By Anne Vitale Ph.D.
By Anne Vitale Ph.D.
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July 28, 1997
Pfafflin and Junge outcome study reference added November 24, 2001
The two most common complaints made by readers of this web site are (1) Therapists refuse to take crossdressing and gender dysphoric individuals seriously, choosing instead to divert them to other issues, and (2) Therapists are too quick to encourage individuals to accept their condition rather than try to cure them of it. In response to the first complaint, I believe it is safe to say that therapists who try to divert their clients away from their gender problems are likely to be inexperienced in working in this domain. As for the second complaint, those therapists who work within the confines of what is possible, rather than try to evoke a classic cure, do so because they have direct experience in treating gender dysphoria or are aware of the medical literature addressing treatment options. In this paper, I will be listing the background of published medical literature regarding psychotherapeutic treatment considerations for gender dysphoria and a short description of how others have interpreted this literature. I will close with my own treatment thoughts.
Synopsis of the Medical Literature
Although there are references to cross gender behavior in the clinical literature dating back to the mid Nineteenth Century, the modern clinical study of gender dysphoria began not with gender dysphoria per se but with the study of transvestism. Magnus Hirshfield introduced the term "transsexual" in 1924 to describe individuals he was seeing who seemed to need more than cross dressing to ease their anxiety. In turn, endocrinologist Harry Benjamin used the term in an article (1954) for the American Journal of Psychotherapy regarding the highly publicized case of Christine Jorgensen. The term took firmer root in the medical literature with Benjamin's use of it in his seminal book "The Transsexual Phenomenon," published in 1966.
Dr. Benjamin, concentrating on male-to-female transsexuals, was among the first to note that psychotherapy with the aim of curing transsexualism was ineffectual as a treatment. I repeat his remarks here to show how far back knowledge of the ineffectiveness of trying to change an individual's gender identity through psychotherapy goes. I must also note that to this day there are no documented case studies showing sustained gender identification reversal due to psychotherapy.
Dr. Benjamin states:
The mind of the transsexual cannot be changed in its false gender orientation. All attempts to do this have failed. Dr. Robert Laidlow, Chief Psychiatrist at Roosevelt Hospital, New York, has studied a number of transsexuals and has come to the conclusion that "psychotherapy has nothing to offer them as far as any cure is concerned." Dr. John Alden, a prominent psychiatrist in San Francisco, fully concurs with this opinion and has repeatedly stated so. Numerous other psychiatrists agree to my own personal knowledge.
Dr. Benjamin goes on to say:
Since it is evident that the mind of the transsexual cannot be adjusted to the body, it is logical and justifiable to attempt the opposite, to adjust the body to the mind. If such a thought is rejected, we would be faced with a therapeutic nihilism to which I could never subscribe in view of the experiences with patients who have undoubtedly been salvaged or at least distinctly helped by their conversion.
In 1969 the Index Medicus introduced the category of Transsexualism. Now hundreds of clinical articles published in the medical literature world wide are referenced there. Another source of clinical data and professional discussion was created with the establishment in 1977 of the Harry Benjamin International Gender Dysphoria Association (HBIGDA). The first order of business the organization addressed was the creation of the STANDARDS OF CARE: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons. Although the Standards of Care make no attempt to delineate for whom and under what conditions sex reassignment is a viable treatment, it does set minimum treatment schedules and professional qualifications for providers. In addition, HBIGDA now holds biennial conferences at which papers are read and discussed at great length by practitioners from around the world.
Authors who have written books devoted to transsexualism are another source of in-depth medical information regarding treatment options. Here is a partial list presented in order of publication: Benjamin, 1966; Green & Money, 1969; Kando, 1973; Stoller, 1975; Koranyi, 1980; Lothstein, 1983; Walter & Ross, 1986; Bolin, 1987; Devor, 1989; Blanchard & Steiner, 1990; Tully 1992; King, 1993; Zucker & Bradley, 1995.
