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Is Transsexualism an latrogenic construction?

Wallace, W., 2015. Is Transsexualism an latrogenic construction?. Reformulation, Summer, pp.24-29.

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This article is generated by my interest in the medical provision of hormone and surgical interventions to enable transition
from male to female (MtF) or female to male (FtM) which kept gender expression within cultural ‘norms’ of male or female, but
also gave a sense of legitimacy and validation to the wish of transsexuals that a “mistake of nature has trapped them in the
wrong body”, (Chiland, 2004). This belief was reinforced in the criteria set by the medical profession that to be diagnosed a ‘true’
transsexual rather than having a transvestite fetish (Benjamin, 1966), you had to not only have a need to be rid of the birth genitals, but also have a need to acquire those of the other. This requirement is unique to transsexuals and is why it can be described as iatrogenic as it provides the “partial realization of fantasies of sexual metamorphosis” (Pauly 1968), partial because, as yet, no surgical or hormonal treatment can enable a man to become pregnant or a woman to produce sperm.

What was there before transsexualism?

Green (1998) describes men wanting to dress as women and women wanting to dress as men as going back to antiquity. And,
more recently, this was seen in eighteenth century cross-dressing men who performed mock marriages with homosexuals in
the Molly houses and bordellos of Europe and North America and the women who dressed as men, married women and worked in male trades, and whose secret was only revealed after their death (Nelson-Jones, 2001). Whether or not these individuals felt the same need required for a diagnosis of a true transsexual today isn’t known, though it suggests that surgical/hormonal interventions may simply be a new way of expressing an age old desire.

Though it wasn’t the fi rst such operation, the 1952 ‘sex change’ of a former US soldier who became known as Christine Jorgensen was the fi rst widely publicised, and resonated with many individuals who identifi ed with Christine as they realised they were not a man who wished he was a woman, or a woman who wished she were a man; instead they were a transsexual. And, as such, came ‘out of the closet’ to request similar treatment, or what Denny (1996) describes as ‘a move to the other
side of the (cultural) closet of assimilation’. The legitimacy behind Christine’s operation lay in the fact that not only was it seen as the only approach to treating feelings of gender identity dysphoria (GID) as it is diagnosed today, but the concept of transsexualism also conformed to the ‘natural’ order of things in terms of the clear distinction between male and
female in a western binary culture (Kessler and McKenna, 1978).

When transition became possible it enabled those who, like Christine, had lived in secret with their gender issues to have
a medical ‘diagnosis’ and, if meeting the medical criteria for a true transsexual, gave access to surgical/hormonal treatment
to alleviate their distress. This, therefore, created the ‘category’ of transsexual. Harry Benjamin, an endocrinologist who is regarded as something of a pioneer in working with transsexuals, stated that: “Psychotherapy with the aim of curing transsexualism, so that the patient will accept himself as a man is a useless undertaking, since it is evident therefore, that the mind of the transsexual cannot be adjusted to the body, it is logical and justifi able to attempt the opposite, to adjust the body to the mind. If such a thought is rejected, we would be faced with therapeutic nihilism.” (Benjamin 1966, p, 116).

It seems that what Benjamin felt couldn’t be cured by psychotherapy was the desire to live as the other sex in a culture that has distinct male or female gender categories; this division is the underlying cause of gender dysphoria which hormone/surgical
procedures hoped to alleviate by enabling transition from one sex to another. It is a view similar to that of Lev (2004) who sees GID as a natural outcome of living within a culture that has an explicit gender system that associates certain appearances and
behaviours with particular gender catagories.

Transsexualism as a release from social constriction

The importance of a more accepting culture is seen in the Samoan Fa’afafine, these individuals are biological males who behave in a range of femininegendered ways and have been an integrated part of Samoan communities for centuries. They “enjoy a societal acceptance and tend to see their cross-gender identity and expression as a source of pride rather than distress” (Vasey and Bartlett 2007). In contrast, the speed with which western medicine operates upon babies born with intersex conditions to assign the most appropriate male or female sex, according to visible genitalia, shows what Denny (1996) describes as the ‘concretised’ division between male and female that is necessary for transsexualism to exist as a meaningful concept in the  irst place. The construct of inter-sex, however, suggests sex and gender comprises considerable variance, as part of a continuum, rather than being something to be diagnosed and stigmatised (and in binary western cultures) operated on to ‘normalise’ the natural.

