No Surgery on Demand (1993)

 No Surgery on Demand

By Dallas Denny

Last November, Sophia Pastel, a transgendered woman from Norfolk, Virginia, came to Atlanta for treatment. The “treatment” she sought was one which fell squarely in the medical realm: introduction of a foreign substance under the skin. In fact, the U.S. Food and Drug Administration considers the procedure she was seeking so dangerous that it has outlawed its use, even by physicians.

In some cookie-cutter Atlanta motel room, Sophia Pastel died moments after receiving a subcutaneous injection of liquid silicone from a “practitioner” whose only qualification was that he had a syringe and enough money to buy a tube of industrial-grade silicone in a hardware or auto parts store.

Sophia isn’t around to tell us if she has any regrets, or if she had enough facts to make an informed choice about the treatment she had elected to receive. But there are a considerable number of individuals, both male and female, who are around to tell the world loudly and abrasively that they have great regrets about having had genital reassignment surgery. One of their primary gripes is that they did not realize what they were getting into.

There are other sources of dissatisfaction with the surgical treatment of transsexualism. Sometimes physicians become disenchanted and proclaim their disgust with the treatment process. Jon Meyer, who was the head of the Gender Identity Clinic at Johns Hopkins University did just that. His feelings on the subject were so strong that they affected his objectivity. His 1979 paper with Donna Reter was a model for bad science, incorporating faulty assumptions, poor sampling techniques, invalid measures, and contrived criteria for the “success” of surgical intervention in transsexualism. And yet its impact was dramatic, as it led to a domino-like closing of dozens of gender clinics.

Also in 1979, the Harry Benjamin International Gender Dysphoria Association, Inc., an organization composed entirely of psychologists, psychiatrists, surgeons, endocrinologists, and other caregivers, proposed minimal standards of care for hormonal and surgical treatment of persons with gender dysphoria. These Standards of Care were introduced because HBIGDA members were concerned by the human misery which was being caused by the unregulated treatment of transsexual persons.

The Standards of Care have been periodically revised, most recently in 1990, and remain the commonly accepted professional standards for treatment. They are a safeguard for both caregivers and consumers. For the physician or mental health professional, their principles and standards provide consensual guidelines for hormonal and surgical treatment. Following the guidelines protects caregivers to some extent from malpractice claims by making them aware of and prohibiting poor practice. For instance, Standard 7 requires peer review before sex reassignment surgery, and Standard 12 makes it unethical to overcharge. For the consumer, the Standards place some restrictions on treatment. Most importantly, they provide a clear path to sex reassignment surgery, progressing from physically nonintrusive treatments such as therapy through more intrusive (and dangerous) treatments, with the irreversible procedure of sex reassignment surgery being at the end of the treatment process, after a period during which the individual must have lived and worked or gone to school full-time in the chosen gender for a minimum of one year.

By following this path, it is possible for the individual, at any point up until the final surgery, to return to the gender of original assignment with the least possible disruption and the fewest possible irreversible physical changes. For instance, an individual in therapy can decide prior to initiating hormonal treatment to remain in the original gender with all physical characteristics intact. A genetic male who has taken female hormones for some time can return to the original gender role with at worst some residual breast development which can be disguised by clothing or removed surgically. Hormonal therapy causes a number of permanent physical changes in genetic females, but even so, it is generally possible to return to the female role. Until the individual is actually anaesthetized for sex reassignment surgery, it is possible to return to the original gender role. And perhaps more importantly, it is possible to halt the process at any point before going under the knife. In other words, the Standards of Care allow a variety of transgenderal alternatives short of complete sex reassignment. They allow the individual to explore these alternative methods of expression, progressing as he or she sees fit, and stopping at any point in which he or she feels comfortable.

