Outcome of Five Cases of Transsexualism (1997)

©1997, 2013 by Dallas Denny

Source: Dallas Denny. (1997). Can research be done in the support group setting? Outcome of five cases. Paper presented at the Second International Congress on Sex and Gender Issues, King of Prussia, PA, 19-22 June, 1997.

Paper presented at 2nd International Congress

On Crossdressing, Sex, & Gender Issues

Research in the Support Group Setting:

Outcome of Five Cases of Transsexualism

 by Dallas Denny, M.A.

 American Educational Gender Information Service, Inc.

Abstract

Most published research on transsexualism has come out of gender programs which provide a highly structured setting in which persons seeking sex reassignment can be evaluated and treated by an interdisciplinary team. However, in the 1990s, most transsexual people neither apply to nor attend such clinics; rather, they put together their own gender team in an à la carte fashion, selecting services and caregivers in a manner typical of procuring any needed medical and psychological services in a market-driven economy.

Transsexual and open transgender peer support groups exist in most major cities in the U.S., and provide education, referrals, and social activities for transsexual men and women without the power dynamics inherent in the “team of caregivers/consumer” structure of gender clinics. Membership in support groups is voluntary, fees are minimal, and, although group members may make suggestions about the pacing of transition, each individual makes his or her own decisions about what to do and when to do it.

Is such an environment conducive to scientific research? I suggest not only that it is, but that some support group settings may result in better outcomes than overly restrictive gender programs. I review research done in support group settings and present outcome data from five individuals who transitioned while attending a peer support group in a major Southeastern city.

Introduction

Sex reassignment—most specifically surgical procedures performed on healthy genitals—has historically, at least since the 1950s, been viewed as a heroic medical procedure which is justifiable only if it alleviates the dramatic suffering of transsexuals reported by Benjamin (1966), Stoller (1968), Green & Money (1969), and others. In this decade, the assumptions that underlie such reasoning have come into question, resulting in an emerging sentiment that individuals should be allowed to do or have done to their bodies whatever they wish. In large and ever increasing numbers, transsexuals are not going to gender programs for sex reassignment, but are serving as their own case managers, calling their own shots, deciding what procedures to undergo and when, and how much counseling, if any, they will have.

Little is known about what happens to individuals who follow such a course. What are their outcomes? Is there a high proportion of “transsexual regrets?” Of suicides? Are they miserable, or contented and well-adjusted, or somewhere in between? No one really knows, as there have until now been few outcome studies on such populations. A notable exception is a questionnaire done by Janis Walworth and presented at the First International Congress on Sex and Gender Issues in 1995 (Walworth, 1997).

More is known about transsexuals who follow the often-strict protocols of formal gender programs. Beginning with Benjamin in 1966, there have been dozens of outcome studies published by members of gender programs. Typically, transsexuals are followed for some years post-surgically, and interviewed periodically. Despite well-publicized problems with follow-up, and despite the methodologically flawed and apparently fraudulent 1979 study by Meyer and Reter, these follow-up studies tend to show a preponderance of “satisfactory” outcomes. Results are hardly unequivocal, but are sufficiently robust to indicate that surgery can be of benefit to the majority of transsexuals who go through clinical programs and are later available for follow-up.

It is important to study non-clinical populations for a number of reasons. First, because they do not have to pass entrance criteria or pay large fees, transsexuals in this group are probably more diverse than those in select clinical groups. Second, individuals outside clinical settings avoid much of the medicalization inherent in gender programs, and so can provide a measure of the effectiveness of such programs. But most importantly, it is important to collect such evidence in order to show the benefits of sex reassignment surgery, as there are those who would very much like to see it ended.

Why have there been few studies outside of clinical settings? Is it because non-clinical populations of transsexuals are unavailable? I think not. Anthropologist Anne Bolin readily obtained access to a support group in the mid-West, and other researchers like George Brown (Brooks & Brown, 1994) who have approached the transgender community have readily found subjects. Perhaps there are no such follow-up studies because clinicians have ready access to their patients, and have not looked elsewhere, and non-clinicians have not had funding sufficient to conduct such studies. Or maybe it’s just that nobody has bothered to look.

