Difference & the Existential - a Positive View

Alice Purnell

B.Sc., R.G.N., Post Grad. Dip. Counselling/Psychology. Psychologist/Counsellor. Nurse
Gendys Conference, 2002

There is a Problem in Treating Identity by Medical Means.

There are traditional dynamics between practitioners and their patients - the omniscient doctor and the respectful sick person, who is at a disadvantage in seeking this help. This has been particularly true of those seeking help suffering with gender dysphoria. GD is not an illness, but rather is a problem of identity, which in the case of the transsexual person, often requires medical and/or surgical intervention to resolve.

There need to be Standards of Care which are inclusive of the informed client, not simply standards designed to protect the doctors and surgeons from malpractice suits brought by hostile colleagues or disgruntled patients. At present these Standards appear to work with the mindset that there is such a thing as a standard person. There is not. Let alone a standard T person. The human mind is complex. A sense of identity incorporates a sense of gender, which surely needs to be congruent with that person's mind. Of course we cannot live a fantasy life, but if a person's gender is incongruent with their body they need medical and surgical help to live the life they aspire to. There is no litmus test for "true transsexuality" any more than there is a standard man or woman, there can only be averages. Average does not mean the same as normal and normal does not necessarily mean acceptable or good. Famine, poverty, pain, cancer, ageing and death are all realities, all normal, but are they inevitable, desirable? Should we not strive for change and improvement in our society? Of course we are still stuck with death, but in the 21st century quality of life and respect are achievable.

No Person should be Forced to Live a Lie,

pretending to have a gender identity they do not have. That is like requiring a heterosexual to live as a gay person. It is not so long ago in the "good old days of eugenics" that doctors tried to cure their gay patients and later transsexuals. These so called deviant people were given electric shock treatment, aversion therapy, lobotomies, drugs and other invasive methods to make them "NORMAL".

That approach is now seen as barbaric, primitive, lacking respect, and furthermore, it did not work. .

Still the mythology that "doctor is always right" persists. There is a often a failure of communication and of trust both ways, which gets in the way of truth and appropriate person-based treatments. The transactional dynamic between doctor and client is often that of a "stern parent" doctor opposing the "naughty child" patient. This makes it hard for a clinician to reach the truth and provide appropriate help for the client.

Instead of directing Care Standards to an individual holistically, the person is required to fit certain standards before they will be helped. A conspiracy of pretence has grown, whereby applicants for hormonal or surgical interventions tell the G.I.C. psychiatrists what they know or believe they want to hear. It becomes a script, so that they will get hormones and treatment for transsexualism, irrespective of that client's actual gender identity. As these clients lie, the G.I.C. psychiatrists become less willing to sort out the truth and see if they can help. The truth is often lost, mistakes can be made. The gatekeeper approach of psychiatrists often means that the client is excluded from appropriate help if they actually do speak the truth. All too often in the past a client will have lied to the professionals, or themselves. It was not unusual for a professional to approach these problems with an attitude of "this is what you need", instead of giving the time to actually help a client. The psychotherapeutic benefit is lost if they act as gatekeepers, rather than as facilitators. Certainly more listening (both ways), more consultation, more taking personal responsibility by the client, and a reality of inclusion in the treatment protocols will help. There is some considerable way to go before this group of people feel properly served by the NHS and some of the more exploitative sections of the private sector and other support services. The client may be so confused as to not know the truth, and will need counselling therapies to discover who they really are and to come to terms with this. It is true that what one wants may not be what one needs; but equally how can a clinician who is exposed to a text rather than the truth judge that the help given or refused is appropriate? Appointments are too brief, too few and far between. The largest GIC's have too many seeking help and are under-resourced.

Care Standards

Standards of Care should be high. They should not be used other than as Guidelines. Nor should they be used by gatekeeper- psychiatrists to exclude those who are distressed, or who do not fit a particular pattern or theory, or view of what a man or a woman "should be" from treatment protocols.

Humans are not totally gender bipolar. We all share masculine and feminine aspects in our personalities and characters. T people present, seeking medical or surgical assistance in reaching a personal gender harmony or euphoria, as opposed to being forced to pretend to be someone they are not, or rejected and excluded from any help.

