Health Provision for Transexuals:

A Care Programme Approach

Jed Bland

Gendys Conference, 1994

A number of issues triggered this article. When it was published in GEMS News, I wrote the following preface: It has been suggested that transexuals cannot become involved in formulating their Standards of Care. Yet they are, after all, customers. The Press takes great delight in criticising Care in the Community, but one of its cornerstones is the right to self-advocacy, something pioneered by transvestites and transexuals back in the fifties and sixties. To quote a recent paper by the Community Social Services Manager for Derbyshire County Council: "Service users and carers are asserting their right to be consulted and make representations about the services they use."

Introduction.

The term transexual means, literally, "across the sexes." The word causes a deal of unease for two reasons. Firstly, it would seem to have connotations of sexual orientation, when it is primarily a matter of self-image in terms of gender. Secondly, it is publicly thought of as a switch from one gender role to the other, literally across. It might be better to use the word between, since there are many so-called transgenderists who have achieved self-acceptance at some point that would socially be considered as intermediate. Some transvestites achieve a compromise where they are able to switch roles.

There are a number of well-publicised people, who have changed to the opposite gender role, and outwardly live very successful lives. The public perception seems to be that they have achieved this by virtue of their role change, rather than because of their personalities. Although there never appeared to be any physical reason for their feelings, they were what are termed Primary Transexuals, who could never have prospered in their original birth role. To quote Dr. Russell Reid:⁽¹⁾ "Cross-sex behaviour with its culmination of transsexualism appears to exist in a wide variety of sociocultural systems. This indicates that disturbance in gender identity/role development is a risk the human species is subject to, rather than that it is induced by a certain environment."

More complicated are the later life transexuals. Are they primary transexuals who have buried their feelings for a lifetime? Or are they people who have tried to conform to a too rigid male role and feel that they must conform instead to a, possibly too rigid, female role?

Transexualism can be the result of some physiological variation, but invariably the problems are in terms of psycho-social adaptation. It is important to recognise that gender is not whether someone is male or female, but how he, or she, feels about him or herself as a man or a woman. In other words, it is based on the behaviours and feelings s/he has been taught, throughout life, especially in childhood, to label as masculine or feminine. Each child compares his, or her, natural, inherited, individual structure of feelings against his, or her, individual experience of gender roles. Some aspects are labelled "my gender" and incorporated, or may be imposed. Some are labelled "other gender" and rejected or discouraged. It follows that no two people's construction of their gender identity can be the same.

Those who write or talk about the subject, or practice therapy, must necessarily be using their own gender identity as a reference. Perhaps no one person's gender identity is necessarily right, for we are talking about a fundamental part of individual personality development, like being gay, for instance.

Few people suggest that one's personality can truly change. Indeed for anything else but gender dysphoria, no one expects it to. Can we be different to what we are, any more than can Eysencks's extraverts and introverts? One can, however, bury one's personality in feelings of what others feel we should be - either real men or real women, and nothing in between. Much of the disquiet, of course, is from the fear of sexual and gender issues, bred into every person in this country, by our parents and past generations.

Should not Society be responsible for ensuring that all its members can live in whatever way they can achieve most?

Definition

The primary diagnosis is given as Gender Dysphoria, defined as someone who has dissatisfaction with the sex of birth and sex role. But gender unease is a natural part of living and developing, especially in teenage and middle age, when people are assailed by a host of new biological and social imperatives. Perhaps we should be talking about a clinical transexual.

The rider is added to the definition that s/he "requests hormonal and surgical sex reassignment." But should this invariably be a condition for receiving help? Let us replace this clause with the words: "and who requests clinical or professional assistance."

