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A Physician-Patient Perspective Rebecca Anne Allison, M.D. |
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"The Real Life Test" -
Hormones and Heart Disease
A List of Therapists Who Treat
State - By - State Instructions
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Christmas Messages 1998: Christmas Remembered
Janice Raymond and There Are No Chance Encounters The Angst At The End
1992 1993 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
"Feminization of the Transsexual"
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First hear a tale of two Greeks. Hippocrates, while not the first recorded practicioner of medicine, left us future physicians with a legacy of scientific curiosity and personal integrity. I remember standing with my medical school class at our graduation and reciting the Hippocratic Oath. In his magnum opus , Epidemics, Book I, Section XI, he wrote:
The Roman physician Galen, writing later on the subject, translated the phrase into Latin as Primum non nocere. The statement defines a way of thinking which places the welfare of the patient above other concerns. A very different Greek, albeit a mythological Greek, was Procrustes. This giant was said to capture victims whom he would force to lie down on an iron bed. If a victim was shorter than the bed, Procrustes stretched him on the rack to make his body fit. If the victim was longer than the bed, it was simple: Procrustes cut off the feet and legs just the right amount. Either way, the victim died. The term "Procrustean bed" has become proverbial for the arbitrary decision to force someone to fit into a fixed pattern. I think of Hippocrates and Procrustes as caricatures of treatment models for a person with transsexualism. Hippocrates would approach each patient with a spirit of concern; he would get to know the patient's individual needs and circumstances. He would make the treatment fit the patient, and he would above all do no harm. Procrustes would approach each patient the same way. Individual circumstances do not matter to him. He would make the patient fit the treatment, and if it meant harm to personal, family, or professional relationships, then harm might be done. Fortunately our treatment model favors Hippocrates more than Procrustes, but not completely. It takes a very dedicated person to care for the intense needs of someone who is planning and making a gender transition. Surgeons and endocrinologists who provide definitive medical care wish to be certain they will do no harm. For this assurance, they rely a great deal on the evaluation by the patient's therapist. The therapy relationship is intimate and critical to the patient's chances for success, peace, and happiness.
The Harry Benjamin International Gender Dysphoria Association (HBIGDA), the professional organization uniting physicians, surgeons, and behavioral specialists, recognizes the responsibility such a therapist assumes. Since 1979, HBIGDA has promoted and revised Standards of Care to aid the therapist and treating physicians. These Standards are written with every intention of bringing help without harm. HBIGDA deserves much credit for their willingness to re-examine and update these Standards. Over the eighteen years since they were first formulated, a more mature understanding has developed of the diversity among transsexual persons. Alternatives to the previous stereotype now are recognized. For example: some transsexuals may decide to complete their transition without undergoing sex reassignment surgery. Many may retain what, before transition, was a heterosexual orientation, i.e. A male to female transsexual may identify as lesbian. Some may choose not to divorce, but to remain with their spouses after SRS. All these alternatives are now recognized by treating professionals, and with the current revision of the SOC in progress, we can expect they will be incorporated into the guidelines. Perfection is not easily attained. As helpful as the Standards have been, there is still room for improvement. Specifically, it seems inappropriate to continue to specify rigid, inflexible time requirements before allowing certain steps in the transition process. Did you realize, for example, the Standards state that breast augmentation should not be performed before a person has been on estrogen for two years? While it is true that hormonal breast development continues for at least that long, many persons choose to have breast augmentation done at the time of SRS. The advantages are obvious: one general anesthetic, one hospital stay, one period off work, and often a discounted surgeon's fee. Any further increase in size is unlikely to be a problem for these patients. The Standards specify a minimum of three months' therapy - or three months' crossliving - before prescribing hormones. While it is appropriate for a therapist to determine a patient's true diagnosis of transsexualism, such determination often takes less than three months. To make the patient wait further before beginning hormonal treatment is unnecessary and frustrating. The major problem with the time limitations in the current Standards is the requirement for a full twelve months' crossliving prior to SRS. I contend that twelve months is arbitrary - dare I say Procrustean - with the potential for doing harm, especially in professional situations. I will discuss this further in my conclusions. In response to the perceived inequities of the HBIGDA Standards of Care, alternatives have been suggested. The International Conference on Transgender Law and Employment Policy (ICTLEP) adopted "Health Law Standards of Care for Transsexualism" at its Second International Conference. These standards are available here for those interested, but I may summarize by saying that physicians providing