There are still Failures in Care and Casualties of the Treatments Available.

One of the first principals of Medicine is "Do no harm". When providing any treatment which is irreversible both client and clinician need certainty. To find this, they need truth, trust, time and an attitude of mutual respect.

I should mention the Conference presented at the Royal Society of Medicine last April 16th in London on "Gender Identity Disorder in Adults - Guidance for the Management of Transsexualism- Towards a Uniform Treatment Approach", caused such a furore since it lacked any inclusion for a proposed National Consultation process regarding the controversial Standards of Care it proposed. It resulted in considerable discussion and work with sister groups and individual people to try to get these Standards right. There was a real problem with the proposed standards of care which were authored by Dr. Brian Ferguson. There was a peaceful demonstration outside and people from all the significant T support organisations attended and had a lot to say. Sadly it ended with no firm agreement for consultation to take place, but hopefully these standards will be dropped. I gained the impression that Dr. Ferguson and the organisers felt out of their depth faced with the reaction of T people and many of the professionals in this field.

There was a volume of largely constructive criticism from the client group. Patient Power and awareness challenged the medic's assumptions and lack of good practice, which seemed to have excluded the client from the team. This approach is contrary to that which the modern Health Service is supposed to provide. The feelings and erudition of those requesting, or insisting, quite reasonably, that we have the same right to consultation as any group requiring NHS help, simply terminated any public discussion of the actual issues in question. The Royal College of Nurses also mounted a Conference in May, about T people in Nursing, and nursing T people.

Those who Oppose Equality for "T people"

We still have sad strange creatures purporting to speak for Christianity in the Evangelical Alliance... They are never consistent. They select texts from the Old Testament and forget the loving text of the New. Do they think we should leave a hair lip as it is, or not strive to improve quality of life for our people? As Christians can they assume that their God actually wishes us to keep slaves and punish them in particular ways as described in the "Good Book"? Have they forgotten the Sermon on the Mount and the Prayer of St Francis? In fact the Bible states "Judge not that ye be not judged". It amazes me that fellow Christians judge others by Old Testament standards, when for example they would not cut off the hand of a thief, or pluck out an offending eye? These misguided people seem ignorant of intersexed people, of feelings of identity which they have never been exposed to. They even appear to be unaware of the fact that diversity is an important part of nature. If a Creator made us She/He did so with love accepting each of us as we are.

As a counselling psychologist I meet clients who have gone, or are going through hell because of the negative attitude they share with some vocal members of our society. These vocal individuals speak as if to represent society, indeed all people, in belittling or somehow disbelieving that the mind is stronger than the body. We each have an identity, a personality. Most religions would say a soul. The result of our thoughts, feelings, actions and interactions shows who we are, and this soul, we are told by the religious, is stronger than the body and has an eternal life after death. The argument to leave things "as God made them" simply does not stand up to genuine Christian values.

If mind is incongruent with the body, an internal war takes place, resulting in a range of symptoms which are painful and harmful to the sufferer. If that person is also assailed by the so called morality and the thought-police mentality of some of these bigots this hardly helps. Many of my clients feel confused and suffer great guilt trips about being different, having been bashed by many a Bible, an unsympathetic world, or by simply realising how upset their parent feels about their son or daughter's gender affirmation.

The media will always give room to thought Luddites. Even some misguided professionals who should know better, choose to have their say without any understanding of the problem. Surely the triumph of Reality over Fantasy is to recognise that the world is inhabited by diverse people, not just ordinary men or women. In the same way that there is a spectrum of races, colours, creeds, beliefs, abilities, disabilities, sizes, intelligences, education and skills, our society must recognise this and give respect to each individual. Even after hostile attitudes change and the law changes, there will still be frightened children, lonely confused T adults and others, who will need some understanding and help from caring professionals. Hopefully one day we might have a Society which is genuinely not fearful of difference.

