Understanding Gender Dysphoria, page 14
Table 5.2. Gender Dysphoria: Pathways in Adulthood
Path 1: Undetermined outcome (an estimated 50% drop out of treatment due to frustration)
Path 2
Path 3
Path 4
Resolve in accordance with their birth sex Engage in cross-dressing behavior and role intermittently (often privately or in distant venues/locales) Adopt cross-gender role and identity, which may include hormonal treatment and sex reassignment surgery
Carroll notes that psychological resolution appears to be more likely among “a subgroup of cross-dressers with gender dysphoria.” They may reflect more of a fetish quality around cross-dressing, tend to be highly motivated (whether such motivation is tied to work or marriage or family obligations), and may conceptualize their concerns “from the perspective of a paraphilia or sexual compulsion” whereby they respond to it with relevant cognitive and behavioral strategies.41
The third outcome (path 3) is the most frequent outcome, that is, to engage in cross-gender behaviors intermittently.42 Bert did try this for several years. For a biological male, this might mean growing his hair out longer, wearing makeup occasionally, and cross-dressing either on the weekends or wearing female undergarments during the day to manage the dysphoria. For these men, cross-dressing is frequently related to sexual arousal (having more of a fetish quality that for some distinguishes it from a classic gender incongruence in which the person feels “trapped in the body of the other sex”). According to Carroll, “the majority of these men are heterosexual, often married, usually vocationally stable or successful.”43 The extent of cross-dressing behavior typically reflects the degree of dysphoria and how successfully such cross-dressing behaviors reduce the felt tension within.
The last outcome (path 4) is reflected in those who adopt the gender role of the opposite sex. They typically proceed to some full-time cross-gender identification. This may involve hormonal treatment and sex-reassignment surgery.44 Throughout this whole process and again with the discussion of hormonal therapy and/or surgery, most mental health professionals reference the widely recognized Standards of Care of the World Professional Association for Transgender Health (WPATH; formerly referred to in the literature as the Harry Benjamin International Gender Dysphoria Standards of Care).45
The Standards note that the primary goal of therapy is “to find ways to maximize a person’s overall psychological well-being, quality of life, and self-fulfillment.”46 Therapy “can help an individual to explore gender concerns and find ways to alleviate gender dysphoria, if present.”47 Emphasis may be on “clarifying and exploring gender identity and role,”48 as well as responding to associated stressors and disclosure of gender identity–related matters to others in the person’s life as appropriate.
To consider hormonal treatment or sex-reassignment treatment, a psychological evaluation is first conducted by a specialist in this area. The evaluation should assess mental/emotional health and gender identity.49 It is strongly recommended (but not currently required) that a person then undergo a period of psychotherapy. The most recent recommendations do not offer a minimum number, as a number can be considered a “hurdle”; a number can detract from the ongoing work of providing services not just in the case of medical intervention; and a number does not speak to the relative differences in clients and clinicians in reaching the same goals in different time periods.50
If a person were to reach a point at which they were a candidate for surgery, it is recommended in the Standards of Care that they live for a year in the real-life experience of living full time as the desired gender.51 Those twelve continuous months “allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences).” The person would present in their preferred gender identity “consistently, on a day-to-day basis and across all settings of life. . . . This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings).”52
Table 5.3. Decision-Making Stages Regarding Sex Reassignment
Awareness Characterized by distress related to Gender Dysphoria
Seeking information Focus on education about Gender Dysphoria and identifying sources of support
Disclosure Sharing with significant others one’s diagnosis and experience of Gender Dysphoria
Exploration
(identity and labeling) Initial exploration of options for one’s identity and identity label along a continuum
Exploration
(transition issues) Further exploration of identity, presentation and options regarding body modification (e.g., hormonal treatment, facial surgery, genital surgery)
Integration
(post-transition issues) Synthesis of identity in light of transition
(A. I. Lev, “Transgender Communities: Developing Identity Through Connection,” in Handbook of Counseling and Psychotherapy with Lesbian, Gay, Bisexual and Transgender Clients, 2nd ed., ed. K. J. Bieschke, R. M. Perez and K. A. DeBord [Washington, DC: American Psychological Association, 2007], pp. 147-75.)
Lev53 discusses a multi-stage model that reflects the kind of decision making a person faces when thinking about sex reassignment. It begins with awareness and moves through information seeking to disclosure to others and exploration of identity options and various issues that arise when giving serious consideration to transitioning. It ends with integration or the synthesis of an identity post-transition.
If we look back at the experience of Bert and Faye presented above, we see that Bert is in the place of exploration. He could identify a time of initial awareness of his gender dysphoria, and he shared how he had sought out information that helped him move beyond the initial thought he was losing his mind. He had also now disclosed to Faye and to an online community, as well as one local friend. Now he was exploring options for identity, which included some intermittent cross-gender attire. He was not at this time considering hair removal, hormonal treatment, or facial or genital surgery.
