The Needs of Transsexuals.
Of the LGBT (Lesbian, Gay, Bisexual and Transgender) Community, the needs of transsexuals are by far the greatest. Let me elaborate on that.
Firstly, Gender Dysphoria/ Transsexualism. What is it?
Transsexualism is a complex condition that can be difficult to understand. It helps to distinguish between the meanings of a number of different gender-related terms:
1. Gender Dysphoria is a condition that describes the feeling of a mismatch between biological sex and the gender you feel yourself to be.
2. Gender Identity is the gender that you feel you should be.
3. A Transsexual is someone with a strong and long-lasting feeling of Gender Dysphoria. The majority of Transsexuals seek to alter their bodies (sexual appearance) to more closely match their gender identity with hormones and Surgery. Transsexualism is the most extreme form of Gender Dysphoria.
The key features are:
1. A strong and persistent cross-gender identification.
2. Persistent discomfort with the assigned natal sex and its associated gender role.
3. Absence of any intersex condition.
4. Clinically significant distress or impairment of social or occupational functioning.
Transgender/ Transsexual: In the LGBT, transgender is the term that they use. This is an umbrella term covering the full spectrum, including transvestites, cross dressers, gender queers, drag queens, Transsexuals, etc. Unfortunately this leads many people to believe that we are all the same, which of course we are not.
Transsexualism is a birth defect that is caused at foetal stage in the womb. It can be looked on as a disability that cannot be seen. The others can be a choice of lifestyle and for sexual gratification; they would not want to change their sex. Transsexuals should not be confused with the Transgendered.
My Biography: My name is Michelle Dibble. I was born on 22 June 1942, in Hayes, Middlesex, grew up in Chelsea, moved back to Hillingdon in 1978. I started transitioning 24 March 2004 and received my Gender Recognition Certificate, December 2006 and Birth Certificate January 2007.
A good part of my working life has been in Pest Control in Senior Management until I started my own Pest Control Company in 2003. I retired May 2005.
Helping Others: My personal experience has been as a M-F Transsexual. But after starting my transitioning, I quickly realised that there was a real lack of help out there and what there was, was hard to access. I studied and learnt as much as I could, initially to make my journey easier and more focused, but extended that learning and have put it to good use so that I can help other M-F and F-M Transsexuals.
Between April 2006 and September 2009, I studied and became a Stress Counsellor to help others face up to the condition and the resultant stress and depression. Often just talking to someone who shares and understands their condition helps.
Transsexualism is a fairly rare condition. Statistics:
• It is estimated that there are about 5000- 6000 Transsexuals in the UK, less than 0.00009% of the population (2011 census of 63.2 Millions). Based on those statistics there are about 30 Transsexuals in the London Borough Hillingdon. As a comparison, Government figures put the number of Gays and Lesbians as nearly 4 million, about 6%.
• Since the start of the Gender Recognition Act 2004, in April 2005, there have only been about 4000+ full Gender Recognition Certificates issued. Between July 2009 and June 2011, 484 full GRC’s were issued. Of these 362 were M-F and 122 F-M. Only about 4000 GRC’s issued in eleven years? This probably reflects the very low numbers of Transsexuals in the UK.
• Many GP’s will never see a Transsexual in their surgery.
• Only about 25% of Transsexuals are female to male.
• Both suicides and attempted suicides are common in transsexuals. Studies generally report a pre-transition rate of about 25%, with
M-F’s relatively more likely to attempt suicide. Transsexual people are far less likely to attempt suicide once they have completed the transition to the other sex. Not many years ago, the figure was nearer to 50%, especially when Psychiatrists were trying to ‘cure’ the condition with nil success, using their cruel, barbaric method of electro shock aversion therapy. Transsexual people are thought to have, generally the highest ‘Attempted Suicide’ incidences among sexual minority groups.
What health concerns do Transsexuals have?
Transsexual people face a unique set of emotional health issues. Living in a body that feels foreign, and being perceived widely as a gender that feels wrong and unnatural is enormously challenging; that awful feeling of being trapped in the wrong body.