In this essay, the intention is to examine the seven main issues that seem to be raised about the sex change:

1. There are no proper Standards of Care, and seeing a consultant once in three months is not enough.

All reputable gender consultants follow the Harry Benjamin Standards of Care,⁽²⁾ as far as they feel able. However, the initial motivation in writing this paper was to review them, and this will be a theme of this essay. I have to admit that my copy was published in 1981, so it is twelve years out of date. I am told that, with the greater chance of litigation by aggrieved families and relatives in the USA, the Standards are continuously under review. This raises one doubt: Can a document, designed to protect the practitioner, really serve the best interests of a client?

2. For reasons that don't seem to be clear, there is an ever-increasing waiting list at Gender Identity Clinics.

Gender non-conformity has been a part of human existence throughout history and in every culture. Initially, the recent increase in the West was attributed to wider knowledge of the availability of treatment, the so-called iatrogenic effect. It may also be that people feel more able to talk about themselves.

However there are general social issues - we have to look at social perceptions of gender behaviour and how they have changed, for instance from Victorian times until the end of World War II, then through to the sixties, then in the post-feminist era.

At the individual level, there are many complex psychological issues to unravel. In view of the clear way out of a person's confusion that the sex change may offer, he/she may label feelings as gender-related. Because gender dysphoria is a totally individual experience, therapy has to be person-centred; the idea of a single path, provided by the psychiatric machine, is counter-productive.

However, gender consultants are likely to face "extreme social pressure," to quote the Standard. Often this will be highly unfavourable, from opinionated transvestites and transexuals, irate families and investigative journalists, which may be destructive, without offering anything helpful in exchange.

Also the consultant "does not enjoy the comfort or security of knowing his decision will be supported by his/her peers." Those in such a position are unlikely to be able to defend themselves while respecting client confidentiality. It is, unfortunately, our best consultants who have the courage to be open about their work, who are most at risk.

If there are problems, my belief is that they are more likely to come from the many provincial gender clinics, and go-it-alone local psychiatrists. These tend not to communicate with others in the field, in a speciality which is changing in its presentation year by year. Gender clinics exist in Edinburgh, Newcastle, Leeds, Manchester, Nottingham, Leicester and Bristol, at least. Of these, only Leeds openly contributed to GENDYS II, the conference at Hulme Hall, Manchester, in September 1992.

Many people, especially those attending provincial clinics, feel that they have become part of some sort of therapeutic conveyor belt, while others feel that they have been rejected out of hand. Many feel that they cannot live as full time transvestites, simply because it does not have that all important clinical diagnosis. Others, possibly, do not understand what a transvestite is. If bisexuality is rejected by both heterosexuals and homosexuals, how much more difficult it is to sit on the fence in terms of gender.

3. Various people suggest that the National Health Service should not be expected to fund the sex change.

Since gender dysphoria is still listed within the Diagnostic and Statistical Manual, one might assume that the National Health Service has a statutory duty to provide care for transexuals.

We, no longer, give people anti-depressants and try to forget about them. Chronically depressive people aren't told to snap out of it and anorexic people are taken seriously. Anorexia, in fact, has many parallels with gender dysphoria, in its combination of inherited factors, social issues and self-image. Gender dysphoria seems to be as old as the human race and Professor Crisp,⁽³⁾ of St. George's Hospital, London suggests that anorexia may also have a long history.

4. Some consultants are said to be too ready to prescribe hormones.

We hear opinionated people talking about "Hormones handed out like sweeties," but are they? One of our leading consultants sees the hormones as a diagnostic tool, another doesn't. Some consultants only prescribe hormones reluctantly, and with a definite commitment to surgery. The important point is that we are talking about self-diagnosis, especially where the problems that have arisen may be primarily libidinal. With men, there may be a wish to end the endless urging of their endocrine system or, where there is aggressive frustration, for them to, more calmly, introspect the feelings that lie behind. We all bring experience of past relationships into present ones, and thence into sexual relationships, erotic or not. By volunteering to reduce the libidinal effect, the male to female transexual can review past experiences that lead to present feelings, and the defences that have been set up, if he has the courage to do so.

