When Sex and Gender Diverge
Emma Martin
[Abstract] Full Text [PDF]
Gender dysphoria is one of the most
misunderstood of all medical conditions. How can a counsellor help a client
who comes to them claiming that they have a gender identity problem? Emma
Martin discusses the most serious form of gender dysphoria, transsexualism
and how so often in the past transsexual people's lives have been ruined by
well-meaning but ill-informed professionals.
Lets start by defining 'sex' and `gender'
as used in the transsexual context. Sex is usually taken to signify a
person's physical characteristics such as genitalia, gonads and organs of
reproduction, which will typically be consistent with the chromosomes.
Gender or gender identity, is defined as a person's innate psychological
identification as male or female.
Where the gender identity experienced is
severely incongruent with the other sex characteristics, transsexualism may
be said to occur. It is still not entirely clear why some people are born
with this condition, but science shows that the likely cause is an unusual
hormone environment at critical moments during pregnancy', such that the
baby's brain and its other sex characteristics develop in different
directions.
Research in The Netherlands1
on the brains of transsexual and non-transsexual people has shown that the
sex differentiation in the brain into male and female, which occurs
throughout the population, is reversed in the case of trans individuals.
Therefore the brains of male to female individuals (trans women or MtF) in
the study fell within the female rather than the male range.
Following on from this, the work of Frank
Kruijver2 and his associates has shown that these
differences in size are related to different neurone (nerve cell) numbers in
the relevant area, the central sub-division of the stria terminalis (BSTc).
The neurone count of trans women (Mtf) fell within the female range whereas
that of the one trans man (MtF) examined fell well within the male range.
This research is increasingly understood to
indicate that transsexualism arises from a neuro-developmental condition of
the brain which induces an innate gender identity that is incongruent with
the apparent physical sex. The research was carefully screened to ensure
that these differences in brain structure occurred, regardless of sexual
orientation, hormone treatment, or hormone variations in association with
illness or orchidectomy (removal of the testes).
Gender Dysphoria
Transsexualism is the profound and persistent
form of gender dysphoria. Dysphoria is the opposite of euphoria and means an
unease or mental discomfort The term 'gender dysphoria' therefore may be
described as a profound unease with the gender assigned at birth in
accordance with the appearance of the genitalia. It is the underlying gender
identity that is the one with which a person is comfortable.As long as the
physical sex appearance is wrong, so also is the gender role with which the
individual will be expected to conform. Perhaps `gender incongruence' would
be a more accurate term.
Treatment involves a 'transition' process
to align the body's physical sex characteristics with the gender identity,
by the use of hormones and, usually, surgery. People often associate
transsexualism with sexuality, that is one's preference for a male or female
partner, yet there is no direct association between the two. Transsexual
people can be straight gay or bisexual, just like anyone else.
What can happen though is that a person's
sexuality can shift during transition. For instance, individuals living as
men in a sexual relationship with a woman may, after transition, be sexually
attracted to a man. Unofficial surveys point to this switch happening in
about 40 per cent of all male to female transsexual people. It can come as a
tremendous shock to the person undergoing transition. Incorrect treatment
can be the cause of serious psychological problems. Severe depression and
suicidal feeling are commonly experienced in pre-operative transsexual
people prior to sympathetic and appropriate treatment. Non-judgemental
counselling can help to overcome this natural reaction of the client to
their gender confusion.
The number of people requesting help for
gender identity issues is on a sharp increase. This does not necessarily
mean that it is becoming more prevalent merely that thanks to recent
positive publicity3 the general public is becoming more
sympathetic and accepting of the condition.
Also the law now offers greater protection
to trans employees and the recent ruling in the European Court of Human
Rights, Goodwin v the United Kingdom4, should
ensure the introduction of further legal changes to protect the human rights
of trans people. A similar increase happened in Sweden and other European
countries when the condition had been properly recognised and legal
precedents set, but this increase levelled off and it is assumed that a
similar pattern will obtain in the UK.
Until 1970 it was legal in Britain for
post-operative transsexual people to have their birth certificates amended.
The case of Corbett v Corbett (otherwise Ashley) put an end to
transsexual people's rights. When April Ashley was declared to be a man by
Judge Ormerod and her marriage declared null, the right to have birth
certificates corrected was revoked. Despite the recent ruling in the case of
Goodwin v UK (referred to above), Britain still hasn't implemented
the changes which would remove it from the company of Ireland, Albania and
Andorra, who alone among the 40 European nations, still deny transsexual
people the right to legality in their true gender.
But this is not just the right to many; it
is also an infringement of a person's privacy. This manifests mainly in the
workplace where having to disclose one's past frequently leads to
discrimination, jibes and abuse from employers, work colleagues and
subordinates. The Criminal Records Bureau has recently introduced a
procedure for searches under which such disclosure would not be made known
to the employer. The Government is expected to amend legislation shortly: In
the 1960s many transsexual people were subjected to aversion therapy; a
process commonly using visual stimulants accompanied by electric shocks to
`cure' them of this condition. Some medical books still claim two successes
from this therapy: What they don't state is that the follow-up survey only
lasted one year, and in the following year both these `successful' cases
committed suicide.
