How do Americans approach Gender Transition?

Kenneth Demsky, Ph.D.


Issue 40
Winter 2007

Guilty as charged and here I go! What could be more predictable than an American saying he prefers the American way of doing things? I hope I'm not yet another 'Ugly American' when I make a case for the American approach to gender transition.

Of course, America is a consumer society, based on certain cultural assumptions - some of which are not so pretty. There is nothing equivalent to the National Health Service in America, so comparisons can only be made between the American system and the private sector here. However, when it comes to gender transition, the American model looks good.

A consumer society conducts itself like a big marketplace, coordinating a million kind of transactions between different buyers and sellers. Someone wants a medical service and seeks out the most qualified person to do it whom he/she can afford, a person who provides the highest level of care in the most efficient and convenient way. In the spirit of the marketplace, the client = the consumer = the customer, with all that implies both good and bad.

Someone in the States who is undertaking gender transition begins by making contact with a mental health professional. There are almost as many reasons for doing this as there are trans people, but the list includes: to obtain objective validation of a self-diagnosis, to arrange informed support for a period of new self-expression, or to seek guidance in negotiating coming out as trans. The mental health professional might be a psychiatrist - a physician trained in psychopharmacology; a psychologist - a clinician trained in doing psychotherapy and counselling; or a psychiatric social worker - a professional trained in advocacy and support. The fees for services parallel this ranking, from highest to lowest.

What I particularly like about the American model of gender transition, and the one I wish to emphasise here, is that the mental health component provides the centrepiece of the individual's transition, rather than a medical service. Usually weekly (but sometimes biweekly) talk sessions provide time and space for examining one's innermost thoughts, hopes and fears, making choices amongst the many variables in the presence of an objective, caring and knowledgeable person who is outside the sphere of one's daily life.

The reason that transition begins in the setting of a relationship with a mental health professional is that - aside from interactions with insurance companies - gender transition isn't conceptualised as primarily a medical problem (like the correction of a bodily deformity or hormonal imbalance) but as a process of personal growth and development. American culture is somewhat more therapy-oriented than British culture, so in American these terms translate immediately into 'Therapy!' Gender transition functions as yet another aspect of the tendency toward self-realisation that characterises the upwardly-striving American populace. At its most positive, American culture is intensely idealistic and dynamic, believing in the possibility of each invidiual to realise dreams and achieve his/her 'personal best'. (In the era when I was growing up, this was phrased as "growing up to be President".) For some, that means changing gender; for others, it may mean making a million dollars, coming out as gay, becoming an artist, inventing a new widget, or even being the first person to walk on Mars. (The well-known negative aspect of this emphasis on individual personal fulfilment is egocentricity and self-preoccupation.)

By making mental health the hub of the wheel of gender transition, individual maturation remains the focus and the authentically-gendered personality (that had been suppressed and neglected for so long) is at last welcomed and cultivated. More concrete aspects of transition require discrete services and are arranged one-by-one: hair removal (for M2Fs), hormones (which in the US are prescribed by endocrinologists rather than GPs), cosmetic surgeries (such as FFS), GRS, and so on. These are dealt with as secondary to the more internal process of becoming fully yourself because the individual is comparatively a passive participant in those procedures.

Since coming to London, I have sought to make available the American approach to transition by forming liaisons with qualified professionals who supply the other spokes of the wheel (if you can tolerate more of this metaphor). Clients are free to choose whom they want for all the secondary services, of course, but they have the option to be directed towards physicians, speech therapists, etc., who work with me to make the American model readily available within the UK private sector.

Kenneth Demsky, Ph.D.


Flat 2, 10 Langland Gardens

London NW3 6PR, England

Tel. 020 7435 6116

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