Despite their rarity, studies outside the clinical setting have been most instructive. For example, Kessler & McKenna’s ethnomethodological work in the seventies (Kessler & McKenna, 1978), and Bolin’s observational study in the 1980s (Bolin, 1988) have played a major role in the reframing of transsexualism and the rise of the transgender paradigm, even if they have been virtually overlooked by clinicians.

I believe that the most productive work in the next decades will be done not with transsexuals in special settings like gender clinics, but in the real world, where transsexuals live their lives. And as new findings emerge, I believe that many of the supposed shortcomings of transsexuals documented in the early literature will be shown to be artifacts of the research methodology.

In 1991, I formed a transgender support group in a major city in theSoutheastern United States. The group was “open,” which means that anyone with a gender issue, any family member or partner, or anyone with a legitimate interest in gender issues could attend. There was already a transsexual support group in the city, but I was dissatisfied with its rigid expectations for its members. Whatever their life situations, members were expected to go on hormones, transition gender roles, have genital surgery, and disappear into the woodwork to live “normal lives” as nontranssexual—that is “cured”—men and women. Individuals who were unwilling or unable to follow such a course were pronounced “nontranssexual” and excluded from the group either formally, via a letter, or by peer pressure. This created a self-fulfilling situation, in which “true transsexuals” were those in the group; those who were not in the group were “not transsexuals.”

The new group had no such expectations. Members were encouraged to explore their options via therapy and find a course that worked best for them. Peers were supportive of members’ decisions, whether they led to sex reassignment, full-time crossliving without expectation of surgery, acceptance of cross-dressing, or, in one instance, moving to another state in search of a religious “cure.” The group nonetheless attracted a large percentage of transsexual persons, with perhaps 60 individuals transitioning gender roles and having genital surgery in a five-year period.

Members of the group came from many walks of life. However, the group, diverse as it is, does not accurately represent the transgender community. Its members tend to be white and of the middle class. The city’s large population of transpersons of color do not tend to attend the meetings, nor do many of the Caucasian transindividuals who are very evident in the city’s bars. Also, female-to-male persons are under-represented.

In my position as a member of the group, I have been in the position of participant-observer, much as was Anne Bolin in her field study, which is reported in her book In Search of Eve (Bolin, 1988). The major advantage of this perspective is that it is divorced from the treatment system and the biases inherent therein. Although I educated group members about the Standards of Care, various medical technologies, and strategies for successful transition, at no time did I serve as a caregiver. Consequently, communication was open and easy, and there was no incentive for group members to please me. In fact, believe me, when group members are not happy with me, they do not hesitate to let me know it.

Before I present five cases, I would like to say that in some ways, my findings are rather different from previous studies. For instance, despite the problem with lack of follow-up reported in most clinical studies, I am in touch with, or could easily get in touch with, practically everyone who has transitioned through the group. Whether or not they continue to attend meetings, group members are part of a network of friends, lovers, and housemates, deriving support from, and giving support to, each other. I am part of this network.

It’s significant that in clinical studies, the problem with lack of follow-up has often been attributed to the less than reliable nature of the subjects. Although it is possible that I had a more honest group of subjects, it seems apparent that previous problems with follow-up had more to do with the quality of the relationship between clinicians and subjects than with the characteristics of the subjects themselves. And not only that, if subjects of previous studies were pronounced “cured” and expected to disappear into the woodwork—and they were—it is hardly surprising that many of them effectively did so.

My study is still in process, but my best guess at present is that my results will show that most group members did very well. In fact, I will be surprised if they did not do as well or better than subjects from gender programs with their manifold requirements—which calls into question the necessity for gatekeeping for the average transsexual.