One glaring omission, however, is that GP's are not providing proper medical support, with physical monitoring and regular blood tests. There is a lack of communication between GP's and gender clinics, as with many other conditions that are handed over to specialists.

5. Some people are choosing reassignment and have found that it has not solved their problems.

If this does happen, it likely that they have used the therapeutic process to hide from their feelings, rather than finding their true motivations. They have been obsessed with the progression: disease - diagnosis - treatment - cure. This is the psychiatric, not the person-centred approach. The latter is one by which the person is encouraged to probe the psychological defences he, or she, has set up.

A significant feature of the statutory sector is that it does not acknowledge the person. What seems to happen is that a client approaches the GP, who, having recovered from his/her amazement (and negative feelings), will refer to a psychiatrist. The psychiatrist plainly often feels completely out of his, or her, depth, and refers on to a clinic for assessment. Having run the gauntlet of all this, it is hardly surprising that the client is obsessed with the goal, feeling he/she has to prove his/her case, and pass the test, seeing the consultant as an impediment, rather than a source of help.

I believe we should drop the terms gender reassignment. If the person is genuinely male-feminine or female-masculine, the term is, in any case, a nonsense. We should, instead talk of a gender appraisal process, terminated by gender confirmation, which is what surgery is already called, if it is required.

We hear disturbing figures for the number of people who are attending gender clinics. Central television reported that the Nuffield Hospital in Leicester has a waiting list of 700. The inference is they are waiting for the operation, which may be misleading. Are they all waiting for surgery, or they just people trying to find out about themselves, to make sense of their lives? Would it be more useful to publish the number who attend clinics, but who find ways of coping?

Some transexual groups make it very difficult for someone to admit to doubts. Textbooks speak disparagingly of people "dropping out." Another phrase I detest is that about "screening out" TV's. Any screening out should be done by the person him/herself. The idea of a failed TV or a failed TS is anathema to me. What is important is winning or failing as a person. If the client doesn't make the grade but has, in the words of Dr. Bryan Tully,⁽⁴⁾ gained "a satisfying sense of gendered self," then the clinic has in fact succeeded in its purpose.

6. Although prospective transexuals are expected to live in role for a period before surgery will be considered, many are cheating.

We hear a great deal about clients changing their clothes on the way to the clinic, then changing back afterwards. In other words, they are trying to fool the psychiatrist that they are living in the opposite role, when they are not. It could be suggested that the only people they are fooling are themselves. Curiously Living in Role only appears in the Standards in two small, obscure paragraphs.

How can a consultant police it? The answer is, of course, he shouldn't have to. One of the central features is encouraging the person to give himself permission to explore feelings that he feels he cannot have as a man. There is nothing, on the face of it, to stop a person wearing the clothes and living in the opposite role any time he, or she, likes. But then, of course, he or she would just be a transvestite. Nowadays, the recurring theme in helpline calls is no longer that transvestites are latent homosexuals or sexual fetishists but men dressing up. Television, in particular, has helped the transvestite community to portray this reality, but it cannot show the feelings that have gone before. In this, transexual clients may be no different from transvestites coming out, though their inhibitions may be that much deeper.

The question that needs to be asked is "what do we mean by living in role "Transexuals say that it isn't the clothes of the opposite sex that is important to them. Why should living in role mean one should dress as if one has stepped out of the pages of Grattan's catalogue? Yet consultants are often accused of finding their clients acceptable only when they conform to the consultant's own stereotype - usually twin-set and pearls.

There is good deal of controversy about the real life test in which the client is expected to live and progress in the desired role for a period. The essential point to put over is that it isn't a test to convince the psychiatrist, but an opportunity for the client to test his, or her, progress in the role.

How does a child learn a gender role? It isn't merely by being dressed in a certain way. It isn't merely by learning ways of speaking and deportment, but by many subtle cues that are learnt by the reaction of others. In other words, one does not simply rely on an elaborate external mask but on one that is built from within, in terms of behaviours and actions/reactions. Thus, the most successful male-to-female transexuals can dress in jeans and tee shirts and still be treated as women, if male to female, or vice versa, by others, without a moment's thought.