Initially, you may not be in the best of health. You will be depressed, your life style, most likely, will not have been ideal; poor diet, lack of exercise, obesity, smoking, drinking perhaps even drugs.
In addition, the process of transitioning to the other sex brings up a myriad of specific challenges, some anticipated and others harder to predict or deal with.
Transsexualism is a very lonely condition; it is not visible so others do not recognise that there is anything wrong with you and are unlikely to be sympathetic; if you can’t see it doesn’t exist.
Transsexualism must eventually be faced. You can fight it for many years but the effects will get stronger, affecting you physically and mentally and if not faced, can eventually destroy you. The good news is that all this, in most cases, is reversible and when you eventually accept and face your transsexualism, your future outlook can be so happy and fulfilling.
Transsexuals will take cross-sex hormones throughout their lives and most will undergo high risk and intrusive surgeries to change their bodies. Both the hormones and the surgeries can have specific health effects that need to be acknowledged and monitored to maintain the good health of the Transsexual. This is why the support of your GP is so important.
You can greatly reduce that risk by not smoking, drinking and eating more healthily and taking up gentle exercise; walking, swimming and cycling.
It is claimed that hormones increase the risk of DVT and breast cancer. Yes, certainly the earlier female hormones in use, Ethinyl Oestrodiol and Premarin did increase the risk of DVT but the Bio-identical, such as 17β-Estradiol used pose a very low risk. ‘Professor Louis Gooren of Amsterdam did a survey of over 3000 transsexuals using bio-identical female hormones against a similar cross section of males not on any medication and the results showed no significant differences. Instances of breast cancer are not known but thought to be low, probably not much higher than that of males’.
I do honestly believe that the cross sex hormones that transsexuals take are very safe, certainly safer than some medications that we can freely buy over the counter, such as Paracetomol, and much safer than smoking and drinking.
Emotional issues for transsexual people: Persons who are contemplating the process of transitioning from male-to-female or female-to-male may encounter a range of emotional reactions, both in themselves and among those around them. Some of these reactions may be anticipated and prepared for; others may be unanticipated, occasionally aggressive, sometimes dismissive and difficult to manage.
From a very early age, our culture makes large and specific sets of assumptions about individuals based on perceptions of gender. Our culture defines what is "appropriate" and "inappropriate”, setting boundaries, behaviour and activities for each gender. Transsexual individuals often experience anxiety and stress as they attempt to fit into a gender role that may match the outward appearance of their physical body but not their emotions or their more internal sense of their gender. Society dictates the differences in male and female behaviour, much of this is learnt and not instinctive. You are encouraged, to live in the sex that you appear to be and not what you feel.
• Most transsexual individuals identify a sense of great relief that comes with finally being able to acknowledge their true selves and live in the body and gender role that is most natural for them.
• Although society’s acceptance of transsexual is improving it is far from complete. There is a growing and active community of transsexual people, both M-F and F-M, in the UK, mostly in groups on the internet. However, many people with transsexualism still face prejudice and misunderstanding about their condition.
• Both suicides and attempted suicides are common in transsexual persons. Transsexual people are thought to have, generally the highest ‘Attempted Suicide’ incidences among sexual minority groups.
• Group support for Transsexuals is important before and during transitioning but post transitioning most of us do not need or want group support, we just want to live in our community, as the women (or men) which we are.
From the day you start transitioning you should start planning every stage of your development:
• Your working future, can you carry on with your present occupation or will you have to look for alternative employment? Will you have to retrain?
• Have you told all your family and friends, if not have you thought of when and how you are going to tell them? The earlier you tell them, the more time they have to get used to all the changes that are going to be happening and in particular, the big day of your surgery. Don’t expect too much and give them time. Some may never understand or accept.
• Have you told your GP? His support will be imperative and long term. If he will not support you, you should find one that will.
• What about your facial hair. A nice dress and a five a clock shadow is a definite no! no!