The topics covered include the endocrinological and surgical aspects of gender dysphoria along with treatment suggestions and possible causes. Although there is still some disagreement as to how gender dysphoria begins and who should qualify for hormonal and surgical intervention, there is a remarkable amount of agreement in several important areas. Most psychologists now agree that gender dysphoria qualifies as a subject of clinical attention separate from other disorders. Further, most clinicians agree that the gender identity beliefs these people hold are profound, deep seated, and non-delusional. Even more significantly, outcome studies now clearly indicate that when three conditions are met: a proper differential diagnosis, a significantly long trial period of living in the gender of choice, and a satisfactory surgical result, there is only a small incidence of post-operative regret. Indeed, in a review of the outcome literature dated from 1961 through 1991, Pfafflin, Junge (1992) reports that less than 1% of the female-to-male transsexuals who had undergone sex reassignment had any regrets. For male-to-female transsexuals the number was slightly higher at less than 2%. I should point out here that satisfaction is measured by self report of improvement in the individual's psychosocial well being.
There is an adage in therapy that says that every therapist should intercede in a way that is the least restricting to the client. If a small change will do the job than that is what the therapist should help bring about. If deeper, more intensive life changing work is necessary, it should only come after the client has gained an insight into how to deal with the ramifications of the change. This axiom certainly holds true when someone presents with a gender issue. An example of a small change might be simply helping someone understand what it is they are struggling with and then helping them make allowances for it in their life. On the other hand, if the dysphoria is profound and sex reassignment becomes a serious alternative the level of therapeutic intervention would be correspondingly deeper.
Before I get into treatment options that have been found to be helpful, I want to discuss a treatment that does NOT work. I have been asked repeatedly why a crossdresser or gender dysphoric male isn't given testosterone shots and why a gender dysphoric female isn't given estrogen? The reason is that gender dysphoria is far more complicated than that. Even though hormones have a strong effect on secondary sex characteristics, libido, and mood, they have no effect at all on gender identity in adults. There is some evidence that the male sex hormone testosterone plays a part in establishing male gender identity in newborn babies. However, that appears to be about the extent of its gender influencing ability. Furthermore, people who undergo hormone therapy are given a thorough baseline physical examination as part of the treatment. Medical records show that with only rare exceptions, the testosterone and estrogen levels in both males and females typically fall within the normal range for their genetic sex.
The problem is that unlike non-dysphoric individuals, people with gender dysphoria experience these otherwise normal hormone levels as the source of much anxiety. When testosterone is administered to a gender dysphoric male there is an immediate increase in anxiety. Conversely, when the same individual is given estrogen, he typically reports experiencing a profound sense of well being. Gender dysphoric females report feeling a similar sense of well being when given testosterone.
As I have stated in previous essays (see The Problem and Implications), I and others believe that gender identity in humans is rarely absolutely male or absolutely female. Recent research has shown that each of us has a gender understanding of self that is more-or-less male or more-or-less female. Further, since gender and biological sex develop at different times and in different places in the body, this gender identity may on occasion have little or nothing in common with the individual's biological sex.
For most individuals, small variations in absolute gender identity add human interest to their personality. Typically these individuals experience no psychological or biological imperative to change anything. However, for that group of individuals who are hormonally or sociologically denied the ability to experience their inner sense of gender, the disparity between biological sex and gender identity is often devastating. Without treatment, it is common for these individuals to live their entire lives in a chronic state of longing to become integrated. In clinical terms this is known as a state of dysphoria. If the dysphoria is severe enough, individuals can become suicidal or so chronically depressed as to be unable to function in a normal manner.
Given the apparent unalterable, imprinted nature of gender identity, the therapist is limited to helping the individual learn to live with his or her condition. In actual practice, depending on the level of anxiety and the desires of the individual, treatment can range from prescribing occasional cross gender expression (guilt free cross dressing) to moderate cross sex hormone therapy. In other cases, it may be appropriate to start the individual on a program that includes complete hormonal and surgical sex reassignment.
For many therapists, the hardest part of treatment is diagnosis and determining the level of severity of the dysphoria. The situation is often complicated by the client's fears and confusion. In addition, gender dysphoria typically exists along with other, more obvious psychological difficulties. Mood disorders such as chronic depression (Dysthymia) and/or substance abuse to ease the pain are two of the most common companion problems.
Some therapists use scales such as the Harry Benjamin Sex Orientation Scale (Benjamin, 1966) to help in the diagnosis and to determine the level of gender identity difficulty. As you would expect they adjust their treatment plan accordingly. Others use standardized psychometric tests such as the Minnesota Multiphasic Personality Inventory (MMPI-II) or the Millon Clinical Multiaxial Inventory (MCMI-III) to look for more familiar non-gender disorders to treat. A third common format is the formal gender program. Usually attached to university medical schools, these programs provide a comprehensive team treatment approach.
