Exceptional People

Whose Greatest Aspiration is to Be Seen As Ordinary.
A Counsellors view.

Alice Purnell, BSc, RGN, P.G.D.C.


Issue 1
February 1998

Over thirty years of listening to those who are labelled Transsexual, or Gender Dysphoric (i.e. those who are suffering from or who have suffered from, Gender Identity Conflict, including physically intersexed people), several common themes have struck me.

The most usual, almost universal theme is a phase of low self-esteem a sense of difference marginalisation of being some sort of monster, a sport of nature, a mistake. Additionally there is almost always a great fear of disclosure. This may continue throughout life reinforced by the legal situation, bad medical resources, lack of counselling or any psychological backup. Society, whatever that is, may be often blamed. The root cause is not solely based on the individual's own life story and the reactions of family and employers or of society in general.

The Legal Tort.

Public opinion feeds changes in the law and vice versa. If the legal mess were resolved, it is clear that the public view would adapt and evolve, as for example it did over hanging and equality opportunity legislation.

Despite the great advances made over the last few years in awareness, increased information and tolerance among the public, the transsexual and the woman or man whose transsexual dilemma is resolved, finds that she or he is far behind the gay, black, Jewish, fat, old, disabled or otherwise marginalised person. As the joke goes you would really be 'p-c' if you were a fat, elderly, black, short one-legged, left-handed, unemployed, single-parent Jewish lesbian. However if you are a woman and your birth certificate says "boy", you are still in deep trouble.

A great deal of progress in finding a remedy for a negative sense of self who is in real terms a legally marginalised person, would doubtless come if English Scottish and Irish Law were to address this legal minefield with the same good sense as the Council of Europe's recommendations arising from the Twenty Third Colloquy on European Law 1993.

The superb work of Press for Change and of individuals fighting for Human Rights and collective expressions of pride like the Transgendered Pride element at London Pride over the last couple of years, have endeavoured to address these issues on a social and to an extent on a personal level.

The Tort of under resourced N.H.S. Care and attitudes.

As a counsellor, a client's self-image is an on-going issue, which is to an extent fed by confrontational psychiatry and an almost entire lack of psychological or counselling backup for this group of people.

There are of course hormonal and surgical interventions which are appropriate for some people which must be under the aegis of medical and surgical consultants. It is also important that psychiatrists are there to assist if clarifying any mental health problems, but one cannot help wondering why the pivotal decision- makers in issues of gender identity in the British Isles are psychiatrists, rather than a team involving endocrinologists, surgeons, psychologists, counsellors and the client?

A protocol has been necessary to provide a care plan, and because of legal implications, particularly encountered in the States, to protect clinicians. These Standards of Care are interpreted differently in various clinics and countries. Some only appear to pay lip service to them, whilst others seem to see them as rigid rules. Implications arise about the pre-operative living and working in role, being single, the age of the patient (at both ends of the chronological scale).

It would seem that there is little room for an holistic approach with far too little input from the patient, who in some cultures is regarded as having little or no say, and only minimal care. So long as gender identity conflict is treated as a "form of madness" this anti-humanistic and improper situation will continue.

Assessment is more emphasised rather than Care, the effect is more like triage than the application of appropriate care. This area of medical and psychiatric intervention would I believe be more effective if a team approach were involved, which includes the patient, and other relevant experts. The Dutch model would seem to be more user friendly whilst in the States patients are now forming user groups, purchasers of appropriate quality care.

In the UK there are problems with an under resourced National Health Service, but a perceived change of attitude from those who have charge of these individuals is desirable. There are casualties of the system which has been installed to help them. Of course it is the less straightforward "cases" that present the most difficulty for the clinician, however a team approach might well reach a more humane way of dealing with these individuals.

Many of the problems are social or practical and the personal is left by the wayside. This seems strange in an area where there are concerns about personal identity and social consequences. However, the medical and psychiatric models of care make little or no provision for any sort of personal therapy.

The attitude of health care providers takes a short term view, and withholds funds, talking about elective surgery and rationing - this is not taking patients seriously. There have been too many suicides and wasted lives for these problems not to be properly addressed.

The issues of guilt and fear are also remarkably common. Partners, parents, children and friendships tend to suffer from actual or perceived marginalisation and discrimination by public attitudes, which until quite recently have been fuelled by the tabloid press and other appalling media exposure. There are many tragedies of loss of personal relationships, isolation, blame, and loneliness which affect the transsexual and significant others in one way or another.

The gender dysphoric is judged by the world at large, even by his or her peers. Does she pass? How authentic is someone if they do not conform to physical or social stereotypes?

The prurient and the inquisitive feel it is quite reasonable to demand the answer to incredibly personal questions. The TS is put under the microscope in a way few other women or men experience. Confusion about the terminology only fuels this effect. "Trans-sexual" implies to many that this is about sex, not identity.

Even some psychiatrists fail to see the significance of gender identity, rather than sexual preference with questions like "Why do you think you are a woman if you do not fancy men?" Is this the only reason anyone should "want to be a woman". I and a few other lesbians, and feminists, would feel like sharpening their scissors at that sort of patriarchal phallocratic attitude.