An approach, favoured by some, is to involve the local Occupational Therapy Unit.⁽⁵⁾ This will give the client confidence when first exploring the role, in safe surroundings, and also give some measure of feedback to the clinic.

7. There is little or no provision for after-care.

Follow-up support is a thorny subject, for many post-ops simply want to disappear into the community afterwards. On the other hand, it would appear that if NHS patients wish to see the consultant afterwards, they have to re-register. In America, where private practice is the rule, the Standards drop a quiet hint that the consultant can charge in advance for post-op therapy and counselling. In addition, a counsellor practising in the client's locality can provide support for day-to-day problems, but if we get the pre-operative process right, post-operative care will look after itself.

Psychiatry, Psychology or Counselling?

I have recently seen the film about Julia Grant, made about fifteen years ago, and was appalled by the attitude of her consultant. Perhaps he had a stereotype of women being compliant and submissive. He put her in the position of feeling she had to prove the seriousness of her intent by having breast prostheses, then was furious when she did so. In short, he just wasn't listening. He seemed to feel that each of his clients should do exactly what he said when he said, having them totally in his power. Yet he was failing them - for, if he expected them to rely totally on him, what source of support would they have afterwards, when he was no longer there? This is an example of psychiatry in the dark ages, a feature common to many practitioners, even now.

The client, at the start of therapy is disempowered by his/her feelings. The professional is in a position of great power, enjoying the benefit of superior knowledge and training. The central aim of therapy should be to restore power to the client.

The situation at present is that psychiatrists work in isolation. Other services, such as electrolysis and speech therapy are found by the client him/herself. Yet increasingly other areas of health work are seen as a team effort by psychiatrists, clinical psychologists, ancillary support workers and counsellors.

The qualifications required by the Standards of Care for a consultant, are stringent and distinctly American. I wonder how many of those in this country could, in fact, meet every one of them? The term "Clinical Behavioural Scientist" is, I believe, peculiar to America. The nearest professional would be a clinical psychologist, but the Standards also refer to psychiatry and counselling/psychotherapy. In this country, these are three different disciplines, with different regulating bodies, and a major problem is the suspicion with which they regard each other. A degree in psychology most definitely does not qualify one to offer either psychiatry or counselling. And so on round the circle.

We need to specify British qualifications. The Standards also say nothing about the surgeon, yet this is possibly the one area that is most likely to prove a disappointment, like the one who, recently, asked his client, "Why on earth do you want a clitoris?"

We keep hearing that prospective transexuals undergo "extensive counselling", but what is meant by this? Anyone can call him, or herself a counsellor. People are doing ten evening classes at their local school in counselling skills and calling themselves counsellors. There are TV's renting a telephone after coming out and calling themselves counsellors - what Dr. Russell Reid calls the Reborn Christian syndrome. Many professions, like nursing, are finding that counselling skills are being included in their training, and quoting this as sufficient qualification. I have a GCE in Handicrafts - I suppose I could call myself a cabinet maker.

As a result, genuine counsellors, having spent eight or ten years learning their business, engaging in extensive psychotherapy themselves, are feeling forced to begin calling themselves counselling psychotherapists. It is a situation they have been trying to avoid, since so many people find the idea of psychotherapy threatening. It shouldn't be - all it means is learning to use one's cognitive skills to make a better life for oneself.

Many suggest that the psychiatrist should not encourage people in their fantasies, but the process is one that enables the client to find if they are fantasies or not. Complicating the issue is the fact that the client may bring a number of side-issues with him or her. Moreover, having found a way out, the client is likely to be in a considerable hurry. It is, of course, important that it is seen as a way forward, rather than a way out.