Order in a World in which People Cannot Clearly be Divided by Gender or Sexual polarity

Rather like Pythagoras 2.5k ago, I do some of my thinking in the bath. The Pythagorean view which Descartes extends - with all in its mathematical place, was an ordered world; in which status, sex, in fact all, was fixed, stratified and was made up of opposites and hierarchies. It was dipolar, as therefore was gender. This ordered Cartesian view, together with the spin off from Judeo-Christian concepts and Freudian psychology, has rather stifled ideas which are challenging to this view. Darwin and Wallace clearly stated that there is diversity, variation, and natural selection. Without variation or diversity there would be nothing from which to select and evolution would not have been possible. Our species, like all mammals, reproduces by sexual reproduction and sexual selection, giving the genes almost infinite permutations, so no two individuals are absolutely identical, not even identical twins. Their experience of life and thought processes will have been separate. Each has an inherent individual identity, a name, a separate existence. Diversity is to be celebrated as an opportunity for nature and for individuality.

So What Makes a Person, is it Nature or is it Nurture?

Psychiatrists tend towards the nurture model, whilst biologists might lean towards genetics as to what creates a person. Obviously it is a combination, but which is the major factor? Being seems to come from nature, whilst feelings derive to some extent from nurture, with elements of nature at a more primal level. How does a cat know it is a male or a female, or a cat for that matter? It does know when it needs food or milk. The urge to reproduce is certainly programmed by the hormones which affect the brain (and by the proteins resulting from our DNA , and the so called "selfish genes"). Desmond Morris with his "Naked Ape" compared human behaviour to that of our cousins the apes, providing further food for thought.

Which feelings come from thought, experience and learning and which from chemistry (hormones) from our ancestors in the gene pool?

Natural Variations

It strikes me that few things in life are clear-cut, save that we are mortal. Sex and sexuality and gender each are a continuum and each is independent, although generally of course one is either male or female, masculine or feminine, heterosexual or homosexual. But what of the hermaphrodite and intersexed people, of the gender neutral, of the bisexual and the asexual person? These are all natural variations.

Recently on television there was a programme by a gay man investigating gay animals. It seems that of course they do exist, the amygdala in the brain of a gay ram is more like that of an ewe than his male hetero-rams. He cannot but be other than he is, in that he is attracted to males even in the presence of ewes in estrous. Sexuality seems to be driven by the wiring in a part of the brain. In fact a physical anatomical gender difference is seen in the stria terminalis of the human brain if Dutch research by Prof. Swaab is valid.

A biological reason for gender or sexual behaviours gets people off the "guilty" hook of having somehow chosen to challenge what is termed "normality" (i.e. "good") in a "perverse", "against God and nature", and an ordered paternalistic state, by being other than "normal" that is to say average or ordinary. A person has to be him/herself.

Boys will be Boys

Over the last several millennia warring states felt the need for clarity, dipolarity; so men went to war and women bore children and stayed home and wept. If you remember your mythology the great Greek hero Achilles was disguised as a girl when he was a child by his mother to spare him death in battles, but when he was offered a spear or a distaff, the twit chose a spear, revealing his maleness that way, so found himself in Troy where he eventually met his fate thanks to his Achilles heel. But remember any half decent Amazon would have done the same thing.

Even Heracles after his great Labours and adventures went to live in a cave with the witch Omphale, where he dressed as a woman and spent his time spinning, bewitched by this woman. After his encounter with the Gorgon who can blame him?

Despite the Greek Republic being described as a democracy and idealised, it was an androcracy. Interestingly the Greeks, with their Gods and Goddesses, were not homophobic, that came with Judeo-Christianity and an all-male-God. It is sad that we have made God in the image of a man, though Christ did turn His back on male power with His ideas of love one another.

Humans are Not Particularly Sexually Dimorphic.

Back to biology - in many species males and females are markedly dimorphic -stag or doe, peacock or peahen. Especially among the birds there are display differences which become exaggerated when females choose a mate. These differences have evolved so that the successful creature develops display colours, feathers, antlers, size differences, rituals and so on. Humans are actually less sexually dimorphic than most mammals. Male nipples and the clitoris reveal a little of the fact that there is a potential in any embryo towards either male or female sexual embryonic development from the "female phenotype". During the growth of a fetus there are vestiges of our history as creatures in evolutionary terms and of the individual in sexual terms.