Public attitudes are even more confused. The ideas of a transhomosexual or of someone who elects to be asexual, bewilder many of the "normals" who of course may be homophobic and probably have not had to face issues of gender identity or their relationship with the so-called opposite sex anyway.

The Tort of Labels.

Labelling people helps if is towards identifying a course of treatment or management, but it stigmatizes people, and can create a group target. Nazi Germany was expert at that as were those involved in the Hundred Years War, the Crusades, the Inquisition, the Khmer Rouge, the Red Guards and all the ethnic, religious and intellectual "cleansing" that has occurred and still continues to this day.

Difference is seen as a threat rather than a delight or a challenge. You can not catch blackness or fatness or gender dysphoria. The challenges in the battle of the sexes and of the genders arise because these aspects of human personality: sex, gender, sexual preference, are seen as bipolar, rather than along separate spectra, as separate continua.

Look for black or white, male or female, man or woman, gay or straight. It is easy to take sides and only see issues. Even the English language reinforces these divides. White, straight, masculine are all positive, whilst black, queer, effeminate are seen as sinister, left handed, bad, or at best not as good; not equal somehow. So is there any justification for anyone calling another person an "it"?

The effect of this polarizing and simplistic didactic is to depersonalise a human being. Not even in hospital is it reasonable to call someone an "appendicectomy" so why do we call anyone a transsexual particularly if they have resolved their gender difficulty? But perhaps after all it is reasonable to do this if their problems continue, as they do legally in the British Isles!

I do not know any parent who would elect to have an intersexed or gender dysphoric child.

"Who am I" is a question all humans find themselves asking at some time or other. "What am I?" "Why me?" "Whose fault is it?" These questions are particularly apparent when addressing this gender paradox.

These sorts of questions demand and create strong personal negative feelings because in part, of the responses of others, of society, and the law and medicine.

The Internal Struggle.

The first great struggle is with self, then "all that is required" is to convince society, parents, partners, medical professionals and the legal system. It is amazing that anyone survives the hoops that have to be jumped through. Once the personal battle is resolved there is sometimes a conviction which is so strong against such a sense of disapproval by others that the sufferers could be described as "Survivors of Gender Identity Conflict. It is surprising that any individual could emerge undamaged by this rite of passage.

This search for an answer, the guilt, self hate, doubt, confusion, despair add denial promotes a great personal struggle for anyone who has to confront being "different."

There is a need to be accepted, to belong, to conform, to be loved, in all humans, however self-contained or detached they may be. To be acceptable many hide their gender identity conflict in the despised body nature provided. To society the body implies a social and sexual role. The assumption that not only your genes, but also your genitals are your destiny, is a tyranny best challenged. Predeterminists reinforce this misrepresentation, neglecting the complexities of the human mind.

Is there a positive Darwinian rationale for all types of variation? I believe he said there is variation and natural selection, thereby evolution occurs. He did not say all variations are advantageous at all times. The advantage is in that variation occurs in the first place.

We might ask what are the advantages in clear gender-body disharmony? I would moot the idea that perhaps in a world conscious only of perceived polarities it is a good thing to have a few people around to remind society of the dangers in this type of monochrome perception of human beings.

Another common theme is the great "guilty secret". In telling others it gives them permission to intrude into very vulnerable areas, to expect a change of attitude from them to the person who has trusted them. In telling there is relief, but there is also great risk, potential destruction of all the artifice learnt in childhood in attempting to hide the dysphoria and live an ordinary life. In the case of someone who is post-op there may be a danger of being perceived as not quite a whole woman or man, again a marginalising dynamic.

Many construct a history, a childhood, a CV, which is "appropriate", but in reality grieve for a girlhood or boyhood, and a life course which was denied by their actual history.

I believe there can hardly be a more self-absorbing difficulty, or dismay in finding an authentic identity which is in conflict with the "facts" of sex and gender. A glance from the midwife who says "boy" or "girl", and gives a clear answer that parents expect. There are only two possibilities. Sons are often preferred to daughters. In Asia it would seem only "boy" is a good answer to the first question about a baby. The midwife's statement seems written in granite and fails to see the person. Even the intersexed baby is assigned one way or the other. There is no free or advised choice. Equally the gender dysphoric person has no choice.

Often there is a survival strategy through the adoption of a double life, or a fantasy life, in which all is perfect. This fantasy is no more fantastic than the assumption that it will go away if the sufferer just tries harder to be a man or a woman.

Patriarchy and the advantages of becoming a man

In Western society the female to male gender dysphoric person usually presents as a tomboy who may become more masculine, may go through a "lesbian" phase. Usually breasts and periods are hated. Jeans and sensible shoes are worn. The challenges he presents our patriarchal society do cause some comments but when "she" says he's really a man he is joining the "right side" in the gender war, which this patriarchal, androcentric society promotes.

