Gender-confirming health care and mental illness

[Adrian]

Ex-transgender woman speaks out about gender reassignment surgery regret
This recent reported case is of a man who clearly had psychiatric issues but was encouraged to proceed with transition and SRS. I feel very sorry for him, and his decision to revert back to being male.
Read about it here:
https://www.theaustralian.com.au/video/id-5348771529001-6095208584001/Ex-transgender-woman-speaks-out-about-gender-reassignment-surgery-regret

Quote:

Former transgender woman Peter Benjamin has told Sky News host Andrew Bolt about how he came to regret a decision to transition from male to female, causing him to return to life as a man. Mr Benjamin lived as a woman for two years and underwent gender reassignment surgery before he determined he had made a mistake. He had spent “a lot of time as a woman” since his teens, but was suffering from anxiety and depression and drank heavily before deciding to transition. “I was cross-dressing, wearing women’s clothes going out socially,” he said. “It was after my wife died I decided I wanted to be a woman full-time.” Not long after undergoing gender reassignment surgery, Mr Benjamin still struggled to cope with his anxiety. “My anxiety was still high, I was scared to go out of the house,” he said. “I was on anti-depressants, I was still on anxiety tablets, and I was still drinking heavily. “I had to drink to get the confidence to get out of the house. “This carried on right the way through until I changed back to being Peter.”

I’m not sure how to react to the crucifix that Peter wears…but his description of how the professionals signed him off for transition is worrying.

[Martina]

Thank you Adrian. That is all very thought provoking and I would like to add to the discussion. Before doing so, I have at least four people in mind to contact to get their views on the issues you raise. They are all transgender and two are post-SRS, so I am interested in their reactions to the stones you have unturned. One is a Professor of Psychiatry whose speciality is mental illness. Only one of the four is Australian and none are members of TGR. I will let you know if any of them have anything worthy of repetition.

I do remember a media article from 2012 about a teenager who changed from boy to girl, regretted it and changed back.
Ria Cooper
The media love negative stories, so there is always a suspicion that the statistics are distorted or even subject to a generous dollop of confirmation bias.

More later.

[Deleted User]

A seriously important topic for all of us regardless of what stage we consider ourselves to be on the TG spectrum
WPATH and AUSPATH devote quite a bit of attention to the issue of mental health as part of the care guidelines for treating transgender patients.
WPATH devotes 12 pages to the matter and on page 22 defines minimum credentials for mental health professionals who work with adults presenting with gender dysphoria.

Among those points
An ability to recognise and diagnose coexisting mental health concerns and to distinguish these from gender dysphoria

Nevertheless i think there is a lack of clinicians with competent experience in treating Transgender patients and that must sometimes lead to terrible outcomes for people like Peter Benjamin mentioned in the Andrew Bolt Interview.

I must express scepticism however at the real motives of Andrew Bolt in this interview.

The number of detransitioning TG people like Peter Benjamin is relatively few but AB is using Mr Benjamins case as a an argument against current treatment programs for adolescents presenting with gender dysphoria. Im comfortable with the programs that the Royal Childrensdr Hospital have put together to handle such individuals

Suicide is always a very sad outcome to hear of in any situation and while noted as above average for those who are TG and/or have had GRS I wonder if the rate is higher say than for others who are in high stress occupations like Armed services, Police or even Veterinarians as I heard recently.

My initiating doctor for Hormone Therapy mentioned and documented the need for a review of Mental Health as number 2, after managing medication. Should she have made it No 1 ?

Dont know about that… but I do think about my situation often and discuss with my GP.. so far I have not needed to elevate any discussion about mental health

[Martina]

The first person I approached regarding this topic was an old friend who had undergone SRS and cosmetic surgery in Bangkok and has continued to lead a mostly happy and productive life, but of course never completely without any pitfalls or anxiety. I shall refer to her as Suzy (her pre-transition name). Here are her comments:

QUOTE:
There is certainly mental anguish when we are at the pre-transition stage and many have the belief that once the operation is complete and we have the physical attributes and all the documents to confirm we are female (such as a revised birth certificate), then all our problems are over. The sad thing is, transition isn’t the end of the journey – in many ways – it’s just the start.
After transition there is no going back to the safe male persona whenever we feel inadequate. That bridge is well and truly burnt and we can only now go forward into the female role.

