Referrals to the Psychiatrist
What does the Crossdresser Want?
Dr M.T.Haslam, MA, MD, FRCP, FRCPsych
Issue 7
August 1999
I first came into the gender scene professionally nearly 25 years ago. Partly coincidentally when, running a clinic for sexual problems in York through membership of the Association of Marital & Sexual Therapists, we collected up a few people with gender problems and subsequently through my closer interest as a trustee for the Beaumont Trust. Gender issues in those days were much less understood; more prejudice was around, wigs were of a poor quality, and individuals with gender problem were much less knowledgeable. So were the doctors!
In the early days of the Beaumont Society, then the only organisation to cater for the crossdresser, they held an annual dinner for members at the BBC restaurant in London, near the Aldwych. I recall attending one where Hinge & Brackett - then hardly known - were the cabaret. Around those days too there was an IRA bomb scare at Heathrow on the date of the dinner. The then president, Alga, from Dublin, had flown in for the dinner 'en femme' and had a flight booked out back the following day. Security was tight. Alga however got home unscathed and was neither challenged nor searched!
Roy Mottram was publicity officer for the society. He did stalwart work in getting gender problems better known and broke new ground cycling around Cardiff at 6'1", wig akimbo, protesting his faith!
A conference in York held in 1975 allowed for the first time a dialogue to be promoted between professionals and representatives of gender and sexual minority groups. The conference report (still incidentally available from the author at £5 a copy) was the first of its kind and featured Martin Cole, Rosemary King representing the Beaumont Society and Liz Stanley speaking on gender role stress.
Referrals, then, from GPs were much less sophisticated, the distinctions between transvestite and transsexual gender distortion were only then being promulgated by Sir Martin Roth, situated at that time in the ivory tower of Newcastle upon Tyne, and the term gender dysphoria had yet to be invented. Nor had Harry Benjamin and the "real life test".
Since then publicity from the media, books and magazines and the mushrooming of organisations catering for the social, spiritual and educational needs of crossdressers of all persuasions and their partners has totally altered the level of sophistication and indeed the confidence of many who seek help.
And wigs are better!
What we must never forget however is that every day new people, young people, are discovering themselves and coming to the often frightening realisation that they are 'different' and that this may cause them singular problems as life goes by. So there are always, new, unsophisticated young people who need our help.
It is important - vitally important, that such people get sensible and informed advice early in their quest. Some example case studies, suitably anonymised will serve to show the type and range of problems that can present:
'A' had realised since before puberty that he felt more at home in girls' company, than boys, and that he had an urge to try on and wear girls' clothing. He had sneaked his sister's clothes from time to time around the age of 12 and 13 and for a while had found it sexually stimulating though this had not seemed to him to be the main thrust of his need. He had been caught out by his sister on one occasion, a girl two years his senior, and this had led to her and two of her friends dressing him up fully - to teach him a lesson - but which of course though it much embarrassed him at the time, he found thrillingly enjoyable. Now in his twenties, he had read a bit about the subject, had acquired a collection of underwear and a wig but had never dared tell his parents nor go out 'dressed'.
How sad that we so intimidate our children that they do not feel able to discuss such things with us - and how sad that society by its prejudices inhibits young people from self-expression. Reality is that society mocks, and parents all too often attempt to force children into stereotypical moulds.
What 'A' needed and what he got, was the opportunity, to talk through all the problems he foresaw, to get some unbiased advice and to be pointed to the ways he could get further knowledge and to talk to other people with similar needs and concerns.
'B' had rather different needs. He had crossdressed since his teens and was now in his forties, recently divorced and concerned to pursue his gender needs more intensively. Basically what he wanted was hormones - to make his body more like he wanted it to be but not to pursue the "sex change op". He wished he were a woman - but not at the expense of chopping off his penis!
The issue of giving hormones is a complicated one. We are changing an apparently normal body of one sex to make it look a bit like the body of the other. At the same time there are potential hazards to the taking of hormones of the 'wrong' sort. For a genetic male to take female hormones is to risk inflammation and clots in veins and slightly to increase the risk of breast cancer and liver problems. For a genetic female the taking of male hormones can similarly cause liver problems and some personality change.