He is not a threat to men. He will look and sound authentic, and of course he cannot get a man's girlfriend pregnant. He can walk tall even if he is not a tall man. Most of these men would like to be taller but he is generally socially acceptable. In private he will mourn the fact that even if he has a good phallus post- operatively, and stands to urinate, he wishes he could penetrate, ejaculate and inseminate like other men.

However he is socially more acceptable, or should I say, less unacceptable, than the male to female, who might, God forbid, "fool" a heterosexual man into wanting to have "homosexual" sex with him.

A sissy is taunted by all. For the MTF childhood can be a nightmare. An adult male to female transsexual person will usually have gone through a masculinizing puberty, which produces irreversible changes to bone structure increase in heights the size of hands and feet deepening of the voice the formation of an Adam's apple, beard growth, coarsening of skin and features, then, sometimes, later, male pattern baldness. These secondary sexual characteristics may take an MTF person outside the usual range overlap which occurs compared with the range of changes in women and can be a disadvantage in "passing" in some cases.

Whatever the administration of "opposite sex" hormones will do, they do not reverse these physical disadvantages she may have to contend with, however well the breasts grow and the surgeon's skill in creating a reasonable set of genitals make her "acceptable". Generally she will have problems 'passing' with absolutely all the people she encounters without any challenges to her identity.

The way most people perceive women is by their appearance, not by their qualities. This superficial view of women is a source of real annoyance to feminists and is a reality. Judgements are made as to the authenticity and desirability of a woman in terms of her appearance, based on stereotypical models fuelled by fashion and current concepts of quality and beauty within a society. Ask any large so-called ugly, fat or elderly woman, if she is given respect, valued, admired by society, and it is easy to see how the MTF woman is assessed in ways that do tend to place her as an outsider to be ridiculed.

Often these women will over-compensate by conforming to the stereotype tyranny. They might wear too much make-up, tarty clothes, very high heels. They may neglect to observe other women of similar build and age group to see how they present. Some might however try to be entirely invisible. Of course these days all are free to develop their own style, but to stand out is to be a target. Some set themselves up as targets.

Many turn their backs entirely on the things they perceive as masculine and pretend to be dumb blondes. They can become the ultimate victims of stereotyping. If they try too hard they are seen as tarts. If they don't work at this, are seen as men infiltrating women's space or as some sort of low-life.

These women are spared periods, but they are denied child bearing. These are the most vulnerable of women. Why then are they not given respect and treated as whole persons who have rationalised their lives by finding a way of being which enables them to function, at least partially, as other women do?

At least in some cases they have benefited from being taken seriously by society by virtue of an education as a boy, but of course that was probably a very painful experience for them. Perhaps now that single-sex schools have to a large extent been replaced by mixed schools we might look to less gender-specific forms of education and of evaluating each other. To be exceptional is to be a target, or, rarely an icon, but the fact is that most people just want a quiet life.

There is nothing particularly unusual in seeking the existential truth about oneself, life and the universe. Living a personal truth is enabling. It allows personal development. However there will be setbacks. The gender dysphoria person uses so much energy and effort in trying to sort our their gender and the challenges to it, how to survive intact, who they are, and how to be themselves, that a counsellor can be a great help as a sounding board as someone who will listen and not ridicule or try to "cure" them. Many hold the text that "normal" is good and right, whilst abnormal is perverse and wrong. Usual would be a good word to substitute for normal.

So what is a counsellor's task?

As a humanistic, client led, counsellor, utilizing an integrative (eclectic) form of therapy, with a leaning towards cognitive therapy and utilizing psychological information, I see my task as listening, enabling the client to find his or her own answers. I suggest that respect for a client allows a greater sense of understanding and truth than perhaps is possible in the transferences involved in the roles of psychiatrist and a patient. There is much more time given, there is no assumption that the client is an ill, mad, bad or sad individual. The key word is respect. There are many ways of being. The counsellor's task is to help the client to sort through the emotions, to assist a client to tell his or her own story, and having found a voice, to find her or has own way of being.

Counselling is not a cure-all, but since isolation and rejection are such common themes among transsexual clients that listening is in itself empowering.

Uncertainty can cause great pain, but with certainty there are still many practical considerations. We live in a real world and so a certain amount of pragmatism is important.

Safety, confidentiality, boundaries, respect, non-judgmental interjections and non directive adult-to-adult transferences are all very important. Many gender dysphoric people can be seen as, or actually are, victims of society, with psychiatric and psychological backup lacking. They have to encounter a second puberty, without parental or peer group support in a society which seems suspicious or ignorant of their struggle.

Until quite recently society the law and to an extent information has dis-enabled, even effectively disabled, most gender dysphoric people. In a sense I am uncertain whether it is the sufferer of gender identity conflict or society which is disabled.

We can learn from our clients. They are the experts. There is a great deal to be said for self-help groups, and for more client involvement in their own care.

What is exceptional about these people is the fact that they are survivors in the face of overwhelming difficulties.

TOP Web page copyright GENDYS Network. Text copyright of the author. Last amended 08.04.98