What therapists are looking for varies from the complex to the very subtle. The more complicated cases involve the existence of multiple personalities in the same individual. There may be a highly developed female self and a highly developed male self with both personalities fighting for dominance. Equally difficult to treat are those people who find it difficult to hold on to any sense of identity for an extended period of time. Typically these people have been abused as children and some may come to believe that becoming a woman may be an answer. More subtle cases involve the visit to the therapist by cross dressers to explore the difference between occasional cross dressing needs or the possibility of being transsexual. In addition effeminate gay males have been known to present to check out the possibility of changing their sex with the belief that if a little effeminacy is fun, more would be better.
Sorting out these individuals from those who would benefit from sex reassignment is obviously very important. However, I have problems with all three of the approaches I referenced above. First of all, I find the Benjamin Sex Orientation Scale to be unreliable. The Benjamin scale is essentially a self report form that assumes that the individual is capable of talking about his or her dysphoria. However, most people keep their situation a secret for decades prior to seeking help and disclosure is usually very difficult. For example, I am no longer surprised to hear that I am the first or second person (after their spouse) they have ever told about their dysphoria. Even then, some people report getting physically ill when they did finally talk about it. I have found that the more I put my clients at ease and get them to open up about their true feelings of gender expression deprivation, the higher up the Benjamin Scale they seem to rise. Those therapists who misconstrue the client's inability to talk about their gender issues as a sign of there not really being a true gender identity problem risk doing great harm to their clients. Beside ignoring the real problem, finding and treating a coexisting personality problem may leave the individual without longstanding defenses he or she has cultivated to keep the gender issue in check.
On the whole, gender identity clinics have provided a great service to individuals struggling with gender issues. Without them I doubt if the legitimacy of the disorder would have been established and sex reassignment given the credibility it now enjoys. There are, however, serious drawbacks inherent in the clinic setting when treating this disorder. First of all, I believe the formal mental health clinical model creates a Doctor/Patient relationship that tends to over-pathologize the problem. Pathologizing, by its very nature, puts all of the power of the relationship into the hands of the clinicians. In the clinic setting, the doctor is well and the patient is ill. To further distance the individual (and I might add, the individual clinicians) from the process, committees sit periodically and review the current case load. Essentially, clinicians, some of who may not have ever met the client, decide if the individual is a candidate for hormone therapy and, eventually, if the patient is eligible for sex reassignment surgery.
I find this autocratic approach to the treatment of gender issues highly problematical. In actual practice, the all power to the doctor format often creates a counterproductive, adversarial relationship between the clinicians and those they would be helping. The clinicians would argue that this is the safest approach and that they are only being responsible practitioners. Professional responsibility is, of course, important but there are ways of exercising responsibility that encourage the client to exercise his or her responsibilty as well. I have repeatedly noted that the more responsibility the client is given in resolving his or her gender issues, the more successful the outcome.
Another negative result of the committee approach is that it tends to seek out straightforward cases and weed out any that may require special attention. The net effect is to eliminate from treatment not only those individuals that clearly do not belong in such treatment, but also those people who want to sort out just how much of a gender problem they have. Other examples of individuals who are often left out include people dealing with the social ramifications of being a crossdresser, people who do not want to complete a classic transition, or post-op people who are still learning how to adjust to the new role in life.
A better model is the classic, one-on-one approach of psychotherapy combined with case management and consultation for difficult cases. In such a model, everyone is admitted into the program and there are no limits or expectations placed on the therapeutic process. Assuming that the client has the psychological resources for making intelligent decisions, it has been shown repeatedly that they can successfully decide for themselves what level of gender transformation, if any, they wish.
I believe it is not the place of the therapist to define their client's gender identity. As in working with any therapeutic issue, the therapist's place is to help the client come to terms with the implications of whatever an intentful therapeutic search reveals. Once a level of intervention is decided on through mutual consent, the therapist should provide a structured program that carefully integrates hormonal and psychotherapeutic treatments. The therapist should be ready to support the client by educating the individual on what to expect both psychologically and physiologically as transition progresses. Follow on support should include just being there on an as needed basis and aiding the client in addressing the inevitable issues that arise with family members, employers, and friends.