• Have you told work colleagues? This is another important stage of your transitioning. How will they accept you and your new self? Do you turn up as your new self or do you tell them first? Do you speak to your boss before your colleagues or the HR department?
• Many Transsexuals are out of work and finding work during transitioning can be very difficult. Have you thought about how you are going to deal with this? Voluntary work is a useful alternative.
• What about going out in public, such as going to your local shops?
• What about travelling, to and from work on public transport?
• What about Public Conveniences, do you look for unisex or disabled?
These are all things that have to be taken into account and dealt with.
Seeking help: Your GP will be very important to you during and after transitioning. He will need to refer you to your Local Health Authority, Mental Health Unit, for them to refer you onto the NHS Gender Clinic. Your GP will not be able to refer you direct, as mine found out after about a three month wait. Your GP will need to regularly monitor your health, carry out blood tests and prescribe your hormones. He will be the most important member of your medical team and support you long term.
How much hormone: This is a very contentious issue. This depends on the individual. How you feel on those levels and the results of blood tests.
The The World Professional Association for Transgender Health (WPATH), formerly known as the (Harry Benjamin International Gender Dysphoria Association1998 Edition states “the administration of hormones is not to be lightly undertaken because of their medical and social dangers.”
Three criteria exist: 1. Aged 18 years, 2. demonstrable knowledge of what hormones medically can and cannot do and 3. their, social benefits and risks.
In the private treatment of Transsexuals there needs to be a flexibility of approach rather than an adherence to rigid gender clinic policies, albeit based on the WPATH guidelines.
Standards of Care: The decision to recommend hormonal and surgical treatment is based on the conclusion reached through the diagnostic assessment that the person’s gender problems cannot be resolved with counselling or therapy and the only reasonable expectation is that the person will benefit from hormones and sexual reassignment surgery.
Care should be patient centred: The Specialist has a responsibility to ensure that the patient understands the criteria for the administration of the hormone regime, the risks, side effects and effects, long and short term before prescribing but generally the patient should normally be prescribed after three months of counselling, after the initial diagnosis. The patient should also be involved in the discussions on their regime. This does not happen. The patient’s opinion seems to be irrelevant.
The Specialist decides when, what and how much and most rely, ‘a one size fits all’. But does it? We are all different and our needs are different. Body mass, build, including height and weight and receptiveness to the hormones. There has been no research on cross sex hormones, so there is no one body that can really give any advice. Specialists therefore tend to err on the safe side and not for our benefit.
Given the chance feminisation closely follows the female puberty and will last at least as long. Most clinics reduce your hormones after about two years or post op. to a maintenance dose; feminisation will cease and be incomplete. Why would our feminisation be that much shorter than the female puberty? This makes no sense whatsoever.
The hormone regime should be adequate, well balanced, consisting of an anti-androgen, Oestrogen and Progesterone and long term. Once post op. the hormones, certainly Oestrogen and progesterone should be maintained at the same level for at least for an equal time to the female puberty. Why would you need to change? The hormones that you have been taking would have already chemically castrated you so the surgery would make little difference.
Some also say that it is age related, the older the less effect the hormones have. However, taking control of my own hormone regime, I have shown by my own Transitioning, that this is not necessarily true. My development has been very effective. More likely is that the clinics prescribe insufficient levels of hormones to the older patients, being over cautious; no wonder the hormones have less effect. 100mcg patches, twice a week, that they regularly prescribe is woefully inadequate. I believe that we need a similar level to other Transsexuals, irrespective of age.
Do we, or don’t we self-medicate? This is a decision that the individual must make for him/ herself. I would not advise for or against. It worked well for me but I self-medicated after much research; I knew what I wanted. It is not a decision to be taken lightly. Self medicating can be safe but it is important to choose your regime carefully, ensure that the Pharmacy you use is reliable and only supplies hormones of the best quality. Most medicines will be generic copies, probably manufactured in India. If you do decide to, then I would strongly advise that you see your GP, to monitor your health and blood levels, as soon as possible.