I will present today five case studies of group members. I have made no attempt to present only successful cases, although I have made sure I have at least one outstanding example of male-to-female transition, and one outstanding example of female-to-male transition. The individual circumstances of all subjects have been disguised.

Case #1: Michelle

Mike T. was a psychiatrist and a Methodist minister in his late thirties, married, with three teenage children, one of whom was autistic. He had been struggling with his gender issues all his life. He had been sneaking his wife’s birth control pills when he suddenly realized that he had to deal rationally with his issue. He contacted a nationally renowned therapist and was referred to AEGIS, a national clearinghouse for transsexual and transgender issues—which, incidentally, I founded. AEGIS referred him to the support group. He began attending meetings and exploring the possibility of transition in therapy. He had been in counseling for many years, but had not until then broached the issue of his gender dysphoria with his therapists.

Mike transitioned fairly rapidly, although not recklessly so. Predictably, his life began to fall apart. His marriage dissolved, the partners in his therapy practice asked him to leave, and his church began proceedings to remove his ordination. Also, the breakup of the family home required that his autistic son be placed in an expensive group home.

From the ruins of Mike’s life, Michelle emerged. Michelle slowly began to rebuild her devastated therapy practice, came to terms with her family members (who eventually became supportive), and successfully campaigned to keep her ordination. Michelle became a leader of the support group until she decided to pull out because she saw an ethical conflict between being a group member and being the therapist of some of the group’s members.

Throughout her transition, Michelle acted with good sense and grace. Keeping her ordination required a great deal of politicking and a great deal of courage. She went to Sunday services at various churches of her denomination; had a reception at her house for her supporters at the church; worked with a group appointed by the church to study the “problem” she presented, answering with good nature their often embarrassing questions; and cemented old relationships and formed new ones over lunch or dinner. She dealt well with local and national media coverage caused by her struggle with the church.

Within three years of beginning transition, Michelle’s church had voted to sustain her ordination, her practice had improved dramatically, and her relationships with her family members was natural and without strain. She is now over a year post-surgical, with no regrets, and her life has begun to assume normalcy.

The challenges Michelle faced would have been overwhelming for anyone, transsexual or nontrassexual, but her maturity and strength of character caused her to persevere against long odds.

Case # 2: Dale

Donna, a systems analyst who worked for a large computer company, was in her mid-twenties. Like Michelle, she had been struggling with a gender issue all her life. She had decided to go to a gym and attempt to obtain steroids, but before she actually did so, she saw a television program which featured members of the support group and contacted the group.

Donna was masculine in appearance, and typically wore men’s clothing. She had been slowly transitioning at work, cutting her hair short, getting rid of her skirts, and taking on the gender-ambivalent name of Dale.

Dale’s approach to transition was very structured, just like his programming techniques. He learned what he could from the group, and thereafter rarely attended meetings, although he remains in touch with group members, and dated one group member for the better part of a year. During this time, he had top surgery and obtained counseling in preparation of beginning hormonal therapy. He was cautious about beginning hormones, wanting to work though his feelings about them before starting, for he suspected that their effect would be rapid and dramatic.

Hormones indeed were rapid and dramatic, causing changes in Dale’s voice and appearance. Interestingly, despite these changes, he never discussed his situation with his supervisor or other employees, one of whom was a lesbian who kept feeling him out. His supervisor collaborated by never bringing up the issue. Gradually, Dale’s co-workers and customers began using masculine pronouns. Dale reported that things were occasionally awkward, but that he did not feel that he was in danger of losing his job.

After he had fully transitioned, Dale left his company to form his own consulting firm. He opted out of the rat race by moving to a country location near the city and chose to work only part-time rather than working to build his business to its maximum potential.

Most of Dale’s family members were aware of his change to the male role, and there was some resistance from an Uncle. Dale, who had always been very fond of his elderly and frail grandmother, and whom he visited frequently, chose not to burden her with the knowledge of his transition, and stopped visiting and calling. He writes weekly. He states that he misses his grandmother a great deal and wishes that he could see her, but stands by his decision not to see her. Several years after his transition and top surgery, he has no regrets.