Interestingly, although treatment appears on the surface to be about gender, it is really anxiety caused by deprivation of gender expression that the therapist is treating. I propose, therefore, that a more descriptive designation for this condition would be Gender Expression Deprivation Anxiety Disorder. The current term, Gender Identity Disorder, often gives people who present for treatment the notion that the individual's gender identity is wrong and that therapy can fix it. Gender identity is never right or wrong. It simply is one of a broad range of qualities inherent in being human.
In sum, people hire a gender therapist because they are overwhelmed by anxiety due to obsessing cross gender thoughts. As in more routine therapy, treatment options should responsibly follow the level of discomfort of the individual. Whatever the course of treatment, in order to relieve the anxiety it must be focused on helping the individual evaluate and then accept their internal sense of gender. Fortunately, gender expression needs are becoming better understood and much can be done to help gender dysphoric individuals short of sex reassignment. There are, however, situations where the struggle for gender expression is beyond relief through prescribing minor life style changes. In some cases, complete hormonal and surgical sex reassignment may be appropriate. Although this may sound radical to some, it is known to be an effective, permanent treatment. Because a gender identity crisis often comes in the prime of life, this means coping with a series of difficult trade offs. It's a little like surviving a natural disaster. Sex reassignment not only means getting used to physical changes, it also requires picking up the pieces and starting over again rebuilding a life. The therapist should be willing and ready to provide ongoing help with that as well.
Benjamin, H. (1954). Transsexualism and transvestism as psychosomatic somato-psychic syndromes. American Journal of Psychotherapy, 8, 219-230.
Benjamin, H. (1966). The Transsexual Phenomenon. New York: Julian Press.
Bodlund, O., & Kullgren, G. (1995). Transsexualism: General outcome and prognostic factors. Paper presented at the XIVth International Symposium on Gender Dysphoria, Kloster Irsee, Germany.
Bolin, A. (1987). In Search of Eve: Transsexual rites of passage. South Hadley, MA: Bergin & Harvey.
Blanchard, R. & Steiner, B. W. (Eds.) (1990). Clinical management of gender identity disorder in children and adults. Washington, DC: American Psychiatric Press.
Devor, H. (1989). Gender blending: Confronting the limits of duality. Bloomington: Indiana University Press.
Exner, K., & Schneritzky, B. (1995). Female-to-male transsexualism: psychological and social follow-up of reassignment surgery in 67 patients. Paper presented at the XIVth International Symposium on Gender Dysphoria, Kloster Irsee, Germany.
Green & Fleming in "Transsexual Surgery Follow-up: Status in the 1990's," Annual Review of Sex Research, 1, pp. 163-174.
Green, R. & Money, J. (Eds.) (1969). Transsexualism and sex reassignment. Baltimore: The Johns Hopkins Press.
Kando, T. (1973). Sex change: The achievement of gender identity among feminized transsexual. Springfield, IL: Charles C Thomas.
King, D. (1993). The transvestite and the transsexual: Public categories and private identities. Aldershot, England: Avebury.
Koranyi, R. J. (1980). Transsexuality in the male: The spectrum of gender dysphoria. Springfield, IL: Charles C Thomas.
Lothstein, L. M. (1983). Female-to-male transsexualism: Historical, clinical, and theoretical issues. Boston: Routledge & Kagan Paul.
Pfäfflin, F., Junge, A., (1992) Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991(Translated from German into American English by Roberta B. Jacobson and Alf B. Meier); IJT Electronic Books, on-line available at http://www.symposion.com/ijt/pfaefflin/1000.htm
Snaith, P., Tarsh, M. J., & Teid, R. (1993). Sex reassignment surgery: A study of 141 Dutch transsexuals. British Journal of Psychiatry, 162, 681-685.
Stoller, R. J. (1975). Sex and gender: Vol. 2. The transsexual experiment. London: Hogarth Press.
Tully, B. (1992). Accounting for transsexualism and transhomosexualtiy: The gender identity careers of over 200 men and women who have petitioned for surgical sex reassignment of their sexual identity. London: Whiting & Birch.
Walter, W. A. & Ross, M. W. (Eds.) (1986). Transsexualism and sex reassignment. Oxford University Press.
Zucker, K. J. & Bradley, S. J. (1995). Gender identity disorder and psychosexual problems in children and adolescents. New York. The Guilford Press.