. “Conversion therapy” aimed at changing the character of the person, to “whip the sissy out of” a trans girl, is clearly vile.

Human rights law recognises it should be our choice whether to have surgery and hormone therapy. Gender recognition should not depend on whether someone has been sterilised. In the same way therapy should explore what gender dysphoria means to this person, and what is the best way to proceed, which may be transition with hormones and surgery, and may not. It should explore mental health problems which arise because of the stress of dealing with gender dysphoria.

So the Royal College of Psychiatrists’ position statement on supporting transgender and gender diverse people is insufficient. It defines conversion therapy as Treatments for transgender people that aim to suppress or divert their gender identity – i.e. to make them cisgender – that is exclusively identified with the sex assigned to them at birth. That has no meaning, because it conflates gender and sex. Expressing their gendered characteristics need not mean presenting as the other sex. Certainly a psychiatrist should explore whether sterilisation is necessary, or may be avoided. Often, trans people do not transition: a trans woman feels her size would make it impossible, a partner would not accept it, and we all bear the costs of being read as trans sometimes. Sometimes the costs of transition are too high. But whether the person can accept themselves as a feminine man or masculine woman, is a different question. That is, are they transgender- not fitting gender stereotypes for their sex- or transsexual, needing to express themselves and function as a person of the other sex?

That feminine man may not be open to considering living as a feminine man, if his attempt to make a “Real Man” of himself has failed, he sees the possibility of being able to express his character as a woman, and has a fixed idea that a “real trans woman” craves hormones and surgery. Psychiatrists need to see people before we are desperate, and need the time to explore with us. They claim gender-affirming medical interventions improve wellbeing and mental health in transgender and gender diverse adults– which is again confused. What is the difference between transgender and gender diverse? There is only one mention of non-binary, where they define gender identity as Self-identification and/or social identity as male/female/other gender. Other gender identities may include gender neutral, non-binary, fluid, and genderqueer.

When a psychiatrist sees someone presenting with gender problems, it is not conversion therapy to explore whether they are trans or non-binary. Possibly, these are not separate syndromes but merely differences in how we see ourselves, not underlying nature but the products of different experiences, not immutable once formed but malleable. Only the stress and anxiety of being gender non-conforming makes the identity seem fixed. The psychiatrist should not impose a course of action but enable the patient to see the best course for themself, including considering courses they had not imagined. Yet it can be unbearable not to know– if transition seems the answer, I just want to get on with it, and cannot see it is not right for me until it is completed.

The College supports psychiatrists in fully exploring their patient’s gender identity (involving their families where appropriate) in a non-judgemental, supportive and ethical manner. That involves considering options- transition, and non-binary expression both in the external symbols and expressing ones underlying qualities. It involves valuing those qualities.

Gender is a spectrum, we say. Some people conform to their gender stereotype with comfort, some reject the gender stereotype but not their sex, some are non-binary, some transition. If it is a spectrum, there are no clearly defined boxes, that someone is non-binary or is transgender, immutably and diagnosably by psychiatrists.

Trans people are marginalised people

I have never shown my gender recognition certificate to anyone in order to prove entitlement to anything. I wanted it, and the legal status of “woman”, but simply assert that I am, and did before I transitioned. When I saw a psychiatrist I got a wee form saying I suffered from gender identity disorder, and so should be allowed to use women’s loos and changing rooms, but I never showed that either. I have not been in such a confrontation. I usually carry a credit card with my female name on it, but have never been challenged.

The TERFs’ paranoid fantasy about self-certification is that any man, even clearly male and dressed male, will be able to go into a women’s lavatory without being challenged, there to prey on and victimise women, masturbate, fantasise sexually and attempt indecent photographs or even sexual assault. As far as I can see it is not just trans women they imagine doing this, but non-trans sexual perverts, who could not be challenged when they went into the Ladies’ because they would simply state that they were trans women, with a perfect right to go there, and no-one could stop them.

Well. When I first saw the psychiatrist, I was still presenting male most of the time, and when presenting male used men’s loos. I would have been scared to go in the ladies’. And while both sexes wear jeans, there are clear differences between the two kinds. Same with trainers, and short or long hair. Some of us wear women’s jeans when presenting male, and I wore a women’s shirt a few times, but still are presenting male and not in women’s space. There are clear differences, and I wanted to appear female rather than ambiguous when expressing myself female. I was afraid of confrontation, so I carried that card.

Of course they criticise us for an extreme stereotype of femininity- skirts and heavy makeup, more pink and satin-soft than most women would ever be, but why should they ever be consistent.