Case # 3: Imelda

Bob, a married man in his early sixties, was an engineer employed by an aerospace firm. He had no history of crossdressing or gender dysphoria, but discovered one day that wearing bracelets put him “in touch with his inner feelings,” which he had until then denied. This led to crossdressing, which in turn led to his joining a support group for heterosexual crossdressers. There, he met members of the open group and joined. He became active in the group and served as an officer for a year. After several years, Bob, now Imelda, stopped coming to meetings. Imelda still occasionally attends gender community gatherings, but is distant with other group members.

Bob went through a period at work in which he dressed androgynously. Profoundly bald, he began wearing a short woman’s wig and gender-neutral clothing. Slowly, Imelda emerged. She broached the issue of her gender transition with her employer—an event of major importance, since her work required that she keep her security clearance. She did a great deal of research into the best way to handle her transition at work, and indeed, was able to keep her clearance and her job, although things were quite awkward at work for several years, and may still be so.

Imelda was soon divorced. She dated several group members; in fact, one group member (Case #4) dropped his femme persona and came off hormones in order to be her boyfriend. She pressured him into it, insisting that he “be the boy.”

Imelda was seeing an endocrinologist who had her on a very large dose of estrogens. On a flight back to the US from South Africa, she suffered a mild heart attack, and had to come off hormones herself. Karma, some group members called it. Eventually, her physician placed her on a medication which shut down her production of male hormones; however, this medication was very expensive and rapidly cut into Imelda’s surgery fund. She looked into having orchidectomy (castration), but its expense was such that she also began looking into having sex reassignment surgery right away. Other group members did not think this was a good idea.

It has been several years since Imelda’s surgery. She continues to work, and continues to present as a woman. She pops in and out of gender community events, rarely being there on time, and rarely staying until they are over. The best way to describe the effect she has on others is that one member said that when Imelda enters a room she feels as if the temperature suddenly drops ten degrees.

Imelda saw several therapists before and during her transition, attending both individual and group counseling sessions. She sometimes spoke in a derogatory fashion about therapists, but this seemed to have more to do with her inability to manipulate them than with the therapists’ actual characteristics. In fact, Imelda was very controlling in a number of ways: she talked her in-transition lover into becoming a “boy” for her, she managed to obtain the necessary letters for surgery despite only a short period in real-life test, and she almost torpedoed an appearance by a noted transgender author set up by her boyfriend when she unilaterally decided the event was likely to lose money and took it upon herself to begin calling the financial sponsors of the event, urging them to bail out.

Does Imelda have regrets about transition and/or surgery? I have not yet conducted a structured interview with her, but there is little doubt in my mind that she does.

Case #4: Mandy

Bob, the manager of an auto parts store, had a lifelong gender issue. He came to the group, attending for two years before deciding to begin hormones. Six months later, Mandy, as Bob was called in the group, was off hormones, having been pressured by her “girlfriend” Imelda (Case #3) to “be the boy” in the relationship. Group members urged her to live for herself and not Imelda; group members pointed out that post-transition life would be that much more difficult if she were not sufficiently feminized by hormones. Six months later, having broken up with Imelda, Mandy was back on hormones.

Bob got into a spot of trouble at work because of having a rainbow flag on his car. He took the flag off, but was dressing in an increasingly feminine fashion. He was tolerated for a time, but was eventually fired. He immediately entered transition.

Mandy had been seeing an electrologist who other group members considered ineffective; in fact, she spent several thousand dollars with no appreciable diminishing of her very dark beard. At the time of transition she had been on hormones for only a few months and had a noticeable beard shadow. Also, Mandy’s hair line, her facial features, and her stature and body build made passing difficult. Group members pointed out to her that transition—and specifically, finding work—might prove difficult. Indeed, Mandy has had ongoing difficulty with employment, and has been unable to afford electrolysis or plastic surgery to feminize her appearance. She is quite obviously a transsexual woman, and while she is proud of being transsexual, the fact is that her readability leads to a very different quality of life for her than for members of the group who are more passable.

