STANDARDS OF CARE AND HORMONE THERAPY FOR TRANSSEXUALS:
ISSUES AND CONSIDERATIONS
By: Tomye Kelley, M.D. Copyright 1987
The Standards of Care state that one must be in psychotherapy 90 days prior to hormones. That's all the document says about the qualification for hormones. Not infrequently the client thinks that this means "attending" therapy sessions for about thirteen weeks and stopping by to pick up a letter from the endocrinologist. In this paper I want to look at just what needs to happen during those first 90 days, or whatever time it may take. Remember, the Standards of Care is bare-bones guide, a minimum standard that should not be undercut. It is not a schedule that says, in this tie what needs to be done, can be done.
There are several things that must be explored and resolution begun before any consideration of hormones. This is not a situation of entitlement, nor is it a situation of self diagnosis and self determination. Hormones are not a benign medication; this medication carries all sorts of possible complications, beginning with the very real possibility of creating a "pseudo transsexual" by hormonally feminizing a genetic male who may only be cycling up or over-reacting to a temporary situation in his life.
EVALUATION AND DIAGNOSIS
This is a process that cannot be rushed, as in-depth case history is essential. Observation of the client over time is an aid to this procedure. It is not enough for a sincere and well-meaning client to come into the office and emotionally insist that he has felt like a woman all his life, or that he is not a "transsexual" but a "woman". The client is paying the clinician to be stronger and more objective than he can be himself. The client is paying for the therapist to spend her time and energy in studying and researching this subject, in fact, to have more information and awareness than he can have. It is though this information and objectivity that evaluation must come.
The client needs to explore in depth his experience in relationships, especially love relationships. He needs to be freshly aware of the attitudes and expectations that he took into those relationships and how well those attitudes and expectations worked. He needs to look at what he got from the relationship and how he will deal with the changes that hormone therapy will bring about.
If he is in a marital relationship, that must be resolved before hormones. The marriage contract implies sexual activity. Taking estrogen will interfere with such activity, if not make it entirely impossible. It is unethical to provide an extraneous medication that is deliberately calculated to interfere with one's ability to fulfill the implied contract. Simply for a spouse to come into the office and state that it is alright with her for her husband to take estrogen is not enough. It is the responsibility of the therapist to see some reasonable resolution between the primary client and the relationship partner before hormones are administered. If the therapist cannot see resolution in which she feels comfortable, it is inappropriate to prescribe hormones.
If the primary client is not ready to resolve the relationship, then he is not ready to make the ultimate sacrifices for his "womanhood". This gives the therapeutic relationship a luxury of time in which the client and the therapist can further explore other explanations for his feelings of gender conflict. Such an event should not be viewed as a failure or a difficulty. It is an advantage and may be the most important element of recovery or discovery for the client. (After all, the therapeutic goal should be finding out what is necessary for the client.)
The therapeutic process needs to focus on the client's attitude toward his genitals. Both the therapist and the client must keep in mind that the medication under consideration is (possibly) going to render his genitals flaccid and non-functional. Even masturbation may become difficult or nearly impossible. What has the attitude toward the genitals been over time? What are the ways in which this attitude has been demonstrated? What time period are we talking about?
During the first 90 days the therapist needs to listen closely for self-reports of cyclical feelings in the compulsive behaviors and feelings. It is the intensity of the feelings and thought processes on which these observations need to focus, and not the frequency. In exploring the episodes from the past when the client sought, or considered seeking, help with the dressing or gender problem, when suicide was attempted or seriously considered, a cyclic pattern of thoughts and feelings emerge.
When the client can be made aware of such a pattern in his own self-report and encouraged to examine this pattern in order to more clearly chart its course, he may well be able to see that what has occurred in the past may very well reoccur in his life although at the moment that feels quite improbable. A full familiarity with the nature of cycling is essential prior to any consideration of hormones.
EFFECTS OF HORMONE THERAPY
I have interviewed dozens of patients who were in the hospital for sex-reassignment surgery only to find they have no idea of the effects of that hormone therapy was having or going to have upon their bodies. It boggles the mind to think of a medical profession that proclaims itself to be the caretakers and protectors of our physical welfare, being content to administer a powerful chemical without full disclosure and full understanding on the part of the patient. Perhaps a part of the explanation for such an occurrence is that the medical profession is reluctant to accept the patient as a partner in their own health care. If such a change in attitude is to occur, it is the responsibility of the patient to cause it to occur. As we hear in the woman's movement so frequently, power is never relinquished willingly; it must be wrestled free if it is to be free.