Most importantly, by their requirement for a period of full-time living, the Standards acknowledge that it is not genitals which make men and women, but gender identity and gender role. Men and women are not created by the surgeon’s lancet, but by their life circumstances as men and women. Surgery and hormonal treatment are merely options which some people choose to help them by altering their bodies to conform with their chosen gender roles. Surgery, or lack of it, does not affect the ability to perform in a gender role in any important way other than sexually. The genital area is, after all, customarily covered by clothing, and the genitalia of others are taken as a matter of faith. Unless we are changing the diapers of other individuals, or are intimately involved with them, we assume they have a particular set of genitals which correspond with their gender role. It is for this reason that Donald Laub has called sex reassignment surgery gender confirmation surgery. It is a private affair that provides the individual with personal satisfaction, but has little other impact. When one has been functioning for some time as a man or as a woman, genital surgery is unlikely to lead to regrets. In other circumstances, the risks are grave.

I would be the last to claim that the Standards of Care are perfect. Certainly, they are flawed. They do not, for instance, provide suggestions for an optimal level of treatment, nor do they sufficiently address the differential needs of male-to-female and female-to-male persons. Certainly, they have been abused by caregivers, who have in some circumstances withheld them from consumers and in others used them as a sword to wave over the heads of often desperate men and women. Certainly, by the very fact that they impose requirements on the individual, they have caused some human misery. Certainly, they were formulated without sufficient input from transgendered persons. But I would argue that the misery they have caused has been offset by more than an order of magnitude by the human misery they have saved.

The fact of the matter is that the desire to change one’s sex is often a transient phenomenon. It can arise secondary to transvestic fetishism or homosexuality, as a consequence of temporal lobe lesions or epilepsy, as the result of psychosis, and because of feelings of inadequacy in the original gender role. It may be present only during periods of stress. The desire for hormonal and surgical treatment can decrease in intensity or even disappear because of reductions in the level of male hormones, because of life changes, or when anticonvulsant or anti-psychotic medications are administered.

Significantly, most people who are transsexual opt for a variety of reasons not to seek sex reassignment. Some feel obligations to family, friends, community, and career which outstrip their felt obligations to themselves. Some cite religious reasons. Others feel that their physical characteristics would make for an uncomfortable and stigmatized life in the other gender. Yet others lack the courage or the financial ability. And of those who actually set out to seek sex reassignment, most do not make it even to a period of crossliving, no matter how transsexual they feel themselves to be. I have heard estimates from leaders of support groups, and it has been my personal experience also, that as many as 80 or 90 percent who begin the journey either abandon it completely or stop some place along the way—and rarely because of obstacles placed before them by the treatment community.

Many end up exploring and settling in gender space well away from the gender box marked transsexualism. And yet many of these people at some point or the other want and actively seek sex reassignment surgery. If surgery was available on demand—if one could walk off the street, place one’s money on the table, and check into the hospital for an immediate operation, the potential for regret would be enormous. This is exactly the situation that the Standards of Care were designed to prevent. I would argue that they have done a remarkably good job.

The vagaries and obstacles of sex reassignment tend to politicize transsexual people. Few escape unscathed. Most are burned somewhere along the way. I myself bear some scars, most of them from men and women who were trying to do what was in my best interest, but who got it absolutely wrong. I have a strong belief that one’s body is one’s own property, to do with what one will. I particularly believe that one’s gender is a matter of personal choice, and not an appropriate decision for anyone else to make. And yet there is also the matter of access to medical treatment. In our society, we are safeguarded from unscrupulous and incompetent medical practitioners, much as we are protected from bad drivers and unsuitable neighbors by traffic and zoning laws. And medical caregivers themselves are sworn to do no harm. They are in violation of the most basic tenets of their profession if they provide treatment which they feel is against the best interest of the patient. Aye, and there’s the rub, for caregivers are subject to homophobia, transphobia, sexism, racism, and all of the other isms that plague society. But before giving hormonal therapy, and especially before performing genital surgery, they must be reasonably sure that they are not damaging the patient. In the case of transsexualism, this puts the physician in the unenviable position of being a social worker, something he or she is not trained or emotionally equipped to do. My belief is that this is the battleground, or, more politely, the negotiating table, on which the interest of the individual is balanced against the interest of society and the interest of the caregiver. It is here that compromise must be sought, so that the most people with gender dysphoria can be helped, and the fewest harmed. It is here that a balance must be found, here that consumers must come together with helping professionals and provide new and better guidelines to supplant or augment the Standards of Care.