When I first read this multi-stage model of decision making, I was reminded of a study we had conducted of male-to-female transgender Christians54 in which we asked about various milestones in their experiences of gender dysphoria. Not all were transsexuals, but some were and had gone through a similar decision-making model. Others were transgender and had not pursued hormonal treatment or sex-reassignment surgery.
As in the model proposed by Lev, there is a time of initial awareness about gender incongruence or dysphoria. In our sample, that was at about age six on average. That stage was followed by a time of internal confusion in which some shared that they engaged in cross-gender behavior; some received consequences for their behaviors or dress; and some reported an emotional dissonance that we believe was likely comparable to the gender dysphoria.
Table 5.4. Milestone Events for Male-to-Female Transgender Christians
Milestone Age Example
Awareness 6
Cross-dressing behaviors (n = 16); atypical play (n = 7)
Internal Confusion 11
External consequences (n = 6); gender variant behaviors (n = 6); emotional dissonance (n = 5)
Thoughts/Reasoning 18
Something is wrong with me (n = 8); need to do research (n = 6); wanted to be female (n = 5)
Attempts to Address Conflict 27
Sought counseling (n = 9); cross-dressing behaviors (n = 9)
Disclosure 35
Told spouse/significant other (n = 16)
Resolution 47
No resolution (n = 11); assistance from others (n = 9); transitioning (n = 9); acceptance (n = 6)
We also asked about how they made meaning out of their gender incongruence, and the more common answers had to do with something being wrong with them, needing to do research and wanting to be female. The “needing to do research” is similar to what Lev described as “seeking information.” Participants in our study also shared about their attempts to address their gender identity conflict. The two most frequently cited attempts were by entering into counseling or engaging in cross-dressing behaviors.
Disclosure took place at an average age of thirty-five. It was typically to one’s spouse. This is a stage that is also captured in Lev’s decision-making model. The age of disclosure is likely to change dramatically in a cultural context in which younger people who experience gender dysphoria are more likely than the previous generation to know what their experiences mean in terms of contemporary conceptualizations and possible diagnoses.
In Lev’s conceptualization, as a model of decision making regarding sex-reassignment surgery, the focus is on making that specific decision. In our study, we asked about resolution and found that many had not experienced a resolution. Some did transition, while others had not and were seeking assistance and support from others. In any case, it was an interesting study that lines up in some ways with what Lev describes in terms of stages. There are certainly key commonalities that a person could be aware of and provide support around, particularly how a person responds to their gender incongruence (both by attempts to address the conflict and by meaning-making structures) and issues surrounding disclosure and resolution, of which there are a range of possibilities.
In the care of adults, the WPATH standards outline several areas of responsibility for clinicians. The first is to follow the standards themselves. Other responsibilities are to make an accurate diagnosis of gender dysphoria and any comorbid conditions (and provide treatment for the comorbid concerns). Clinicians are to provide accurate information about a range of options and the implications of each. Therapy around these concerns is also to be provided. It is in the context of the therapeutic relationship that the clinician determines the client’s readiness for hormone treatment and surgery, and this would at some point entail a more formal letter of recommendation (with relevant history documented) to colleagues in the medical and surgical fields. The clinician then serves as an important member of a multidisciplinary team, demonstrating collegiality to further the clinical care of the client. Care may be enhanced through education of family members, employers, faith communities and perhaps others. The clinician is then to be available for follow-up with the client as needed.
If the client has an intersex condition, many of the assessment and treatment issues are similar, overlapping with what we have already been discussing. However, these are different experiences. Tom Mazur and his colleagues note that the differences between those who have an intersex condition are significant and recommend that clinicians
obtain a thorough history including chromosomal pattern, diagnosis, etiology (if known), surgeries, hormone treatment, pubertal development, and history of medications taken (up to and including current prescriptions). When obtaining a medical history, particular attention should be paid to factors believed to be associated with gender change in persons with intersex. Questions to ask might include the following: Did the person have late (after age of three years) or no genital surgery? If the person is an adolescent or adult, is their puberty (secondary sexual characteristics) discordant with their assigned gender? Is the person sexually attracted to individuals of the same gender, meaning the gender to which the person with intersex was initially assigned?55
Indeed, the DSM-5 would have clinicians note an intersex condition noted under the diagnosis of Gender Dysphoria. The clinician is still assessing readiness for possible sex-reassignment surgery. However, there are important differences that may have more to do with psychological issues if the person was assigned a sex at birth, raised in that gender role and then comes to a different phenomenological experience of themselves later in life.