It is not a realistic worry, I thought. When transitioning, I wanted to avoid scrutiny and feared mockery or worse. I had some horrible experiences of transphobic attack. I did not have the self-confidence to go in a women’s loo dressed male. But then I thought, I could not sustain expressing female if I started to sleep rough. My wig would become unpresentable quicker than my clothes. Trying to keep warm, I would wear anything. This week, still Autumn, temperatures are forecast down to 3°. Trans people are extremely vulnerable. The demand that we dress to a particular standard, so that some people object to shoppers in night clothes in the local shop, is particularly onerous on us. I could manage that. I bought women’s clothes in charity shops, but never wore them threadbare. I could pass as a member of ordinary civilised society.

Rough sleepers, just like new transitioners, would want to avoid scrutiny, because they are likely to be hurt if noticed. Us normal people are a threat to them. Trans folk having difficulty finding work might not have much money to spend on presentation, or be able to afford electrolysis.

And, forbidding men women’s loos imposes a standard of acceptable passing on us. Does this trans woman look like a man dressed up, and if so should she be limited in a way trans women in stealth are not? No, I say, the right to transition should not depend on your looks.

I want the apparent man to be able to use a women’s loo, because I sympathise with the trans woman who cannot pass or cannot afford suitable clothes. Where is your sympathy? Of course I sympathise with women who have experienced sexual assault and are wary of men, but their rights might be reconciled with trans women’s, if there is imagination and good will. Women’s rights are not incompatible with trans rights.

And trans folk are more likely to be marginalised than cis folk. We just are. Transition is the most important thing in the world to us. For marginalised trans folk, I want the right to express as the acquired sex. That may mean some people disapproving of how we look, just as people always have.

Transgender medical care

I am on several trans facebook groups. One is for activists, and discusses trans in the media. Another is a support group, and there are two strong themes there- how long the poster has to wait for my psychiatric referral, and how wonderful it is to have their operation at last. Often people give daily updates when they are in hospital: they are so happy! You would see your GP and say “I am trans.” You want NHS psychiatric referrals to confirm this, because that is the way to get hormones and surgery; anyone can change their name and clothes. You see a psychiatrist locally, who refers you to a specialist gender clinic. Before you see the gender clinic, you are certain of what you want. You are trans, and you need a medically supervised transition. Your friends online, and perhaps IRL too, tell you that is what they want and how wonderful it is finally to have it.

You have the idea transition is the answer to your problems, and then you join trans groups which confirm that. All you hear is confirmation, and the idea that true trans folk need Gender Confirmation Surgery is still strong even if we also hear that not all trans folk have it.

Problems with dilation come up now and again, but not enough to convince pre-op people that there are serious difficulties.

You see a psychiatrist and say you know you are trans, and have known this for years, or for all your life. Ideally that psychiatrist would explore with you- who are you, really? Why do you want this? What is it in you that you call “trans” or “female” or “feminine”? But you see them for an hour once every six months, and that is impossible in the time available. It needs a depth and direction of psychotherapy they are not equipped to offer, even if you were in a place to participate in it.

There are also psychiatrists who will see patients privately. Mine used hormones as a diagnostic tool: he would prescribe them to every patient who consulted him. He said fantasists would balk at taking them, and never come again. I feel desperate people would know that this was what they were supposed to do, and take the hormones.

I, being desperate, knew this was what I was supposed to want and took the hormones. If you transition, they help you pass.

I transitioned in April 2002 at work. I thought, even though I don’t know if in five years I will be trying to live as a man, I need to do this now. I did not want The Operation immediately. I found I wanted it more and more as time went on. I had it in February 2004. In Autumn 2003 I was depressed, and my GP gave me more and more Citalopram. In February I ceased being depressed, and remained not depressed though the GP steadily reduced the anti-depressant. I thought that was proof that the operation was right for me.

And now I say I was poisoned and mutilated, the operation is a sham, a con, we want it because of social pressure and minimal medical intervention confirms we can have it because we really want it. There is no place for a psychiatrist to probe beneath the desire for the operation, even if they wanted to. We resent the delay, and resent the “gatekeepers” who might stop us having the operation we want. I did.

This is the way to happiness and acceptance! I knew I was not a man, I repeatedly curled in a ball on the floor weeping “I am not a man, I am not a man, I am not a man, I am not….” At the Sibyls we talked of it. We knew transition was terribly difficult, and we might not make a go of it, but there was no question that it was the difficulty stopping me, not any doubt that “I am trans therefore transition including surgery is right for me”.