Although she searched extensively, Mandy was able to find only one job—cooking in a restaurant. She was incensed that she was not allowed to wait tables, for the restaurant was owned by a transsexual woman who “should have understood.” What the owner probably understood was that a food server with Mandy’s problematic appearance would cost her business. Mandy resigned after several months, and worked doing telephone sales for several months. When that job proved financially unproductive, she decided to go to school to learn how to apply artificial nails. Group members told her that her city is wall-to-wall with nail parlors, and that nails sell for as little as fifteen dollars per set; they wondered how she could possibly make a living doing nails. Mandy went to school anyway. She experienced considerable discrimination and harassment at school. Afterwards, she was turned down for employment in many nail parlors, and finally found work in a small parlor in the suburbs; however, her earnings were very small.

Mandy was still in the group, and was in fact, an officer for a year. Group members suggested that she might consider taking a roommate and finding a less expensive car in order to lower her living expenses, but she did not do so. Eventually, she quit her job at the nail parlor. She finally found a job delivering bottled water, but was fired when a new manager came on board and saw her. She found a job at another delivery company, where she makes minimum wage and some tips. The business is gay-owned, and she was incensed when the owners came to her and told her that they were convinced that Mandy’s appearance was cutting into their sales and that they were going to limit Mandy’s delivery area to the gay-friendly parts of town. This cut into Mandy’s income.

Throughout this period, Mandy was the Treasurer for a gender conference which is held in a Midwestern city. The Board of the conference discovered—unfortunately, just as the conference was gearing up—that she had embezzled approximately seven thousand dollars, the amount, coincidentally, there was in the bank account. The Board agreed not to press charges only if Mandy would make regular payments in restitution. Mandy has been paying regularly for two years now.

Mandy has not had surgery, but is slowly building up a fund to allow her to do so; she is able to do so only by working two low-paying jobs. On the eve of this presentation, she told me her surgery date had been set.

Several years into transition, Mandy has been embittered and politicized by her work experiences. She no longer comes to group meetings, although she is in contact with group members and socializes with them. She is angry at the gay community for not being supportive enough, and has written several letters to the gay press on the subject. Certainly, her situation is difficult. Well-educated, intelligent, and personable, she is nonetheless unable to get a good-paying job, and finds it difficult to keep even menial jobs because of discrimination. She gets catcalls and jeers almost every day of her life. Even people who have no difficulty with Mandy’s transsexualism feel uncomfortable around such an angry person.

Assuredly, Mandy could have handled her transition in a better way, but the fact is that her physical characteristics—her detectability as transsexual—cause her to be discriminated against. She does not regret her transition, but is understandably unhappy about her current low level of income and indignant about the treatment she receives from others.

Case #5: Jaxa

Jaxa lives in a small Georgia town about an hour’s drive from Atlanta. At about age 13, she told her family that from then on, she was going to be a girl—and she was. She attended high school as a girl. Although almost everyone in her town “knew,” she was able to live fairly comfortably as a woman.

When she was 23, Jaxa happened upon a gay magazine with a help column. When she wrote, explaining her situation, her column was printed, and she was referred to AEGIS. I met with Jaxa and told her about the requirements for transition. She presented as typically female. She was practically unreadable, and quite attractive. Jaxa had never been on hormones.

Although Jaxa attended only a couple of group meetings, she remained and remains in touch peripherally.

Jaxa attended counseling sessions long enough to get a letter for hormones. Hormones made little difference in her appearance, serving only to round out her features a little.

About three years after she approached me, Jaxa had SRS. She was such a hit with her surgeon that she appeared with him and her boyfriend in a short feature on The Playboy Channel.

It is now about three years since her surgery. Jaxa works as a waitress in a sports bar. She has no regrets.

I will present further results of this study this September in Vancouver at the Meeting of the Harry Benjamin Gender Dysphoria Association.