Although transsexuals are, as far as can be ascertained today, biologically normal, inter-sex conditions show the importance of ‘resting on the hyphen’ in relation to nature and nurture influences on transsexuals. As Bolin (1988) describes it is “ironic that the more scientifi c and complex the determinants of biological sex become, the less they can be relied on to indicate gender”. This refl ects the more enlightened view of less restricting cultures around sex and gender, and demonstrates how medical and cultural ‘voices’ can bring confusion to environmental and biological issues. To the extent that genetics infl uence biological development, so cultural acceptance or restriction of gender expression infl uences the mental health of the individual.

The discrimination and victimisation experienced by others stepping out of cultural norms, such as gay and lesbian individuals, is seen as perhaps ‘worse’ for transgender and transsexuals because they challenge norms attached to sexuality and gender
(Marx & Katz, 2006). Similarly, the way in which gay and lesbian individuals were persecuted and stigmatised, so too transsexualism has been pathologised. Socorades (1969) said “Transsexualism represents a wish not a diagnosis. It is a wish present in transvestite homosexuals, and schizophrenics with severe sexual confl icts. The issue comes down to whether
individuals in these categories of mental illness should be treated surgically for what is a severe emotional or mental disorder” (cited Lev 2004, p31)

The surgical and hormonal interventions to ‘cure’ can, in CAT terms, be seen as dysfunctional target problem procedures to escape feelings of gender dysphoria experienced by individuals who fail to fi t into the male/female dichotomy. This belief has been around far longer than the surgical, hormonal, or psychotherapeutic, interventions that all perceive transsexualism as a problem to be ‘fi xed’, as was homosexuality before its removal from the DSM in 1973. Given the ‘double whammy’ in which culture sets the boundaries and the medical profession pathologises behaviours that step outside of them, it is not a great
leap to imagine the feelings of those living ‘secret’ lives when Christine’s sex change became known, and which gave ‘hope’ of escaping their secrecy via the ‘cure’ of transition.

Creating a wider repertoire of gender expression

The relevance of this today is that transsexualism now sits on a sex and gender spectrum that includes Lesbian, Gay, Bisexual,
Transsexual, Transgender, Inter-sex, Queer/ Questioning and Asexual (LGBTIQA). This spectrum demonstrates that there
are more ways of expressing gender identity that do not require medical interventions or possibly only hormone treatments or partial surgery. The importance of this is that instead of altering the body to fi t the mind, and creating the transsexual, both body and mind are allowed gender expression on a broader spectrum, as in more accepting cultures.

A broader spectrum may also show the folly of trying to fit gender expression into categories, as is shown in categorising
sexuality into heterosexual or homosexual. Bi-sexuality shows sexuality to be more fl uid than concretised. In transsexualism
this folly is shown by a male in a homosexual relationship who wants to change sex, and who moves to the category of ‘straight’
once transitioned to a woman, and living with the same male partner. The permutations for this shifting of categories are
enormous, but do the categories really matter? In a more pluralistic society it should be acceptable to move along the gender
spectrum with a transgender, rather than a transsexual, expression of gender diversity.

As the range of gender expression expands in western societies it may be that the concept of transsexualism (i.e. transition from one to the other) is outdated in terms of being the only way of ‘liberating’ individuals from feeling ‘trapped’; especially as there is more awareness of how the cultural norms trap individuals in its binary distinction. Cultural norms are amplifi ed through the conduit of family, peers and wider society, and internalised by individuals in all ‘walks of life’, including therapists. These infl uences appear to contribute to the “rigid” binary perception of sex and gender described by Hakeem (2012) which may reside in the ‘unconscious’ but ‘seep out’ in conversation (and therapy) around gender issues.

