One Size Fits All…

“One Size Fits All”… and other lies… Or  “Why it matters”

Beyond mere scientific curiosity, there are other compelling reasons why we need to recognize the two types of transsexuals as distinct and having separate etiologies and life arcs.  Research on appropriate treatment protocols is confounded when we don’t segregate them.  Treatment itself is less effective and potentially counter productive when using the wrong protocol, or when using a ‘one-size-fits-all’, middle of the road protocol.  Finally, we dishonor who we truly are when we don’t recognize the differences.

Consider that our present protocols for treating gender dysphoric teenagers is a muddled attempt to reconcile the experiences of autogynephilic (AGP) MTF adults and young HSTS, both FtM and the minority MTF feminine androphilic.  If MTF “late transitioners” did not exist at all, would we be as concerned about attempting to delay puberty as a reversible treatment, given that transkid teenagers rarely have regrets or negative outcomes when given full HRT instead?  But we do have AGP teens for whom transition and HRT are not warranted, who go on to live very satisfactory lives as heterosexual cross-dressers.  If we fully recognized and diagnosed the two populations separately as teens and young adults, we would have very different treatment protocols.  We could access AGP teens as to the level of gender dysphoria distress and stability and provide puberty blockers for them, will allowing HSTS to proceed to HRT.

Consider also, that our present protocols for adults have a requirement that a candidate for sex reassignment surgery have been living full time as their new sex before surgery, as though that fact somehow guaranteed that post-operative regret would not occur… or that surgery is simply providing genitals that match the social gender in which the client is living.  Neither is the case!  Sex reassignment surgery may, in fact I would strongly argue, is not contra-indicated by still living as one’s birth gender.  If we didn’t have the example of transkids for whom living in their new gender and sex reassignment surgery are intimately linked, would we have this requirement?

It’s possible that without the existence and example of feminine androphilic MTF HSTS, whom many AGP transwomen attempt to emulate closely, Western Society might not have developed and accepted the medical category “transsexual”.  But now that we have decades of data that show that AGP transwomen are the majority, and that that majority does find improvement (at least palliatively in most cases), should we not review the assumptions that were made in the early years that only “true” transsexuals, those who needed to both live full time and rid themselves of their unused genitalia, are the only ones who would benefit from HRT and sex reassignment surgery?

Might the original purpose of the “real life test” have been not simply to reduce post-operative regret, but was (wrongly it turned out) a means of weeding out “transvestites” (autogynephiles) who were thought to not be able to pass such tests?

I would argue strongly that there is absolutely no association with living full time and lack of post-op regret.  Further, I would argue that for many AGP individuals, the “real life test” requirement is needlessly socially and professionally destructive.  How many AGP individuals would have benefited from HRT and/or sex reassignment surgery to rid themselves of the anatomic-autogynephilically induced gender dysphoria without having needed to live as women full time?  How many of them would have found a life of integration far better?  A life of the “bi-gender” individual, one who is professionally and socially a man during the weekday, but socially and sexually a woman during the evenings and weekends?  Our present protocols discount these people.  They must make a choice between no surgery, or up-ending their professional and social lives.  How many individuals have been falsely declared to have been treatment failures because after SRS, they “de-transitioned”, having obtained their true objective and now free to live their lives without the so called “Standards of Care” dictating their lives?

In therapy, the two types have very different needs.  First, most HSTS do not need therapy.  But our Standards of Care (at least as practiced, if not as written) require that one have been evaluated by a therapist or psychiatrist before any medical interventions.  Why should a feminine androphilic HSTS be treated differently than any other young woman?  Why should she need to get “permission” before having breast implants and not a natal female?  Could it be because she is conflated with autogynephiles for whom many practitioners are concerned may regret such interventions?  What of FtMs?  Many natal females have breast reduction surgery, but aren’t required to obtain letters from therapists before hand.  I argue that our protocols for transgendered people have been developed with experience of autogynephilic MTFs, for whom such evaluations and therapies are recommended.

Autogynephiles suffer from severe shame and guilt.  Many cross-dressers report a cycle of purging, throwing away their feminine wardrobes in self-loathing.  Many autogynephilic transwomen have had similar histories, but rarely discuss this or other autogynephilic experiences with their therapists, rightly or wrongly, assuming that the therapist is wearing their “gate-keeper” hat and might not “OK” them for HRT or SRS if that were known.  Because both the AGP transsexual community and their therapists fail to face head on the issue of autogynephilia, this shame and guilt remains untreated.  Instead, the client is left with secret denial or other defenses.  Because she has not faced her own autogynephilia, she may stigmatize others who are processing their autogynephilic experiences, shutting down group therapy discussions on the matter and even attacking other transwomen in public forums, harming the transgendered community at large.  Worse, for the individual, is that the shame, guilt, and denial are lurking in her psyche, waiting for some dark moment to come crashing to the fore, when her defenses fail, and the reality of her autogynephilic sexuality come crashing upon her.  The result may be catastrophic, perhaps even fatal.

The suicide rate among transgendered people is well known to be high.  Medical intervention is intended to alleviate suffering; but because the two types are not fully differentiated and because autogynephilia is not openly acknowledged, AGP transsexuals remain at risk for mental heath problems, especially depression and anxiety.

The two types should never be grouped together for therapy.  The two types have completely different goals and concerns.  Further, there is a very unfortunate tendency for AGP transwomen to attempt to model themselves upon transkids, to the point where they edit and even confabulate histories to match those of HSTS, interfering with the therapeutic process. Worse, this process of editing and confabulation puts pressure on their families, in effect gas lighting wives and mothers, who are required to acquiesce and either accept the false history or end their relationships.  Conversely, HSTS are very often uncomfortable around autogynephiles, leading them to emotionally, and even physically, to withdraw from the group.  Comparing themselves and their experiences to the other type is also very damaging to their self-images, for differing reasons for each type.

Would HRT protocols be different if the types were not conflated?  Consider MPA, a synthetic progestin.  It is well known to sharply reduce libido.  Many AGP transwomen find their autogynephilic arousal intrusive and unwelcome.  For them, MPA may be a welcome addition to estradiol… or even alone.  But for feminine androphilic MTF HSTS transkids, reduction in libido is never desired.  For them, micronized progesterone is a better addition to estradiol.

Would protocols be different for the two regarding fertility?  Many AGP transwomen are already natural parents, having sired children with their wives or girlfriends.  But what of the young AGP transwomen who have not yet sired children?  Would they not benefit from banking their sperm before beginning HRT?  Would the same be right for MTF HSTS transkids?  I would argue not.  First, it would mean that they would have to wait for spermatogenesis, which would also mean damaging exposure to endogenous testosterone.  Better to begin HRT without ever being able to generate sperm.  Further, for the slightly older (post-pubertal) transitioning HSTS transkid, consider the psychological implications for her future husband… surely if they elect to pursue surrogacy, it should be his sperm, not hers?

For these, and yet other practical reasons, it matters that the two types be officially, scientifically, medically, and socially recognized as distinct.

Further Reading:

Essay on the need for segregated group therapy.