|Psychotherapy|   |Sex Modification| 

Psychotherapy

Historical non-surgical approaches

Many alternative procedures have been used therapeutically in the treatment of gender disturbances which are not geared toward Sex Reassignment Surgery. Early treatment centred around Aversion Therapy with the use of drugs, and later in the 1960’s Electric Shock Aversion was prominent. In the late 60’s and early 70’s, psychologists started turning to the use of Desensitisation and Assertiveness Training as well as ‘Shame Aversion Therapy’. Hypnosis was also used as well as other psychoanalytic methods. (Annon, 1975) Eber (1982) tells us that many psychotherapists, however have "....accepted the thesis of irreversibility of the transsexual feminine identity." (Arndt, 1991:128) They would argue that any known forms of psychoanalytic or somatic treatment of Gender Identity Disorders are quite futile or even harmful, bearing in mind the pervasive and deeply imbedded nature of gender identity.

There are many exceptions, however which indicate that cross-gender behaviour, as a symptom of deeper psycho-sexual issues, is ‘treatable’, but with more advanced and less ‘ethically’ questionable interventions than those mentioned above. There are also many psychiatrists and psychologists that would define Gender Identity Disorders within the framework of other psychiatric disorders and treat them as such. From these perspectives Sex Reassignment Surgery would be facilitating the growth of deeper disturbances, and placing the individual in a psychologically dangerous position.

Modern Psychotheraputic approach

Psychotherapy continues to have an important role in the treatment of all patients with gender identity disorder. Most patients, following long-term psychotherapy, give up their wish for sex modification{1}. Many transsexual persons suffer from a variety of other personality disorders and mood disorders. Psychotherapy is generally considered vital for a proper diagnosis, to deal with co-morbid psychopathology and psychological conditions to which the gender dysphoria may be secondary{2} . It can help the patient set realistic life goals for work and relationships, to define and alleviate the patient's conflicts that may have undermined a stable lifestyle and to present a range of options apart from surgery that may have not been seriously considered by the patient{3}.

It is important that those with Gender Dysphoria are aware that there are alternatives than ‘changing the body to fit the soul’. However, modern psychotherapy today has been largely influenced by the lobby groups to accept that homosexuality is no longer a disorder, which can be seen in the latest few editions of the Diagnostic and Statistical Manual. We may also in the future see Gender Identity Disorders wiped from the list of psychiatric disorders and added to the list of ‘normal variations of human behaviour’. Consequently there will be ethical considerations which must be adhered to when attempting to aid a person in change, regardless of whether or not he himself requests intervention.

From a behavioural perspective, Annon has also reported cases where there have been successful attempts to apply learning based procedures. Also orientation form homosexual to heterosexual has been seen. (Annon, 1975) Likewise Barlow et al (1979) has observed successes in non-surgical treatment of disorders, such as Modelling.

There are also may reports of religious conversions, which lead an individual to seek alternative solution to sex-reassignment. (Arndt, 1991) In these cases individuals have endeavoured to trace the causes of their Gender Dysphoria and facilitate the ‘healing’ and rebuilding of their damaged and incomplete identity. Many books and ‘testimonies’ have been written as ‘self-help’ resources, ‘recovery groups’ have been established and professional and para-professional referral agencies exist specifically to support and offer psychotherapy to those with Gender Dysphoria or some form of Gender Identity Disorder (Leach, 1995) Keller et al (1982) observed that at one clinic where group psychotherapy is a routine part of the evaluation of Gender Identity Disorder, half the patients elected non-surgical solutions to their disturbances.

Sanda Davis, from a psychoanalytic perspective points out that the cross-gender part of the person appears resistant to treatment, but it comes from the ‘executive’ part of the self that has chosen an unhealthy solution to meet its needs. Therefore therapists must be trained not to mistake the determination for a sex-change "which has been masterminded by the ‘introject’" for the real need of the person. (Davis, 1995:179) She would agree with Obsfield, a psychoanalyst (1985) who argues even in cases where individuals are controlled by a strong cross-gender introject, given sufficient social and personal factors that support the biological gender, the person can evolve toward a gender identity congruent with biological gender.

 |Psychotherapy|   |Sex Modification| 

Sex Modification

Sex Modification Procedures

Sex-change treatment programs are traumatic. Patients are started on sex-change hormones and administered with increasing doses over a period of 1 - 2 years during which time they are required to live full time in the opposite gender role, necessitating that they inform everyone they come into contact with of the change{4}. This can result in difficulties at work and leave the individual feeling isolated and without the support of family or friends{5}.

The surgical sex-change procedures that follow are extreme, painful and complex and have numerous potential complications and they are limited as to what they can achieve. The surgery renders the patient infertile and they must learn to live with various imperfections compared with the biological members of the sex to which they have been assigned. Furthermore, psychological integration of gender role and identity cannot be achieved through surgery{6}. In time some patients realize that reassignment has not necessarily brought them the improvement in life that they had expected.

Sex change procedures can be devastating, however, to those patients who have been misdiagnosed and who subsequently discover and resolve the underlying cause to their condition. It may be difficult or impossible for such patients to ever revert back to their biological gender.

Whilst many medical professionals oppose the use of sex modifying procedures on both medical and ethical grounds, the lack of success that some clinicians have experienced in attempting to alter the most severe, early-onset gender identity disorders by traditional psychotherapy, together with the alleged success of sex reassignment, has compelled a few medical practitioners to allow surgical treatment as an alternative. Sex modification involves hormonal and surgical treatment for the purpose of changing the physical appearance of the body to resemble that of the opposite sex.

Apart from a few professionals working in the area who consider that sex-modifying procedures may provide some benefit to a broad range of gender dysphoric patients{7}, most professionals who practice in the area believe that such treatment should only be considered as a last resort{8} for a highly selected group of individuals{9} with severe gender dysphoria and who remain unresponsive to psychotherapy{10}. These patients often present with early-onset cross gender identification and severe gender dysphoria and refuse to participate in any kind of psychotherapy or talking type intervention{11}.

The question as to whether or not sex modification procedures actually provide any real benefit over the long term has yet to be answered{12}. The question as to whether or not psychotherapy would be a more effective treatment for severe gender identity disorder also remains unanswerd. It is estimated that only about 1 in 10 patients who request surgery are considered eligible and yet a disproportinate ammount of published research has been devoted to the surgical management of transsexualism. The psychological and medical needs of the majority of transsexual persons have, in this way, been largely neglected. The availability of sex modifying procedures has distracted effort from investigations that would allow for the non-surgical management or prevention of many gender identity disorders.

Furthermore, the idea that transsexualism is a physiological disorder outside their control is more palatable to patients than the stigma associated with a mental illness. Patients suffering from gender dysphoria resist psychotherapy in the same way that patients with anorexia nervosa resist weight gain and transsexuals likewise embrace sex modification procedures in the same way that anorexics would embrace liposuction were it to be offered as a treatment for that condition.

Eber in 1980 stated "Working with the encouragement of the news media, patients and physicians have created a circus atmosphere that has inflated and distorted the diagnostic, treatment and social issues; a fad to which the medical profession has pandered." (Arndt, 1991:116) Sanda Davis also suggests that the way Gender Identity Disorder is currently presented, interventions with medical treatment help the disorder to progress and sets up the whole family, social and political environment in a way which gives the disorder ample field for expansion. She argues that everything is shaped and reframed according to the distortion of self imposed by the disorder and the fantasised solution of the individual. "People have followed the path created by symptoms" (Davis, 1995:36)