Macho Response
Many MtF transsexual people fight the
condition by trying to be more 'macho' than they really feel. Joining the
services, often the marines, SAS or the police force is surprisingly common.
Marrying and having children is another disaster waiting to happen. Only a
tiny percentage of married couples where one partner is finally able to
admit their transsexual status manage to stay together.
Waiting lists are long on the NHS, not only
for the operation but even for initial consultations. Seeking private
treatment can be quicker but there are still procedures that should be
followed5. Although there are many variants to the
transition process for MtF transsexual people, the same basic elements are
involved. The introduction of oestrogen and sometimes progesterone (hormone
therapy), and anti-androgens to inhibit the production of testosterone,
occasionally an orchidectomy (removal of the testes) will be done prior to
more extensive surgery. Together these treatments help to feminise the
features to a lesser or greater degree, by softening the skin and causing
some breast development
Although the introduction of testosterone
to a FtM person causes the voice to `break' and therefore become deeper, the
reverse is not true for MtF people. Here the new voice has to be learned.
Being able to make a phonecall without giving your name and yet be assumed
to be female is the ultimate test. Another area where things differ for MtF
and FtM people is that of bodily and facial hair. Removal of testosterone
and replacement by female hormones does not stop facial hair growing whereas
the introduction of testosterone for FtM people promotes hair growth
allowing beard growth to occur.
Real Life Experience
One process which is vital to a successful
transition, in virtually all cases, is that of the Real Life Experience (RLE).
This is the period of one or two years when a preoperative trans person
lives fulltime in the new gender role before irreversible changes are made.
Being able to function `normally' including socially and in one's working
life are key pointers to a likely successful future. The RLE is not intended
as a diagnostic tool for the medical professionals but rather as a guide to
trans people themselves, as to whether this is the right way forward for
them.
The operation to align the bodily
appearance more closely with the gender identity experienced, is reasonably
straightforward nowadays, at least for MtF people. Although it is a long
operation (four-five hours) there is a very high success rate, not only in
the operation itself but also in the psychological condition of the patient.
But as with all operations that involve long periods of general anaesthetic,
if other medical conditions are present or a patient is overweight or smokes
heavily, the dangers are multiplied and may prevent a trans person from
undergoing the surgical aspects of transition.
Frequently social conditions, family
commitments, career commitments etc. limit the extent to which an individual
will be able to transition. Transsexualism is now legally and medically
recognised as a 'serious medical condition'6 that should
be treated. Even so, many transsexual people still have difficulty in
obtaining NHS treatment and have to resort to private treatment. Many people
travel abroad for their operations.
| Nature not nurture in
gender identity
When Harry Benjamin introduced the
condition to the medical world in the 1950s, he favoured a
biological explanation. It was only some time afterwards that
Professor Money's findings seemed to trigger the change in
classification to that of a psychiatric disorder or mental illness.
For many years the experiment by Dr Money7 on a
baby whose circumcision operation had gone tragically wrong,
resulting in a mutilated penis, was believed to be proof that
nurture played the vital role in the formation of gender identity.
Dr. Money advised surgery on the boy to restructure his genitalia to
look like a female and instructed the parents to raise the child as
a girl.
This 'treatment' was reported by
Money as having been entirely successful. It was only years later
owing to the vigilance of Prof. Milton Diamond8
that the true ending to the story was revealed. The 'girl' had
undergone a second sex reversal operations and had never been
comfortable with the imposed gender, despite female hormone
reinforcement. It then became clear that the overriding force is
that of nature and that nurture plays at most a minimal role in
gender identity development.
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Counselling can play a vital role in the lives
not only of transsexual people but also their partners and families. Many of
the clients who come to me have previously seen other counsellors and
describe how they have tried to talk them out of transition, saying such
things as 'You're a man, you have a penis between your legs, you admit you
are attracted to women'. 'This is just a fetish that you will get through'.
'You must realise that you can never be a real woman'. All this achieves is
to destroy any confidence the person may have and leads to depression and
worse. This is what happened to me in the 1970s followed by two years of
really strange experimental group therapy to try and reinforce my
'masculine' side. It failed then, and it fails today: Transsexualism is a
condition that can only be self-diagnosed, but that does not mean that
everyone who presents with gender discomfort of any kind is transsexual.
That's where it gets tricky and why in the early stages of treatment, it is
important to allow people to explore, fully, their own gender feelings
without being pressured to follow a rigid treatment regimen.
Treatment should be patient led and allow
for flexibility. Those who wish to continue towards the goal of transition
should be given appropriate support and validation of their feelings, but
those who discover along the way that this is not for them, should be
allowed to change direction again without being made to feel that they have
failed. They will still need a great deal of emotional support.
