The path to Gender Reassignment:
Before I commence my paper I want to make it quite clear from the start I am not criticising any of the professionals or establishments involved in our community's care. As far as I am concerned they do a magnificent job, given the tools that they have to work with. It's the tools that they have to work with that I am addressing.
As things stand at the present time it looks to me as though we are currently at the threshold of a new dawn for those who have, or are about to transition. The Gender Recognition Bill, having received Royal Assent earlier this year is presently being worked up into its application stage and present estimates suggest we can expect a formal process to issue a new birth certificate to those who have completed their re-assignment process sometime in the early part of next year. At the other end of the system we have long had official recognition of the condition, albeit not perhaps in a category that some are quite happy with. So we will have official recognition of both the condition and the completion of the process. But what about the bit in-between?
To me the present system, rather loosely based on differing variations of the American Harry Benjamin guidelines seem very much accentuated towards receiving approval for surgery, rather than a process where candidates can obtain and practice life skills to enable them to take their place in society in the opposite gender role to the one that they were brought up in. In my experience those who are in the process of making the change who integrate into the gender community have a much better quality of life afterwards than those who go through the process with out any significant social contact with others in the same situation. It's the comparison between the super hero who nips into the nearest telephone box, (if you can find one these days!) gives a couple of twirls and emerges with their underpants on the outside of their everyday clothes and suddenly they have the ability to fly! For the MtF two snips, a couple of tucks and a few stitches changes their anatomy into female so they must be a woman now! I don't think so! The accent on getting approval for surgery seems to obscure the fact that when you are living your everyday life is doesn't really matter what's between your legs, it's what you are, the manner in which you act and behave, and what you look like that determines how others see you, and that in turn determines the way that they interact with you. Being comfortable in the role, and accepting of the social conditions that it brings with it are far more vital factors in the chosen lifestyle than surgery. Don't get me wrong I not suggesting that surgery is wrong, or should be discouraged, but that it should come later, not earlier.
The spread of the Internet, with its e-mail lists and on line groups has produced people who I have watched race each other towards gaining approval for their operation, but without any practical experience of the necessary everyday skills required to be accepted in the gender role that they want to be in. They pick up the phrases and statements that suit their goal and it has even been suggested that some actually change in the toilets at the venue of their appointment for their next meeting with the specialist! Having gained consent for surgery, the operation date approaches rapidly and then what! They burst out of the metaphorical tunnel of their reassignment process into the daylight of their new world without the ability to cope with their everyday life. Regret at their decision and the option to revert are frequent considerations as recent press articles have shown.
The final process of gaining a new birth certificate looks as though it will be based on a panel model. I am suggesting that as a community we should develop our own British model for the process of transition and that it should also be integrated with the process that leads to the change of birth certificate. Something rather along the line of a level 2 or 3 NVQ instead of the present occasional interview process. Coursework is required! Confidence and acknowledgement of the chosen gender role should come before surgical intervention. In fact the WHO classification puts the desire to live and be accepted as a member of the opposite gender first, with considerations of discomfort with anatomical sex afterwards. A lifestyle first approach will also help those who have entered into the process for the wrong reasons. For me there appears to be two significant causes of MtF's in particular wanting to transition for the wrong reasons. The first is being uncomfortable with managing their male sex drive, feeling that being without what they consider to be the offending parts will cure the problem. The second are those who consider their life in their present gender role is a failure and that all will be fine on the other side of the fence. In neither case will a satisfactory outcome be achieved, in fact it is only more reason for the press to pick up the story and trumpet the inadequacies of the present system.
I mentioned at the beginning of my talk that I felt that the professionals do a grand job considering the tools they have to work with. The tool I have already mentioned is the shortcomings of the treatment guidelines but there is the issue of the actual drugs used in the process. There have been no formal tests or clinical trials for actual approval for the manner in which drugs are used for the process of gender reassignment either during or after transition. In fact it is technically possible for professionals who prescribe for this reason falling foul of their own professional standards bodies! There is also a significant lack of long term monitoring of the effect of prescription regimes postoperatively. One GP who held an open forum at a support group meeting I attended stated that they were flying by the seat of their pants in dealing with health issues of their post operative patients. They relied on information gained from the Internet and the patient themselves. The facts of the matter are that there are specific issues of healthcare for Trans people, for example a MtF postoperative female needs regular screening for breast cancer, but does not require a cervical smear. It is also possible that they might suffer problems with the prostrate! It's no surprise that this situation exists, after all the measure of success of the whole process is the ability to merge into the community at large.
A common national approach along panel/NVQ lines should involve not just professionals but the existing support groups thus giving a local access to the whole process. In turn this would then involve members of our own community, thus keeping those who have transitioned in contact and able to provide feedback on their ongoing situation and experiences. We already have a significant number of organisations who have their own specialist areas, such as legal process, scientific research, and partner support and a combined grouping of these skills would go a long way towards providing a better standard of life for those already in this community and those seeking to join it. There are models for such an arrangement in the not for profit organisations that promote and regulate particular sports such as SCUBA diving and the BSAC.
Attitudes towards our community have come a long way from the early days and successes reported in the papers have helped, the most recent example of Nadia winning Big Brother has generated in the main a lot of positive press coverage. There is not quite the same fear of rejection by the community at large that there once was, but there is still work to be done. By getting our own house in order and quietly managing our affairs effectively we can consolidate the present position and move forward.
Finally I realise that the concepts expressed in this paper are very conceptual ones, but my objective was to provide food for thought and promote meaningful discussion. I have been on receiving end of Helpline calls for some 12 years now, and also know well several people who have themselves transitioned, for one of whom I was best man at their wedding some 20 plus years ago! We now are in the position of having formal recognition of the condition, and shortly legal recognition for completing the process of change, but we don't quite seem to have the actual process itself very well organised.
Citation: Pepper, J., (2004), The path to Gender Reassignment: Have we got it right yet? GENDYS 2004, The Eighth International Gender Dysphoria Conference, Manchester England.
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