Some people with an intersex condition may pursue sex-reassignment surgery with the intention of identifying as the other gender; others will identify as intersex. Still others may choose to live as the gender they believe they are psychologically without pursuing surgery for a number of reasons.56
Most people who are unfamiliar with Gender Dysphoria may make assumptions about surgical options. There are actually a number of surgical procedures available, although the most frequently discussed for the biological male who is transitioning is vaginoplasty or the creation of a neovagina (with a penectomy or the removal of the penis and orchiectomy or the removal of the testes). Male hair can also be removed, and corrective surgery can be performed on the larynx. Surgery to enhance the breasts (breast augmentation) can also be performed. People vary considerably on which surgeries (if any) they have done. For the biological female, the breasts, uterus and ovaries can be removed. Some patients will also request phalloplasty or the creation of a neophallus. If the patient has an enlarged clitoris (sometimes as a result of taking male hormones), it may be cut loose in a way that it can be experienced more like a penis (metaidioplasty).
Many adults who are diagnosed with Gender Dysphoria do not undergo any of these surgeries. They may not be prepared to do something as permanent and complete, or they may believe that their dysphoria is manageable without taking such steps. Some people who undergo some of the surgical procedures do not undergo all of the options that are available to them. When interacting with people who are navigating these decisions, unless there is a clinical rationale for asking about specific surgical procedures, I recommend letting the person tell their story in their time, including sharing from their experience about the decisions they have made, rather than initiating with a line of questions or out of any attempt to satisfy one’s curiosity. In my experience listening to transsexual persons, being asked about these surgical procedures can be experienced as a rather invasive line of questioning that no one else is subjected to.
One author reports that about three-fourths or more of those who complete sex-reassignment surgery report satisfaction with their new identity and only about 8 percent report poor outcomes with surgery.57 Others have reported that only about 2 percent actually regret sex-reassignment surgery with 4 percent expressing dissatisfaction with the surgical outcomes.58 A recent study that examined outcomes over a fifty-year period in Sweden (1960–2010) indicated a 2.2 percent rate of regret for both MtF and FtM transsexual persons.59
One way to look at figures that indicate a fairly high degree of satisfaction is that they reflect a funnel that begins broad with those who first seek help due to their gender dysphoria, particularly as the dysphoria rises to a level of significant distress or impairment. Once properly diagnosed with Gender Dysphoria, they face several options as they now have a name and way of conceptualizing what they experience. This is followed by those who then might consider the removal of body hair and some cross-sex identification on a part-time basis. Then, over the course of time, as various considerations arise—experiences in therapy, experiences with one’s family and peer group, experiences in part-time cross-gender role and especially full-time cross-gender role (or “lived informed consent”60), issues associated with cost, and so on—some people will be more likely to consider voice/vocal training (if they have not done so yet) and one or more surgical procedures.
What we know at this point is that those with a female-to-male conversion report adjusting better, on average, than those whose conversion is male-to-female, although again there is great variability. Many people attribute this to it being easier to “pass” when a person has transitioned from female-to-male rather than male-to-female. Older persons pursuing reassignment do not report having as favorable outcomes as younger persons.61
Also, those who follow the Blanchard typology report that more autogynephilic transsexual presentations end up regretting their sex reassignment than those who have been understood to be androphilic transsexuals, and this may reflect the tendency to be “less strongly driven by gender dysphoria than full-blown transsexuals.”62 In other words, if a person’s experience of gender incongruence is not of a classic transsexual presentation but has a more paraphilic quality about it, the best resolution may very well not be sex-reassignment surgery but rather other psychosocial interventions that address the association with arousal. Lawrence63 discusses options that fall short of sex-reassignment surgery, although there are complexities with autogynephilic expressions (e.g., not all wish to live full time as the other sex) that may make it difficult to complete the Standards of Care as they are currently written.
As one might imagine, better outcomes and rates of satisfaction among those who go through sex-reassignment surgery are related to positive surgical outcomes, as well as consistent use of hormones.64 One female-to-male transgender person I spoke to shared that he had the chest reconstruction surgery to address the primary source of gender dysphoria but had not had additional (“lower” or “bottom”) surgery and was working in therapy on the treatment of body dysmorphia (preoccupation or significant concerns) associated with his current state.
Although previous research65 on follow-up of transsexual persons tended to be rather favorable, researchers tended not to follow the person over a long period of time. A more recent study66 that provided data on long-term follow-up reported increased risks for suicide attempts, death from suicide, and psychiatric inpatient care that are “considerably higher risks” than the general population.
This study found substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalizations in sex-reassigned transsexual individuals compared to a healthy control population. This highlights that post surgical transsexuals are a risk group that need long-term psychiatric and somatic follow-up. Even though surgery and hormonal therapy alleviates gender dysphoria, it is apparently not sufficient to remedy the high rates of morbidity and mortality found among transsexual persons.67