Understanding a client's condition
How can we tell whether a client is
transsexual, transgendered or merely has transvestite desires? Another
tricky question, as all these conditions overlap to some degree and the
client could well not know which category they fit into or even try to fool
themselves into thinking that they are transvestite when they are really
transsexual or vice versa. It's only after years of talking to friends and
clients from all these areas that I find their words giving away the truth
of their situation. The same stories repeat themselves time and time again.
The same feelings of alienness, 'One day I'll wake up on some distant planet
and someone will say "It's OK, The experiment is over, You're
home"'.
| The Computer Industry
There is a predominance of
left-handedness or multi-handedness9 amongst
transsexuals and a huge numbers of engineers and computer experts,
far out of proportion to the rest of society. Seven years ago, in a
small survey, I realised that there seemed to be far too many
'trans' people working in the computer industry10.
Four years later, an article in an American on-line magazine11
stated that 15 of the world's top computer games designers were MtF
transsexual people. I have spoken about this phenomenon with Prof.
Milton Diamond of the University of Hawaii, perhaps the world's
leading expert in transsexual and intersex conditions. In a recent
email from him his reply was 'Absolutely, I have no doubt there is a
connection'.
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The main role of a counsellor in dealing with
transsexual people is to help their client explore the possibilities and
alternatives available, investigate the effects that these will have upon
their clients and their family, friends, and of course their career
prospects. Although it is illegal to discriminate on grounds of gender
identity, many transsexual people find it impossible to find employment12.
It is very important to let clients know that this is no easy option. How
would they tell their work colleagues, their partner, their parents or their
children and what reaction would they receive? How would people feel about
them using the female toilets? How would they react to snide comments and
laughter or even physical abuse in the street? How would they survive if
unable to find work? Do they realise the hours that they will have to spend
'learning' how to speak as a woman, the years of electrolysis needed to
remove facial hair and the many other new areas of life they will have to
learn? And what about the cost? Private treatment, including facial
feminisation, electrolysis, the operation itself and other associated
procedures, can easi1y add up to £30,000 for a MtF transsexual person and
even more for a FtM trans person embarking on the immensely complex
reconstructive surgery: [Webmanger's note: Please note, that
most of these questions and concerns are irrelevant for FTM trans people to
consider. There are other issues for FTM transpeople.]
The need to change
It is almost impossible for a non-transsexual
person to understand the 'need' to change sex, and for a true transsexual
person it is a need, not merely a wish or whim. How would you feel if you
had spent your life knowing that you were male yet had a female body or vice
versa? But let us not forget the unfortunate partner who is told by her
husband that he really is a woman - a woman who has been acting an
artificial role, often for many years. In order to gain a degree of empathy
with a transsexual client or a client who is the partner of a trans person
you need to put yourself in those roles.
Most transsexual people start transition
with all the best intentions. 'I won't go full time until I can really
pass'. 'I'll wait until the children are older'. 'I won't skimp on the time
I live "in role", just to make sure I can hack it'. The trouble is
that once the first step on the road has been taken it is very hard to keep
to these promises. The mind plays tricks on you, the mirror shows a
perfectly passable woman when the reality is something very different. And
yet it is confidence that is the key factor to a successful transition
confidence, but not over confidence.
In a strange quirk of fate, it was while I
was counselling a postoperative transsexual client that I finally admitted
the truth to myself. A simple question from my client 'What is it for you?
Is it the clothes?' and my immediate reply, 'No, It's just right, It's
natural, It's how things should be'. After 51 years of fighting against the
condition, my struggle was suddenly over. I knew the truth and at long last
I was actually able to accept and admit it to myself. But perhaps that is
when the real struggle starts. That is when a totally non-judgemental
counsellor can come into their own.
This article represents the views of Emma
Martin and not necessarily the views of people or groups with which she is
associated. She would like to thank those who provided critiques prior to
publication.
References
- Gooren, Swaab, Zhou et al. A sex
difference in the human brain and its relation to transsexuality. Nature
November 1995
- Kruivjveret al - Male to female
transsexual individuals have female neurone numbers in a limbic nucleus. Journal
of Endocrinology and Metabolism 2001. This paper received the GIRES
research prize for 2002
- Changing Sex - Channel 4, Coronation
Street (Hayley) - Granada, I want to be a man - Channel 4, My Millennium
(Emma) - Channel 4 etc.
- Goodwin v The United Kingdom 2002
- Harry Benjamin Standards of Care (version
6) 2001
- A, D and G v North West Lancs Health
Authority 1998
- Money - `Ablatio Penis' Normal Male Infant
Reassigned as a Girl - Archives of Sexual Behaviour 1975
- Diamond & Kipnes (1998), BBC Horizon -
The Boy they turned into a Girl (1999)
- Green - Biological Markers of Transsexual
Origins
- Martin - Occupations of Trans People 1995
- Next Generation On-Line 1999
- Whittle (GIRES workplace survey) 2002
Contact information for Depend, Emma Martin,
FTM Network, Gender Trust, GIRES and Mermaids was also given in the article
Citation: December, 2002
Vol 13, no. 10 an article published on the Internet by CPJ - Counselling and
Psychotherapy Journal
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