An example of this, in my own work, is in a conversation I had with a female therapist about a MtF transsexual who had surgery, and wanted to transition back again. Her comment to me was “so, he found being a woman isn’t as easy as he thought it would be”. This appears to refl ect the underlying assumptions members of one sex can have about how it is seen by the other. This may also be evidence of the transsexual, herself, holding an ‘idealised’ view of herself as a woman before disappointment followed transition. It is exploration and recognition of these internalised, and often out of awareness, views of sex and gender on the part of therapist and transsexual that open the way for a more meaningful therapeutic dialogue.

The familiarity of transsexuals’ inner and outer issues to CAT therapy

Today there is recognition that the restrictive scaffolding from family, peers, media and wider society has enormous infl uence on individuals’ views of what it means to be male or female and how the sex and gender roles attached to them should be followed. Fraser (2009) describes the consequences of this on some transsexuals as being a diffi culty in locating a core sense of
self and trying to be someone else by developing a “hyper masculine or hyper feminine self” in an effort to please parents, siblings or peers. This could be understood in terms of internalisation, reciprocal roles and procedures and, in CAT, can
be seen as a procedural loop which implies that if the individual fails to comply with the cultural norms they must be ‘mad’ and which fails to explore how cultural norms may be driving the individual ‘mad’.

This resonates with Benjamin’s (1966) description of medical interventions being to ease distress rather than cure something felt as wrong. And, if the aims of therapy are seen as psychological rather than physical, is it to give a greater understanding of the meaning given to the concept of masculine and feminine in relation to the internalisation of social norms. Therapeutic approaches that explore the impact of internalisation of social norms on the individual have fl exibility to explore both
intra and inter- personal diffi culties in a way that assists in making sense of their inner world; “who am I?” While others need help in managing their outer world, work, family and friends; “I know who I am, but how do I live out in the world with an authentic gendered self” (Fraser 2009).

The stereotypical sex and gender roles that are internalised from birth contribute to the diffi culty experienced by the LGBTIQA
in society, though from media coverage, and more individuals ‘coming out’, there is greater acceptance of diversity in western
society which allows a ‘stepping out’ of the ‘closet of assimilation’ that individuals have found themselves in as a consequence
of the prevailing medical construct and its diagnostic and categorising culture. CAT tools and concepts could provide a sound therapeutic base for exploring the inter- and intra-personal issues associated with gender variant individuals as CAT should not be bound by the prevailing cultural rules, but should instead see those rules as another ‘voice’ that accepts or constricts the transsexual in becoming who they feel they are.

I am a newly accredited (February 2015) CAT Psychotherapist working in secondary care for Somerset NHS Foundation Trust, my role also includes coordinating referrals for Mendip, South and West Somerset. I have a particular interest in working with Personality Disorders. william.wallace@sompar.nhs.uk

References
Benjamin, H. (1966), The Transsexual Phenomenon. The Julian Press, Inc, New York. Bolin, A. (1988), In Search of Eve: Transsexual Rites of Passage. Bergan & Garvey, New York. Chiland, C. (2004) Transsexualism, illusion and reality. Sage Publications, London. Denny, D. (1996), In search of the “True” Transsexual. Chrysalis: The Journal of Transgressive Gender Identities, 2 (3). Fraser, L. (2009), ‘Depth psychotherapy with transgendered people’, Sexual and Relationship Therapy, 24: (2) 126-142. Green, R. (1998a), Mythological, historical, and cross- cultural aspects of transsexualism. In D. Denny (ed), Current concepts in transgender identity, New York: Garland. Hakeem, A. Z. (2012), Advances in Psychiatric Treatment: Psychotherapy
for gender identity disorders. 18: 17-24. Kessler J. S. & McKenna, W. (1978), Gender: an ethno methodological approach. New York: Wiley. Lev A I. (2004), Transgender Emergence: therapeutic guidelines for working with gender-variant people and their
families: Routledge Taylor and Francis Group. Oxfordshire, United Kingdom. Nelson-Jones, R (2001), Theory and Practice of Counselling and Therapy (3rd edition). Continuum, London. Pauly I (1968), The Current Status of the change of sex operation, Journal of Nervous and Mental Disease, 147,460-471. Vasey & Bartlett (2007), Perspectives in Biology and Medicine 50 (4):481-490.

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Wallace, W., 2015. Is Transsexualism an latrogenic construction?. Reformulation, Summer, pp.24-29.

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