This brings me to the belief of some members of the transgender community that hormones and sex reassignment surgery should be available on demand. I think that would be a terrible mistake. I’m sure that there are transgendered persons who are unable to meet even the minimal requirements of the Standards of Care, who cannot get together the funds to see a therapist for the ninety days required to obtain a letter authorizing hormonal therapy, or who, even if therapy were free of charge, could not, because of substance abuse or mental health problems, manage to show up on time for appointments. I’m sure there are people who are caught somewhere between masculine and feminine presentations, unpassable in either gender, who are forced into prostitution or drug-dealing by an uncaring and unfeeling society that will not allow them access to legitimate work because of a gender-ambiguous appearance. I am sure there are many who cannot afford therapists’ fees.

(Author’s note: The following paragraphs were written about transsexual people in the Tenderloin area of San Francisco, California, a population which is characterized by substance abuse and prostitution. It does not refer to transgendered persons in general, who are no more and no less functional than any other segment of the population).

I can understand the frustration of seeing so many lives in the Tenderloin squandered, so many people lost in process, stuck in place. I see it nearly every day in my own work. Yet I would argue that the main problem of many people who are unable to follow the very minimal requirements of the Standards of Care is not gender dysphoria, and that giving them free access to hormonal and surgical procedures would be harming many more of them than it would help. The dysfunctionality of most of these people is not in my opinion due to transsexualism, which does not, after all, automatically render all transsexual people dysfunctional (consider how many transsexual physicians, airline pilots, computer engineers, and business owners there are). No, the dysfunction is more often due to alcoholism, to drug addiction, to immature and inadequate personalities, and it is here that effort should be expended to rehabilitate. Treating the transsexualism will not automatically clear up all of the other life problems, but when the individual is coping with other aspects of life, he or she will be more likely to be able to deal with gender dysphoria.

I am not in favor of waiving the counseling requirement for these people and giving them hormonal treatment ad lib. Most of them have little notion of how hormones will affect their bodies and their minds, of their options in life, of what transsexualism is and is not. How, then, can they give informed consent? My answer is that they can’t. Giving them treatment without informed consent would be gross malpractice on the part of any physician or of any mental health professional providing authorization for hormonal therapy. And the complexities of what sex reassignment will hold in store for them cannot be communicated in one thirty-minute session; they need to explore their lives and feelings at depth with a mental health professional. And it goes without saying that I am opposed to surgery on demand.

Providing someone with treatment which will ultimately make them unhappy is far more cruel and uncaring than placing minimal requirements on them on the front end. My belief is that much more damage will be done by opening the candy store than is presently being done by requiring contact with a therapist. Allowing someone under the influence of drugs or alcohol, someone who is psychotic, someone who is not thinking clearly to make life- and body-altering decisions is like giving a child a loaded gun. They cannot make informed choice, cannot give informed consent.

The Standards of Care may have been put together by well-educated, middle-aged white males with incomes in the upper five figures, and most of whom were heterosexual, but that does not automatically mean that they are sexist, racist, classist, homophobic, or transphobic, as some in the community have claimed. The Standards of Care are, when properly interpreted, not difficult to understand, and despite the roar that might arise from the Tenderloin from this statement, not difficult to comply with. Nor is there great expense involved. Like any other of life’s endeavors, transsexualism requires individual initiative. Helping transsexual people should not consist of the gender dysphoric equivalent of bottle-feeding, but of providing them with opportunities to work and play in safety and dignity, without fear of physical attack or harassment, in a community which will allow them to make a legitimate living, and with information which will let them make informed choices. The rest is up to the Sophia Pastels of the world.

Yes—Surgery on Demand

By Christine Tayleur

The Harry Benjamin International Gender Dysphoria Association’s (HBIGDA) Standards of Care are misogynist, classist, and homophobic. They assume that transsexuals are pathetic, pathologic people who cannot make informed decisions about their own lives. They put all of the power for transsexuals seeking gender confirmation surgery into the hands [of] psychotherapists (usually non-transsexuals) who may approve or deny it at will. There is no appeal. We have the right to control our own bodies and lives. We should not be subject to the whims of care providers, much as a non-transsexual woman has the right to abortion on demand.