In our nearest relatives in the animal world, the chimps, sexual dimorphism is more apparent than in humans. Dominant males are much bigger, and stronger than the females, or their less dominant brothers and rivals. As social creatures, like ourselves, their genes are to an extent their destiny, most males behave one way and females another. Their society is stratified, with alpha males and alpha females, with issues of position and dominance in the group or tribe clearly defined and tested during childhood and adolescence, by play and by the status of their parents (especially the mother). The way we perceive ourselves and others perceive us is to a great extent defined by our gender and its place in society. During the last two millennia of patriarchy the roles, and reflecting this, the dress, of men and women have been dictated by various "norms" and prohibitions. But boys are expected to be boys; and girls to be girls, from day one of a child's life. It is hard for a mother to accept that her little girl has become a man, or is a dyke, often much harder, for example than if she is a drug addict, alcoholic or a criminal. Perhaps even harder for an only son of a Moslem to be accepted by his father as a woman.

Women in a Man's World.

The MtF T person joins the "wrong side" and it would seem suffers more approbation than her FtM counterpart. Our society has only offered women the right to property and to the vote during the last century and there is still some way to go for real equality. Only during the last eighty years Western women have gained something like equality in matters of political power, ownership, position in the law, creativity or being taken seriously as sentient beings.

No longer are we "owned" by men - by our father, then a husband, with the somewhat limited expectation of dependency and housework and children. Since the advent of the pill many women enjoy the same sexual freedom as men. At the same time better education, strong role models and challenges to male superiority, mean that women are moving towards something a little nearer equality .. though traditional "female" jobs are still paid about 20% less per hour than male ones.

So I wonder why anyone with a brain might want to think of themselves as a woman when there are still such inequalities? But that is not really the point, I suggest that a person's gender identity is fixed before birth. Normally a girl has a female gender identity, and she is stuck with it. It seems some people are born with the "wrong" chromosomes, since it is not an "XX or XY chromosome" which only defines sex. It is more complex than that, just as the genes themselves are complex, together with the proteins and the numerous copies of SRY among the genome affecting sex and probably gender. Sex is more complex than a Y chromosome probably being an incomplete X, and the Y always making a male of the fetus. Much further research needs to be done to clear up this situation.

Sex, like Gender, is not Dipolar

Nobody is, as the papers say, "born a man" - thank God. Imagine the consequences of trying to give birth to a twelve stone 18 year old? No a baby is born . It might look like a boy or a girl, but many are in-between or unclear. In a six week period as a theatre sister in a local children's hospital, I saw eleven such children with testicular feminization and others with various problems from hypospadias to genital ambiguity. The genitals do not conclusively define a child's sex or gender for that matter. Humans are complex, we may be born male or female, both or in very rare cases neither, just as s/he may prove to become hetero/homo/bi or a/sexual in terms of sexual preference. During the late 19th and early 20th century Freud developed his theories of psychoanalysis. These have a somewhat misogynist and pessimistic pervading view of humanity, driven largely by ego based dark forces which could be manipulated by a psychoanalyst or a psychiatrist, or by a paternalistic state. His followers adopted and adapted these theories to manipulate the masses by advertising and brainwashing. They used the controls of "normalcy" and made average, normal and standard as something to strive for and to control populations, even to sell ideas and goods to, replacing religious faith with their own mythologies and consumer driven values. This Cartesian view of humanity fails to see the person; whilst a client led, humanistic and existential view of the individual, shows there is variation among individuals. This challenges Freudian psychology in that it recognises that there is much that is to be said for personal autonomy and that there is also much that is innately good in people. Of course not all individuals are innately good or altruistic, or selfish or bad, for that matter. Neither are we doomed to anarchy if we recognise the person.