In all events, the client can and must be a partner in the critical decision of whether or not hormone therapy is to occur. An intelligent decision can be arrived at only when the client has full knowledge of what he can and cannot expect from the medication on all three levels: physical, psychological, and emotional. He must know the risks and the early warning signs of these risks. He must have an accurate expectation of all the various kinds of changes he can expect to happen. Equally as important, he needs to know what will not be affected by hormone therapy.
The client must know the complicated monitoring process that is essential to his future health. The frequency of these tests must be clearly understood; monitoring too frequently causes undue expense and inconvenience for the client. Monitoring that does not occur with sufficient frequency and thoroughness takes unnecessary risks with the client's health.
Abuse of the medication can result in excessive atrophy of the genital tissue, resulting in insufficient tissue from which to construct female genitalia. Continued or extreme abuse of hormone therapy can cause a break in the client's health and in some cases has resulted in death. Abuse of hormones coupled with substance abuse (such as alcohol) can surely lead to death. Hormones are not a benign or recreational medication, and their misuse without proper supervision can have critical results.
Before anyone goes on extraneous hormone therapy they need to have a clear understanding of the anticipated effects as well as the time frame in which they can expect these effects to take place. It is improper for the physician to administer hormone therapy with no plans to deal with the problems that such medication will surely cause. Physical changes will take place. Psychological effects will occur. Some emotional changes may be evident. All these frequently observed changes should be made known to the client and the most frequent time frame should also be made known. It becomes the client's responsibility to explore possible resolutions for these change- points before they cause a problem.
Clients are often wrapped up in themselves and focusing almost entirely on self and self-needs. The outside world has been seen as so controlling and demanding, without concern for the client's needs and feelings, that now he is saying, "It's my time!" In this light, clients may view their taking or not taking hormones as being their business and theirs alone. Seldom can any of us live (for very long) in a vacuum. Family or professional emergencies or celebrations do occur, and it has become essential that the client make an appearance. If the client has decided to make his changes in hiding, his appearance at this point in an androgynous state or (more confusingly) as a partially womanly person can produce extreme discomfort for himself and for others. The point at which secrecy can no longer be tolerated is certainly at the point of starting hormone therapy. Thus a clear understanding of the time frame for changes and the beginning of resolution with the family are essential.
For the business place, the client must again be aware of the time frame for physical, psychological, and perhaps emotional changes. He should be considering what his options are. It very well may be necessary that he develop some new options. The time for such development is BEFORE the need arises.
As a matter of fact, given the progression of the effects of hormone therapy, the client needs about three steps in his plan. These steps should be based on three levels of development and change. Until and unless the client is willing to do effective work in this area, it is not appropriate that hormone therapy be administered. It further might be mentioned that a pre-transitional client who is not employed, who has not resolved the issue of supporting one's self and establishing a plan for the future, is not an appropriate candidate for hormone therapy. The reasons for this position are self-evident.
To many this seems an unnecessary consideration. In fact, it may be. However, I require that it be covered. This is a paradoxical item, also. First, hormone therapy is not a recreational medication. It is not appropriate that it be used to produce a she-male body for sexual satisfaction or personal titillation. Hormone therapy, as stated several times, is not a benign medication. It is not appropriate that it be taken just to "see how it feels", or to "try it on for a while and see if I really want to be a woman". These are issues that need to be explored in therapy, not with chemicals.
Hormones are not a substitute for tranquilizers to be used to help a person get through his days and make it easier for him to cope with life. Nor should hormones ever be prescribed to allow the client to "keep up with the others". don't disallow this one too quickly! As needed as peer support is, and as many needs as it does fill, one of its major drawbacks is that it can generate a seductive atmosphere with a "keeping up with the other girls" feeling likely to creep in.
The Standards of Care says the client should receive 90 days minimum of ongoing psychotherapy with a single clinician before hormones. I have tried in this paper to spell out for you some of the tasks that must be completed prior to any consideration of hormone therapy, regardless of how much time it takes. Remember, the person you are taking care of is YOU! No one else can do that as well as you can.