hormonal therapy or surgical sex reassignment must require only that (1) the procedure will not aggravate a patient's health condition; and (2) the patient must execute an informed consent and waiver of liability. This removes the therapist from the decision making process. How should the "patient's health condition" be defined? Should it be limited to physical conditions which would complicate hormonal or surgical treatment? Any competent physician evaluates physical conditions in the course of an examination, before informed consent is obtained. I think we should be more concerned with "health conditions" which complicate the decision on the part of the patient to seek such procedures. Often cited as so-called "imitator syndromes" are such disorders as schizophrenia, bipolar disorder, multiple personality disorder, and borderline personality. The concern with these syndromes is not to prevent someone with these diagnoses from making a transition. Indeed, such persons may concomitantly be transsexual. However, other persons may receive appropriate medical or psychotherapeutic treatment for one of these conditions, and may no longer desire to transition. Such persons would be treated improperly if the ICTLEP standards were followed to the letter. Or perhaps a person may express a desire for sex reassignment, but after closer analysis - and therapy - they may find they are more comfortable defining themselves as a nontranssexual transgendered person, or as a gay male or a lesbian. If we interpret the ICTLEP standards loosely, to include all the above as "health conditions" which may be aggravated by therapy or surgery, then these standards should provide a margin of safety for patients and doctors alike. But how does an internist or a surgeon make a decision that their treatment "will not aggravate a patient's health condition" if that condition is best investigated by a behavioral scientist? On the other hand, if the standards are interpreted as concerning only physical "health conditions", then they may be read as essentially allowing surgery on demand. The risks of this approach - to a person who later feels transition was a mistake - can be catastrophic. We in the "community" are deceiving ourselves if we believe such persons do not exist. From a medicolegal point of view, if I perform a procedure on someone who is incapable of giving informed consent, then any document of consent I have obtained is worthless in court. A surgeon who performs SRS on such a patient will be at great liability risk. Persons with "imitator syndromes" or who later identify as nontranssexual could argue they were incapable of giving consent since they did not have the benefit of appropriate counseling. It is, of course, possible to create a model for transition which allows for an evaluation to ascertain that transition is appropriate for an individual, then gives that individual a great deal of autonomy to proceed according to her/his wishes. One such model which I have examined is Extended Informed Consent, a document prepared by TransEqual of Ontario, Canada. After a thorough, excellent introduction, the conclusions of this document are as follows: Patients requesting sex-change surgery should undergo a psychiatric examination, limited to the determination that the patient is not under the influence of any "imitator syndrome", is dealing in objective realities, and is capable of fully appreciating the gravity of their requests. This examination should be extensive enough to provide a competent peer review to the referring medical practicioner, but not so time consuming or exhaustive as to be oppressive to the patient. An evaluation of the person's capacity to choose wisely for herself will involve collaboration between the "patient" and her therapist. This collaboration could involve anything from one interview session to an extended series of visits, depending on the maturity and rationality of the "patient". Once it is agreed that such a person is able to make wise choices and accept the consequences of those choices, then there should be no further right to demand "waiting" before any medical or surgical procedures may be scheduled. My proposal places great responsibility on the transsexual person herself and on her therapist. I contend: this is as it should be. Already we rely on our therapist to guide our major, life altering decisions. Isn't an expert, empathetic therapist still indispensible to help us with the adjustments we must face in transition?
I myself am an argument - and I know others - for flexibility in the time limitations for SRS. When I transitioned I was compelled to leave my medical practice in Mississippi. After completing the legal aspects of my name change, I began seeking another practice. I worked at "locum tenens" positions while conducting my job search. After considering numerous offers, I found an excellent opportunity in another state. However, the date they wanted me to begin was only eleven months after I began crossliving. I could not postpone the date, and I could not request several weeks' medical leave after I had been in practice a brief time. My therapists, both primary and second opinion, were in agreement, and approved me for SRS after ten months of crossliving. This breaking of the rigid requirement has allowed me to continue my medical practice and have a wonderful life post transition. Studies are needed comparing persons who have SRS after less than a year with those who waited a year or more: how have they adjusted? Are there problems unique to early surgery, or are these people just as successful as others? Unless it can be shown that early SRS adversely affects our future lives - and I don't believe that will ever be shown - then the Standards should allow for flexibility and individualization. Then we will truly "do no harm". |
