Transsexualism: Processes of Referral and their Vicissitudes.

An extract from a paper read to the Northern Gender Dysphoria Conference.

Dr. Ronald St.Blaize-Molony


Issue 1
February 1998

Anybody who goes to a psychiatrist needs to have his head examined.

(apologies to Samuel Goldwyn: I am sure the quotation is inaccurate.)

The heyday of the movies was in the 1930's. The films were made to make money. They did, but they also created a modern art form. This was due, in no small measure, to the fractured English of the early movie moguls, who were mainly Middle European émigrés. No translation of literary oeuvres to another medium, no dreary talk-overs. The message of the new medium was camera, action, movement and they mastered it. Primus inter pares among these geniuses was one Samuel Goldwyn who became almost as famous for his unwittingly penetrating off-centre one-liners as for his films. The double allusion sub-heading this article captured the message of my paper which ended the proceedings of the Northern Gender Dysphoria Conference. This was entitled The Process of Referral and its Vicissitudes. Alice Purnell suggested I make a précis for the Gendys Journal, so here comes my 'Gateshead Revisited'.

Not for the first time have I discussed what I wanted to say via someone else's commentary. On this occasion I am indebted to Jed Bland whom I know, as yet, only as a pen pal, though I owe a debt also to his writings.

He wrote in a letter to me: "You are seeking to challenge the existing therapeutic structure, as a society for customers." Add - rather than a resource in which to treat patients and again this is true. I said to myself "Yes, that is indeed what I would like to convey."

The summary of the paper printed in the proceedings (almost) says it well - thus starting from the end so to speak: "The process of referral to and within psychiatry (not psychotherapy, as the Proceedings has it) is itemised as formal and informal. The hazards of each are illustrated by reference to (disguised) clinical material. Attendant problems such as confidentiality are addressed and the problems of settling in with a psychotherapist are considered as a related issue."

My clinical material derived from three patients referred to me during hospital work as Consultant Psychiatrist before I officially and finally retired from Clinical Psychiatry - in the process freeing myself from the burden of the medical model and freeing myself to speak my mind for myself and others. Each patient had, as I hope I showed in the original paper, been incorrectly diagnosed and, in one case, tragically so, steered precipitately in the wrong direction. None had had an antecedent period of psychotherapy before embarking on a full programme of treatment aimed at the realization of a transsexual goal.

Formal referral usually takes place via a GP. With luck, the patient will meet with sympathy, understanding and a meeting with a local psychiatrist, or go direct to a specialist gender clinic. Informal referral is intended to describe those who are sufficiently informed as to make their own way to a gender clinic. In retrospect, my postscript in the original paper vis-a vis settling in to a successful psychotherapy could have been described as self referred. But, this might have been confused with informal referral.

Those whose disguised stories I used to represent hazards inherent in referral were:

A phobic patient who was enjoying the physical side of a homosexual relationship but found himself so passive he decided this was so stereotypically female that he must be transsexual.

This was confirmed at a gender clinic and he was offered to start on a treatment course to become a transsexual. A native indolence, combined fortuitously with a financial stringency in regard to travelling to prevent him undertaking the trip to the clinic, and towards transsexualism. He became protectively more claustrophobic and homebound. After some psychotherapy sessions it was clear to him that, if the equipment to enjoy homosexuality were taken from him, or diminished in any way, he would be most distressed. After eight sessions he was out and about, and ready to address his pathological passivity with a counsellor for the gay community in his home locality who had joined us for the final three sessions.

A highly-educated young lady, preparing a post-graduate thesis, who had been living a lesbian lifestyle.

She had been suffering mood swings and in a euphoric state had watched a programme on the television screen about transsexualism. She gained a powerful conviction that she was transsexual. In retrospect, almost certainly an authoctonous delusion. She also knew how to make her way to a gender clinic and was started with despatch on the chemical road. She entered a phase in her mood swings so manic and so public that she had to be placed on section. She came under my consultant care. Again this lady had had no psychotherapy prior to the inauguration of the physical treatment for transsexualism. She soon became euthymic under the influence of phenothiazines. We had daily psychotherapy sessions and once again it materialised itself that her life was the lesbian one. Had she had psychotherapy before embarking on the transsexual journey this would have clarified itself. Not that I am saying this would necessarily have averted mood swings, even so severe as to necessitate temporary hospitalisation. But psychotherapy could have continued during and after, and confidence in her orientation consolidated. This may well have had, over time, an effect as stabilising and less toxic than lithium.

A female to male transsexual whom I met socially, had found his way to specialised consultation via his family doctor.

Having been transmuted to being a man he found himself living in limbo - a nobody from nowhere, going nowhere. As he said his attempts at social life resulted only in becoming a shuttlecock between "gay boys" pestering him and "dominant lesbians" pushing him around. Asking had there been any psychotherapeutic lead-up to the programme I got the anticipated "no." Saving for the return journey was not enough, I advised. I tried to make a strong case for saving more so that there could be a psychotherapeutic prologue which would continue during the narrative and as epilogue.

Publicly or privately the path is perilous. The structure of the Health Service as it is evolving both gradually and by mutation is becoming the enemy of those once most prized attributes in medicine - being treated as a person in trust and in confidentiality.

The new managerial structure does not even attempt to treat a disease, let alone treat a patient who has a disease. Instead the disease is "identified" and "managed" in ways that will present the best political image, rather than the best clinical outcome and is certainly not designed to give a priority to the interests of patients. A bureaucratic command economy allows computerised records to be "accessed" easily in a system that now claims only to "deliver a service" to "identified" "purchasers" for their "customers". Increasingly the words "client" and "consumer" are replacing "patient," a word that comes from the Latin "patior", I suffer. Within such a commodified nomenclature, where can warm words like "trust" and "confidentiality" find a meaning. There are sinister developments in our society which may make things even worse. GP surgeries are being considered as targets suitable for "bugging". The Catholic confessional has already been bugged in Austria. A generation is growing up for whom that sort of tomorrow is already here, since they have been gradually and quietly softened up to take it for granted.

The aim of psychotherapy for the wondering or even convinced transsexual aspirant is to create an encounter within which she can come to the fateful decision, secure that there has been full exploration in a sympathetic context. A terrifying isolation within an unstoppable medical momentum is the worst of all the many unsuitable possibilities. But, before embarking on what is to be an existential experience a psychotherapist must be found. This done, there has to be the process of self-referral alluded to at the beginning of this article. This I have called the Treatment Alliance. It is essentially the non-neurotic, rational, reasonable rapport which the patient has with his analyst and which will enable him to work purposefully, within resuscitated Oedipal arrangements. The reality element allows the forging of an identity of aims within a matrix of trust and confidentiality. Don't forget the latter. Demand absolute confidentiality. In everyday language it is a great help if therapist and patient like each other from the start. Should there be initial qualms have no hesitation in seeking another referral. Your psychotherapist should be someone you feel you will still get on with, even during the period of misgivings inevitable in psychotherapy. Your psychotherapist should be separate from the medical procedure you are contemplating. The first message is psychotherapy first. The second message is a Merry Christmas and a successful New Year to all those within the network and those with sexual dysphoria.

Dr. StBlaize-Moloney is a psychotherapist working in private practice in East Sussex, England, who may be contacted through the Network.

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