How could I refuse the way to happiness and acceptance? I knew I wanted it, at a time when I was unclear about wanting anything else.

The social pressure is still there. There are a variety of messages- here I read Gender non-conforming kids – such as boys who like dolls or girls who hate dresses – aren’t trans. Trans people feel a disconnect between the person they’re seen as and expected to be and the person they actually are. What neat boxes! Why should anyone imagine they really knew which box fitted them?

I was poisoned and mutilated. Transgender medical care did not protect me from that. It could not.

Self-discovery while presenting male would have been difficult. Transition without hormones would too. I would not have passed as well. The operation removed my depression, and meant I could swim and wear trousers comfortably. It was good for me, and so this second-best, good enough is so enduring. We know what we want, and are desperate to get it.

Gender dysphoria in children

Far too many children are accused of “cross-gender behaviour”. This could lead to lasting damage. The Gender diversity and Transgender identity in Children factsheet of the American Psychological Association says 5 to 12% of girls and 2 to 6% of
boys exhibit cross-gender behavior
. With numbers that high, the definition of “normal gendered behaviour” is the problem, not the children. Let them play, experiment, be who they are!

It is hard to estimate the numbers of lesbian and gay people. Do you survey how many have ever had homosexual experience, or who have had homosexual experience in the last year? And people are still scared of saying they are gay rather than straight, and will identify as heterosexual despite gay experience. But asked to place themselves on the Kinsey scale, with six boxes rather than two, only 72% of British adults identified as exclusively heterosexual. Wikipedia is interesting on this, and that is as far as I have gone- I am not an expert, merely trying to form my own understanding of the best way to treat children. People are far too complex for either/or, gay/straight, trans/cis. My personal interest is in beta males with viragos, derided so long as not real men, as pussy-whipped. Such beta-males can be very feminine.

So I love the APA’s position now:

There are three main approaches to psychological intervention with gender diverse children including a “gender affirmative” approach, a “wait and see if these behaviors desist” approach, or actively discouraging gender non-conforming behavior. The gender affirmative model is grounded in the evidence-based idea that attempting to change or contort a person’s gender does harm. Psychological interventions should aim to help children understand that their gender identity and gender expression are not a problem. Providers should aim to non-judgmentally accept the child’s gender presentation and help children build resilience and become more comfortable with themselves, without attempting to change or eliminate cross-gender behavior. Children who experience affirming and supportive responses to their gender identity are more likely to have improved mental health outcomes. Gender identity is resistant, if not impervious to environmental manipulation. Moreover, attempts to change a child’s gender may have a negative impact on the child’s well-being.

Parents and schools are the problem. Most of the therapeutic work is with the parents, to prevent them suppressing the child’s harmless but surprising behaviour: Often, the most important intervention is helping the family to cope with and live for some time with the uncertainty about the child’s gender and sexual identity development. They need to be advocates for their children. Providers should advocate for children to be safe in schools while exploring gender diverse expression. Pardon me while I scream at the floor- “Children should be safe in schools”! It needs to be said!!!!!!! If children’s natural, harmless gender expression is not tolerated by parents, schools or peers, they may exhibit the usual extreme stress reactions of children, such as “Oppositional defiance” or “ADHD”; or depression, rocking, cutting…

The fact sheet at first appears to distinguish “gender diverse” children, who express their gender in ways that are not consistent with socially prescribed gender roles or identities, from “transgender” children, who consistently, persistently, and insistently express a cross-gender identity and feel that their gender is different from their assigned sex. Later, though, it conflates the two: Fully reversible interventions such as a social gender transition including changing clothing, name change, new pronouns, or changes in haircuts may be indicated for some gender diverse and transgender children. And why not exploration? Let little Stephen come to school as Clare occasionally, if s/he wants. Let Clare be boyish and Stephen girlish. We need to know which the child is at the time that hormone therapy is prescribed, and not before.

APA fact-sheet pdf.
beta males.
Wikipedia on demographics of sexual orientation.

Gender psychiatrist

I am one person. This is not immediately obvious.

Penny Lenihan, at Charing Cross, is my eighth psychiatrist. I liked her practical manner, and she shook me up, so that I don’t want to go where I am going this weekend. Cos it ain’t competent me that is going, but shit me, shit me who does fuck all and whom I despise. She observed me communicating calmly and well, and me weeping in anger frustration and sadness, and said “You compartmentalize”.

And I think that’s a bad thing, and I should stop, and I don’t even know what she means by it, particularly. One of my thoughts was that this is a good experience, because however unsettled I feel now I might get to better ways of coping. And now I think that I might bring things to consciousness: see what I am doing, see I have choices.