Generally, it is suggested that psychotherapy is not very helpful, but clients may see it as a way of preventing them from reaching their goal. Usually, they are highly defensive about their pasts, and have often unwittingly rewritten it. Nevertheless it is an important part in helping clients to find their 'selves', whether or not they go on to reassignment. The psychiatrist is likely to have much trouble in relating to what his clients describe as masculine and feminine. Usually he, or she, will concentrate on how well the client is likely to fare in the opposite role, in terms of appearance and mannerisms. A major contribution to the client's progress is finding someone who will acknowledge his, or her, feelings and in finding someone to whom he, or she, can speak freely. The aim should be to promote this path, countering the client's feelings that he, or she, has to pass a test to become accepted.

In that the person may be seen to be labelling feelings that are important, as belonging to the opposite gender, and then feeling that they cannot be expressed, an important feature of the therapy is giving permission to do so. A transvestite coming out for the first time invariably goes into an endless round of dressing, attending meetings and so on. Having, at last, given himself permission to express his feelings openly, he does so at every opportunity. For the later-life TS, often still closeted, whose feelings are much stronger, and which may have been bottled up so much more tightly, it is the acceptance on a programme and the prescription of hormones that gives permission. It should be an opportunity to introspect those feelings and align his life-plan with what is possible. This is the real purpose of the life test. Often, however, the scenario of diagnosis - treatment - cure, or labelling - hormones - operation, becomes an excuse, like masturbatory climax, to avoid introspecting feelings. For some, the sex-change process becomes a concrete answer to confusion, replacing sexual fantasy as an emotional defence. This is reinforced by media attitudes and the classical psychiatric scenario.

There is little room here to deal with the prescription of hormones and their effects. The libido lowering effect for men is useful, if the person is encouraged to introspect the feelings that lie behind any sexual feelings or frustration. Certainly, unlike tranquillisers, they do not appear to be addictive, and side effects are fairly well understood. Emotional effects are less well understood. There may be a link with the innate neuroticism of the client, but there may be an element of giving permission to be emotional, in a person who has labelled emotionality as not compatible with the male role.

If we assume that the clinical behavioural scientists referred to in the Standards (who, in fact, take the leading role), are what we call clinical psychologists, we need to examine the benefits and disadvantages they may have. Unlike psychiatrists, who deal with mental issues from a medical viewpoint, psychologists work in terms of operational dysfunction, applying psychological diagnoses rather than medical ones. While centering on the condition described, they see their remit as also addressing the client's whole lifestyle and environment, but as detached observers.

Obviously there are overlaps in the way the three disciplines work in practice. While the psychologist does not enter the client's life in the way that a counsellor does, a problem with the person-centred approach is that it is lengthy and its unstructured nature makes the development of psychometric tests attractive.

What often seems to happen is that the client may be told something like: "You're very nervy, you know!" Perhaps, the wish for reassignment is seen as a result of the nerviness, rather than the possible result. The client takes umbrage and tries someone else. Often, the client feels the consultant threatens his/her defences and counter-transfers; either saying "He doesn't like me", or "He's a prat!"

Psychometric tests, referred to in the Standards, are the province of the clinical psychologist. What may happen is that tests of emotionality, spatial abilities and so on, are used, focusing on the masculinity or femininity of the client, when reliable measures simply don't exist. The fundamental fallacy here is in trying to prove whether or not someone is, or is not, transexual, when gender is, after all, a construct of our cultural imagination.

The important issue is where the client is, as a person. It would be much more appropriate to use ordinary, everyday tests that highlight his/her internal constructs, especially in terms of relationships (Kelly, Hinckle), self concept (Stephenson, Rogers) and his/her level of self directedness, internalised locus of control (Rotter) and self-efficacy (Bandura) - the person should be positive and forward moving. It must be emphasised that there are no right or wrong answers, but a clear result from a concrete test might act as a neutral referee, and might provide a short-term goal for the next three months; to evaluate long term goals several years in the future. Most people are very defensive about any approach to their internal psyche. Transvestites and transexuals often have defences which are virtually impenetrable. The psychometric test becomes a tool by which the person may be encouraged to confront the significant people and experiences in his, or her, past and, perhaps, modify his, or her, cognitive interpretation.