The Standards of Care were developed by a group of non-transsexual psychotherapists with little or no input from the transsexuals whose very lives are affected. This group was predominantly white, heterosexual, male, and wealthy. The Standards are based on a pathological view of transsexualism that transsexualism is somehow a “disorder” or disease.

We need medical services. However, there is no reason that our community should be a medical colony. We have a great many expenses: hormone therapy, doctor visits, electrolysis, legal expenses and surgery. Only a very few enlightened insurance companies will pay for surgery, but the overwhelming majority will not. The earning power required to pay for the other attendant expenses is usually only available to white men.

Transsexuality is not a mental illness. Because transsexuals live and grow up in a transphobic society, many transsexuals suffer from social harassment and family abuse. As a result, many transsexuals suffer from emotional problems and internalized transphobia. The Standards of Care are based on the medical/psychiatric model that so dominates and oppresses.

While supportive counselling can certainly be helpful to many transgendered people, especially those who have suffered as a result of transphobia, there is no reason to require people seeking gender confirmation services to undergo counselling. As a counsellor with some ten years of experience, I know that results are generally poor when a person is forced to undergo counselling because it sets up a dynamic of mistrust. The individual will wind up telling the counsellor whatever he or she wants her to know or thinks the counsellor wants to hear. I don’t blame her. A counselling relationship must be based on trust.

Transsexuals tend to have to struggle with finances. Many are downright impoverished, particularly transsexual women. She often earns “women’s” wages, earning 59% or less of what a man makes. Preoperatively, we have the expenses of electrolysis, hormones and often legal fees. Sometimes we may have child care or child-support payments in addition to everyday expenses. To add mandatory counselling to this list adds unreasonable expenses. It is classist. It assumes an individual has money to spare. It is racist for the above-mentioned economic facts. The huge economic resources required to pay therapists are often available only to [several words lost].

It is a situation of “caveat emptor” —therapists can charge whatever the market will bear. The Standards make it unethical for a therapist to overcharge. However, there is no genuine cost containment written therein. The Standards only provide lip-service to this. One therapist I know of charges upwards of $90 an hour. She is a charter member of HBIGDA.

Therapists can charge whatever the market will bear. Here in the San Francisco bay area, there is only one therapist who takes the state medical insurance (available to disabled people and pregnant women only). However, females-to-males have huge expenses as well. While they don’t have electrolysis, their surgery is often two or three times the cost of male-to-female.

The only city program in San Francisco that provides medical services requires that an individual be, first of all, a San Francisco resident. Second, its waiting list is several months long. Finally, when an individual gets in to see someone it takes six months to get on hormones. Other programs, such as gender clinics, ship their services out and require one to find a therapist after paying them a huge fee to see if you qualify. Further, the gender clinics often require that an individual’s sexual orientation post-treatment be heterosexual.

The HBIGDA Standards of Care are misogynist, homophobic and transphobic. They regard transsexualism as a psychosexual disorder (supplanting ego-dystonic homosexuality and homosexuality in the Diagnostics Statistics Manual of the AMerican Psychiatric Association. The APA is a notoriously sexist, homophobic, classist, misogynistic organization. The APA uses its massive resources to defend its members against former patients who sue their doctors for sexual abuse or psychiatric torture.

In my view, the vast majority of transsexuals know exactly what they are getting into. It is the physician’s job to explain exactly what one can expect from surgery and what one cannot. This is called informed consent. If someone goes in for open-heart surgery, the physician does not require a psychiatric or psychological clearance or evaluation; they suggest a second opinion. Good idea, but that’s not the same as the HBIGDA requirements of a minimum of six months to one year in therapy. Some gender clinics require two or more years!

The notion that we are somehow a class of people incapable of making a decision that has such earth-shaking consequences as gender confirmation surgery is patronizing and rotted in sexism. After all, we either once were women (ostensibly) or are confused men wanting to “chop it off.”

By forcing people to get counselling, we push them towards cut­-rate butchers. We thus increase the likelihood of suicide, death by sepsis, or other types of complications arising from bad surgery.

Christine Tayleur works as a counselor at the Tenderloin Self Help Center. This article is ©1993, 2013 by Christine Tayleur