Average Timescale to SRS through the NHS: I won’t give a full break down, but if all goes smoothly, it could be five years. If as in my case the GP is unaware of the referral procedure, it would take longer. By self-medicating you could reduce that, five years by quite a few months, possibly more than a year. How often do things go smoothly with the NHS.
My concern is that now with the funding cuts, money will become tighter for the support of Transsexuals, being given lower priority and that things will get worse rather than improving. Even five years could just become a dream. The PCT’s need to understand, that this is a serious condition that must be dealt and not a choice of life style.
The private route can be much quicker, as soon as 2 years or less; I did it in 21 Months. However this will be very expensive and out of the reach of many Transsexuals.
Transsexuals needs: When we reach the stage where we really need and ask for help, we need that help quickly, not in three, six even as long as 18 months. Usually our depression has reached a stage where we are physically and mentally suffering, many of us feel suicidal.
I know that I certainly did; this showed itself in my comfort eating and drinking, suffering health. I became clinically obese and was becoming a candidate for a heart attack; I couldn’t even climb a flight of stairs without becoming breathless and my heart pounding. It was becoming a case of do or die. In my case self prescribing helped and gave me the breathing space to take stock and plan my way forward. Positive action is a powerful tool.
The hormones would never have been enough on their own, only progressing to the reassignment surgery would. But for me was a good start.
We do need help and support, but unfortunately, I found that there was very little help and support available and few understand our problems or the condition at this very difficult time of our lives. Those that are not Transsexual cannot possibly understand what it is like to be a Transsexual and how hard life is, even just managing on a day to day basis. It is constantly with us; we may push it into the background but cannot forget it, it is always there and eventually must be faced, because as time goes on it gets stronger and stronger.
We have quite a few gender clinics throughout the Country and in London, both private and NHS. Unfortunately, many of these are not as supportive or patient friendly as they could or should be.
While we wait for that first appointment with the Gender Clinic, we need help with that stress and depression. We don’t want to be given anti-depressants; that is only masking and not dealing with the problem, we want proper support. This is where the mental health unit fails us.
Regular Counselling, during that wait, should be a priority and three months after that initial diagnosis and Counselling and if appropriate, consider asking the Patients GP to prescribe cross sex hormones. This would certainly be within WPATH International (World Professional Association for Transgendered Health) and NHS Guide Lines.
Most gender clinics have preconceived ideas and expectations of what they want of you, including your Real Life Experience; either intentionally or unintentionally, setting targets, but no real help on how to achieve those targets. You are very much on your own. I hope that in part, I can help to readdress this. We are all different, so what was right for me may not be right for others. Help must be tailored to suit the individual.
In Conclusion: I am probably at odds with most Gender Clinics and Practitioners, especially over the use of hormones, and in particular, the use of Progesterone, but the advantage that I have is that I speak from experience and of actually listening to other Transsexuals and their experiences. I know what benefits that I have gained from my regime.
You must make your own judgement as to who is right. It is time that these Clinics treated us as intelligent adults who can make their own calculated decisions and take responsibility for those decisions. It is our lives and you the professionals, have a responsibility to listen and help. We don’t want others deciding for us and dictating to us. Talk to us, listen to what we have to say, you might just be surprised at what we do know. Even Private clinics, where you pay a fortune for the service, in general you are allowed little input and your opinion is ignored. How dare you?
Of the LGBT Community, the needs of transsexuals are by far the greatest. The LGB have to learn how to adapt to their life style and live in the general community, in relationships of their choosing.
Transsexuals have to unlearn how they have had to live all their lives and learn to live in a totally new role, at the same time change their whole bodies, physically, mentally, morally and emotionally by intrusive surgeries and high doses of cross sex hormones. Can you imagine the enormity of this?
What Transsexuals do have in common with Lesbians, Gays and Bisexuals, is that none of us have a choice.
There is a responsibility on the NHS and the medical profession to provide proper and decent care, this rarely happens at the moment. Is it really asking too much?