I got a different view of Serra Pitts. Dr Lenihan has some familiarity with my case, because she has been supervising Serra, who was a trainee and is no longer working with the clinic. I was unaware Serra was a trainee. It is “contrary to protocols” that trainees work with patients privately after sessions at the clinic end. Dr Lenihan will see that the new trainees are aware of the protocols, she says drily. And now I see, yes, that is appropriate; and Serra just not turning up for work does not mean Serra having great difficulty but Serra doing something any employer would object to.

We started by discussing what hormones I was on. She saw no reason for me to be on norethisterone, and did not think my emotional issues were anything to do with hormone doses, though she did want me to see the endocrinologist.. This morning I have been entirely miserable about that: so much of what I have done over the last four years to get my head together has been at best useless. So we were off to a bad start: I thought I would be discharged. She asked if I had been offered group therapy. Well, no; I would be willing to attend but needed it sold to me: what might I gain? So the offer of groups appeared rescinded, because I was insufficiently enthusiastic, and I was confused.

Like many group patients, I like to imagine I am better than the people I would meet in the group; and perhaps fear opening up to them.

Serra told me that the clinic is under great pressure to put patients through, and achieve desired outcomes. I should come knowing what I wanted to get out of it.

So because my emotional issues are not particularly related to transsexuality, she will refer me to my local CMHT. Yes, I do know that means Community Mental Health Trust. I know what they will say: “Sorry, we have no funding”. Well, I am not a risk of killing someone, and if I were they could always leave me to the prison system.

So I gave myself permission not to go to the AM clerks’ conference, and considered the possibility that I would be still tearful, there, and actually disrupt it, rather than merely gain nothing and give nothing to it; and decided that the risk was worth it, and that I could get there without undue difficulty, and would just go.

Antoine Caron, The Triumph of Winter

At the Gender clinic IV

At Charing Cross Gender Identity Clinic, Serra the psychotherapist grants me absolution over something which puzzles and shames me- or helps me find it for myself, which is better.

At the election, I felt it would be good to campaign for the Green Party. It seemed like a desire: to put leaflets through doors, to support our candidate, her motivation and her activity. Yet I did not, when others were doing it or on my own. I wondered at this. I have read that the best liars are the ones who believe their own lies, and wondered if this was me, pretending to a moral position others would find attractive without the reality of it. Nor was I certain how to distinguish a real desire from a fake one like this: I would like to place some reliance on conscious judgment as well as what I unconsciously do. I would feel more in control, even if that feeling was an illusion.

She called it the difference between what I want and what I feel I should want. It is alright to rebel against the Shoulds, to be myself. I am not conflicted, not really.

The day before, I saw Dr Lorimer, and asked him about the colo-vaginoplasty, which I had thought of asking since I first saw him twenty months ago. He said he might refer me to a surgeon. Oh! What do I feel about this? It is not the same as my previous surgery, as what I have now is so much better than what I had before that. Yet my opening scarcely accommodates two phalanges of a finger. It brings up old stuff, of the horrors of dilation and my sense of shame at failure.

I Want an opening in me, though I do not understand, though I am entirely gynaephile. It cannot be social pressure. I remember my mother’s adhesions after her bowel operation, for the removal of a cancer, and how sick they made her- but surgery has moved on a great deal in twenty years. Serra can help, giving me ideas about how to contact people who have had the operation. She herself has heard both good and bad experiences of this op from her patients.

I had expected Dr Lorimer to discharge me, and instead he referred me to his colleague Dr Lenihan. I thought, why should I see her, what good would that do me? My appointment is in November, and I may not attend. But I love to see Serra, who says lovely things, making me glow-
Because I believe them, she says-
and because I feel I am growing and changing and she helps.

I also asked him why take hormones, and he said, to avoid osteoporosis. Again, that makes little sense to me. People report a huge gain in energy on HRT, and it has seemed to affect my emotional lability. I should have challenged him, perhaps. Perhaps it is true.

I noted after that I said about that, how our unnamed understanding is real. (Today, Saturday, I feel such happiness having had a text from her.)

I make connections, I talk to people in the street, and that day I tried a high risk one: a woman, talking on her phone by the pedestrian crossing, said “He likes me!” I turned to her and said “Congratulations”. This merely confused her, it was not a good connection, and it will not put me off.

I told Serra of the Oresteia, and she said “I love hearing you on that play.” It was the right play at the right time for me. It made me understand it better.

Zhao Mengfu