After the second World War ideas about individuality, existentialism and freedom have allowed many people to look deeply into who they really are, in terms of sexuality, sex and gender, rather than live unchallengingly as who they "should be". People are coming out of all sorts of closets. As the closets empty to cries of "freedom, respect, equality" - Cabinet makers, lawyers and politicians shudder! The conventional, the insecure, the powerful and the bigot fall off their perches and feel frantic about the challenges to "family life, society and the world as we know it". It is a shame ethical and religious matters have become embroiled in this debate, because belief is challenged by the existential. There is great fear of anarchy among the hierarchical. But there is no excuse for intolerance save when the behaviour of one damages another (abusers, rapists, terrorists, pedophiliacs, murderers, do need to be stopped).

Guilt Trips

To be different means generally to be made to feel not as good, guilty, ashamed. The weapons of the bigot are the same as those of the abuser, using fear, guilt, and power to control the victim. Why one wonders do some people react so negatively to those they perceive as different? Lepers still exist in our land, minorities who are not accepted are easy targets for the bigots, media, and unenlightened. Stereotyping is a good way to dehumanise... the immigrants, blacks, Moslems, Jews, cripples, asylum-seekers, gays, Trannies.... Perhaps it becomes harder to be a bigot when you see a real person whose aspirations to be loved, respected, accepted are as reasonable as your own.

If we think of the fertilised egg as a potential person. It is generally, but not always, possible to predict the sex of the embryo defined by the genes, visible to some extent in the pairs of chromosomes. These genes probably act as switches as the fetus develops, as do hormones produced by the fetus and in the maternal blood stream. Physical and neurological growth takes place, so that nine months later a reasonably healthy baby will hopefully be born, with its own body map developing in its brain.

Gender Identity depends on all the "right switches" operating at the right times, the right hormones, temperatures, timings... so many variables, not least the genetic makeup. The environment within the womb needs to be perfect - no stress, drugs, chemicals, cigarettes, hormones, the right acidity etc. Then comes nurture after the baby is born. We are all accidents or experiments of nature. To a lesser extent I think nurture also has a role in reinforcing or releasing inherent traits. Variation, including gender identity, is a natural consequence of the complexities of human development. Even by year two of a child's life he or she will probably know how he or she should behave, because of all the positive and negative reinforcement of his parents and his peer group. Usually the child will not need to challenge this.

I believe that a sense of gender identity is latent at birth. By the time we are adults we know well the prohibitions about crossing gender divides, especially if a boy has been a sissy. There is much denial about being feminine if you were born a boy, less so about being a tomboy if you were a girl.

There is a caution in all this. Hate of one's sex or gender is not the best reason to adopt the other. This is reactive gender identity disorder, rather than one which is a drive towards what is right, it is away from what was unpleasant. There are no guarantees that the other side of the fence will be any less uncomfortable. I have met clients who I would describe as autoandrophobic, hating maleness, because of some trauma in earlier life. A sense of being is a stronger indicator of self, rather than a sense of not being. Both sets of feelings are equally powerful.

It is also dangerous to rationalise that you are living in the wrong gender if you prefer the clothes of the other, or as a guilty transvestite you feel released from guilt, if you describe yourself as a transsexual person. It is a big and almost irreversible step to officially and physically permanently cross the gender divide. Costs are high, so one needs to be certain. I do not just mean financial costs, but emotional costs to those we love and who love us.

Your genes are not always your destiny. These challenges to identity can mean that the search for, and a sense of, personal identity, of whatever gender; allows those with gender identity disorder to question, in a very healthy way, the whole ridiculous inequalities which still exist in our society. Gender is only one dimension on being a person. In a sense what sort of man or woman or un-gendered or polygendered person you are is an even more challenging question. A personal identity is vital to each of us. Many are not so challenged. Many T people would prefer to never have had to face these problems and the challenges of an unsympathetic society. However perhaps we will soon be celebrating diversity in a rainbow world, where there is plenty of room for difference. Frequently a person with gender identity disorder feels sure about his or her gender, but they also feel isolated, rejected, confused, betrayed, not good enough, guilty, even suicidal. Surely they should be enabled to feel liberated, freed, joyful by that recognition and experience. There is a high price to pay for freedom. Sadly partners may also be hurt and families disrupted.

How then Can the Therapist or Counsellor Help her/his Client?