So who should be given hormones - anyone who wants them? - only the 'pure' transsexual whatever that is? Or should it be at the whim of the doctor? Certainly in this day and age the doctor has always to be looking over his or her shoulder at possible litigation should any untoward side effect occur, and no GP is likely to prescribe without specialist supervision and advice.
But who should be the arbiter? The patient after all owns his body - but asks some one else to 'muck it about' so all the good and bad points must be carefully rehearsed to ensure 'informed consent'.
The Charing Cross criteria - based largely on Harry Benjamin's ideas in the USA are in the author's view however excessively restrictive. To insist on additional assessment, even to the extent of discontinuing hormones already started by other professional specialists, and to adhere too rigidly to the 'real life test' is unrealistic in some respects, particularly in times of high unemployment.
To pass in the female role one must not have stubble. Ergo, electrolysis must be completed before a realistic real life test can start since a three-day's growth of facial hair is needed in order that electrolysis can be effective. So the client needs to have made the commitment at least eighteen months ahead of going full time (since facial hair clearance is going to take that long) and if going ahead, hormones are going to be very helpful - indeed necessary - to stop male hair regrowth and encourage feminisation - before going full time.
This can lead to a number of catch 22s as case C will illustrate.
'C', a male to female self-diagnosed transsexual had started on this path six years before. Living a long way from London the question of specialist referral had been the first obstacle. In these days of Trusts, who should pay?
The initial referral was made locally in 1992 after a year hormone therapy was started. 'C' was led to believe that within about three years she would be able to work successfully in the female role. She started electrolysis and began to live in the female role - at this stage she could not therefore work since she was not able to pass convincingly as a female in her old job, but was anxious to expedite the process into the real life test.
It is doubtful if there were surgical expertise to perform genital surgery in the locality where C lived. Furthermore the hoped for changes with hormones were not impressive. Because of the lack of normal earnings, the house had to be remortgaged.
They reckoned they could survive the next two years with a loan.
At this stage the local Trust through the Health Authority agreed to fund a visit to Charing Cross for a tertiary referral. There she was invited to stop hormones for six months whilst they did a proper assessment and to embark on a two year 'real life test'. C was not over thrilled by the advice! She did start on anti-androgens subsequently. The increase in weight from fat deposition was disappointingly rather more on the belly than on the hips and bust.
C had to rely increasingly on partners earnings, got on to income support but could not afford her electrolysis nor private medical treatment. She did not wish to drag out the process a further two years however and did not therefore wish to stop hormones, but got wrong with Charing Cross as a consequence. Further delay was caused by the local psychiatrist's illness, and this took us to 1996. Trips to Charing Cross meanwhile were very expensive and recovering expense from the Social Services lengthy. Vouchers could not be obtained in advance and her partner's fare could not be covered so she had to travel 'en femme' alone, the journey taking so long that stubble was showing by the time she arrived at the London terminus.
These pinpricks show really a lack of understanding and excessive bureaucracy on the part of the agencies concerned. And all the while time is ticking by and the money getting shorter, the process getting more difficult and morale taking a dive.
Where are we in 1999? The only local surgeon is inexperienced (would you risk it?) Private surgery is now out of reach. Charing Cross will still be at least a year or two off - (waiting list) and the bank has foreclosed on the mortgage. Six years has gone by! A salutary tale!
The final example, D, is genetically female. He/she has now been on hormones for some six years, has had a deepening of the voice in consequence, good facial hair growth leading to a creditable beard and has been able to retain his job whilst changing to the full time male role. But he can't stand to urinate. That is fairly crucial. But in the present state of the art you go for phalloplasty? In Brussels perhaps. Even so, a lot of pain, a lot of plastic surgery, scars and very occasionally after a while they fall off. But most women other than lesbians want a boy friend with a 'willy'. So one's social life is fairly celibate.
How do we sum all this up? The simple crossdresser needs a bit of counselling but more especially needs to learn the skills that his sister learned from her mother's knee onwards. You are who you are. Do what you do do well; and other clich?s.
But for those who wish to progress further, an experienced psychiatrist will offer you useful counselling that you are bound to need, access to hormones and to surgical advice if and when you need or want it - and an advocate when the world seems against you. Pick the right one!