If the person is genuinely in charge of his, or her, life, there will be no need to doubt the person's ability to prosper in the chosen role best, with or without the operation, and the aim would be to help her/his progress in this direction. If not, the question is irrelevant. The person would not cope in any role and help with this would be the primary aim. Furthermore, if psychometric testing is used simply as a way of rejecting people who are not demonstrably transexual, they will still not have found themselves, and the clinic will have failed them.

The Care Programme Approach.

Increasingly, in all areas of health work, the care is seen to extend beyond hospital admission and discharge. Emphasis is shifting to the Care Programme Approach.

With the reorganisation of the National Health Service, there is increasing reluctance to refer to sources outside the local health area, and local psychiatrists may well feel pressured to go it alone. Under such pressure, a properly written programme, with Standards of Care built in, are not only a protection for the client, but for the psychiatrist, who can then tell his Unit Manager, "This is why it is not within my capability."

Thus, the consultant psychiatrist who formerly worked on his, or her, own, becomes the leader of a team; each member bringing his, or her, special expertise, to the benefit of the client.

As the leader, the consultant has special experience in transexual issues, having worked for a period of years in gender clinics. In fact, as now, he will spend more time with his counselling hat on, so among his qualifications will be accreditation by the British Association for Counselling, or a similar body.

His psychologist highlights various issues for the client to address and can perhaps assist in a structured progression.

He will also know which surgeons have a proven track record in acceptable operations, if needed. Meanwhile, back at home, the GP will provide medical and physiological monitoring, a glaring omission in the Harry Benjamin Standards.

Most clients, as well as professionals, feel three months is too long a period between sessions. Invariably gender clinics are centralised and are heavily subscribed. Most clients cannot, in any case, afford to travel the long distance more frequently.

A solution is to involve local accredited counsellors, often attached to general practices, to provide clients, who often are forever living in the future, with day-to-day holistic therapy and support, working with the psychiatrist at the central clinic, who provides condition centred therapy.

In addition there will be peripheral services. Electrologists who are prepared to work on transexuals, and are sufficiently skilled, are not easy to find. Occupational therapy units have already been mentioned; assistance with speech and deportment are likely to be helpful.

Conclusion.

I have allowed myself the luxury of ignoring economic issues in this discussion, but what can be afforded should not limit what we say we should have. Somewhere in between will be found a working compromise, I hope.

Whatever the problems and the deficits of the NHS it gives us a yardstick by which the national standard of health care can be measured. Though the private sector is likely to continue, due to long waiting lists, the National Health Service will be setting standards, rather than trying to deny the existence of this aspect of its work.

The view for most professionals is fragmented and incomplete, since, as in most British health care, there is little in the way of statistical recording. Budgets are controlled by accountants and managers, rather then people who understand people. It is hardly surprising that the operation is seen as elective cosmetic surgery. If a responsible and realistic programme is developed, the National Health Service has a better opportunity to say what it can, and what it can't, pay for, justifying the expenditure. Yet it will be providing and promoting better therapy than exists at present.

1. P.Cohen-Kettenis, L G J Gooren & R Reid, (1993) Psychiatric and Psychological Aspects of Transexualism, XXVI Colloquy on European Law, Amsterdam.
2. Standards of Care: the hormonal and surgical sex reassignment of gender dysphoric persons. The Harry Benjamin International Gender Dysphoria Association Inc..
3. Crisp. A, Royal Society of Psychiatrists Conference, Scarborough 1993, reported in Daily Telegraph (8, July 1993)
4. Tully.B, (1992) Accounting for Transsexualism and Transhomosexuality, London: Whiting and Birch.
5. Jessop. N, Occupational Therapy with a Male-to-Female Transsexual: a case study. British Journal of Occupational Therapy Vol56, no.9, Sept 1993.