It is my belief that the Client Leads in Effective Gender Counselling. I refer you to my talk at GENDYS 2K. It is damaging to a client if a counsellor tries to act as gatekeeper, as someone who has, as a goal, to get all her clients into surgery, or to prevent this. The counsellor or psychotherapist must not work to a personal agenda, but needs to facilitate and to listen. Humans are complex, multidimensional individuals and their counselling is to help them through a difficulty or series of problems, to find a way of being which is comfortable, practical and life enhancing. Not to seek and have any effective counselling is to invite later problems. Some clients feel and need long term counselling, whilst others seek counselling as a form of crisis intervention, or to help them to think through what they want to do, can do, or will do, about their gender identity conflict or whatever issues may arise connected with this in themselves or their loved ones.

What is the Role, Purpose or Goal of Counselling?

My experience is that counselling in the context of gender dysphoria will be at its most helpful if it is both cognitive and eclectic. We are not dealing with a mental illness, but with an unease about lifestyle, body and personality, together with the spin-off produced by a critical society and the consequent guilt trips felt by those who are victimised by this hostile attitude. In "Client led" counselling I would suggest the client will describe what he or she feels is the problem and the counsellor's task is to assist the client towards finding what the actual problem may be, and consider how this could be addressed. In doing so the client grows less confused by the layers of feelings and more able to resolve the difficulty. It is important to challenge irrational beliefs and involve a client in being informed and taking personal responsibility. A client is invited to engage their mind as well as their feelings towards finding a way of being which is acceptable, possible and practical for his or her lifestyle. This process can be rapid or protracted, but does mean that the client has a fuller understanding of her or his feelings, goals and solutions. The client needs to weigh up emotional and practical cost to self and others against benefits.

So what do I mean by my title Difference and the Existential?

Chambers Dictionary defines existentialism as "A term covering a number of related doctrines, denying objective universal values and holding that a person must create values for himself (herself) through action and by living each moment to the full". The Existential movement as described by Heidigger in 1967 is a philosophy which concentrates on understanding existence in contrast to the earlier Cartesian preoccupation with thinking, on being rather than knowing. It suggests sum ergo cogito I am therefore I think, instead of cogito ergo sum. Sartre places stoicism in the face of anxiety and despair. Laing (1960) places awareness of the self and others before consideration of the unconscious process. Carl Rogers in his book "On Becoming a Person, a Therapist's View of Psychotherapy", in his chapter entitled "A Therapists View of the Good Life", he describes what he calls the characteristics of the process in which he talks of an "Increasing Openness to Experience" as the polar opposite of defensiveness. If a person could be fully open to his experience, every experience, every stimulus - whether originating within the organism or in the environment - this would be freely relayed through the nervous system without being distorted by any defensive mechanism... The "good life" appears to be a movement away from the pole of defensiveness towards the pole of openness to experience.. this involves an increasing tendency to live fully in each moment... the self and personality emerge from experience.

I suggest that this sense of freedom, touched nervously on by Sartre in his book "Intimacy" is both liberating and frightening. If taken up as a way of being, the shackles of society's view or by self-stereotyping can be abandoned and an individual can emerge. What sort of person can one then be? A Lacota Sioux friend of mine, NapeWasteWin suggests a good dictum "Be the best version of yourself you can be". A half-life self stifled or crushed by stereotyping into the oppression of labels and self-doubt is no life at all. Suicide is not a good option. Be yourself, not who you are told you "Should be". It is better to exist than to exit.

I maintain that diversity is a normal aspect of nature and difference must be respected but need not divide us. As individuals our thoughts can inspire or crush us, as can the words and actions of others. Society has for far too long been reinforced by outmoded and unjust laws, which have marginalized, stigmatised, even penalised the T person. It is time to walk tall! We need not be harmed by others, or by ourselves.

Identity seems to be made up of inherent characteristics upon which life superimposes further layers. One can choose to live as the person one is, if no harm is done to others. Living in the light of day, with windows open and curtains drawn apart, or to live behind shutters, with windows closed, to live a restricted and often secret life. This cannot be healthy.

Life is not a dream, nor should it be a nightmare or a prison.