This is where more mental anguish can develop and continue.

The answer is planning and preparation.
Mannerisms, style and most of all voice therapy must be in place before full transition. The 12 months that we are expected to live 24/7 as a female, is not so much a hoop that we have to jump through to convince the psychiatrist, but a training ground for us to hone our skills. It doesn’t matter that we’ve always felt female, but we need to unlearn all the male behaviours we had developed over the decades.
It has to be said that even with all that in place, sometimes nature deals us a poor hand. If you are overly tall with very masculine features then you won’t have such an easy ride than someone who is shorter and has naturally soft features. It’s a very unfair situation.

Now in my own position, I went post op in 2010 and would say I’ve had an easier ride than most. I’ve been fortunate in that I have had a lot of help and support by a close female friend, but I have also gone to great lengths to make sure I succeed.

Do I have mental anguish now after all these years? – To a certain degree I am always on alert. In the place where I’ve now worked for 6 years, no one has a clue to my background. I’ve told no one there of my past. I don’t think it’s because I’m ashamed, or feel I would no longer be accepted, but I feel my past was simply a private medical condition, which is now all fixed up and it’s no one’s business.
With this in mind, whenever I’m in conversation I have to be careful when I talk of my past. It could be easy to slip up in the early days, but now it’s not a problem.
Another area I’m always monitoring is my voice. Occasionally as I’m driving to work, I find myself singing through the scales, getting higher and higher, just to make sure my voice is in tune with a female.
After all these years, speaking with a female pitch comes quite naturally – so naturally in fact that sometimes I worry that I’ve dropped back into some male frequency.
So I think although I don’t suffer from mental anguish, I do have this monitoring going on in my head in the background. I don’t think it’s a big problem as after all these years I’m still pretty stable.

We do hear a lot of examples where after transition we end up with lower paid jobs, or even unemployed. I have been fortunate in that my employer at the time of my transition was very supportive.
However eventually I left that job for other reasons.
In my present employment, the position is much more senior and with far more responsibility than any job I’ve had before.
It’s ironic that now I’m a female, my salary is far higher than it ever was as a male.
UNQUOTE

In a PS Suzy added “It’s been good therapy actually going through this.”

Of course everyone is different, as are their circumstances, and it seems to me that Suzy might be the more rare example in that she seems to have discarded her past in order to lead a completely new life as a woman. I am sure that very few people would be able to do that, primarily because our lives are usually interwoven with family, friends and our local environment which, I assume, most are reluctant to give up. So the mental stresses and strains on Suzy might be rather different to those who choose a very different path.

Let me give you the example of Stephanie (not her real or adopted name). As a male, John (not real name) worked as a scientist in a research facility; I was a distant work colleague but we had no interaction as we worked in offices located in different parts of the country and our paths rarely crossed. However, one day, I learnt that John had undergone SRS and was now back at work as Stephanie. Years later, I asked one of the other male scientists, Stan, what he had thought about it at the time. (Stan does not know of the existence of Martina.) Stan replied that it had been no problem at all because John had told everyone in the facility what was about to happen before the event; his intentions were completely transparent, open and honest.

So there were no shock-horror revelations and Stephanie could perhaps be termed a “declared trans-sexual” (as opposed to those who avoid any recognition of their previous gender).

I have no idea what anguish or mental trauma Stephanie experienced during this process, but I wonder if a person (MTF or FTM) who declares their new status to all who know them may escape some of the angst that a person who is trying to hide the change may suffer. It is certainly something to consider.

Sorry if I am meandering but it is a complex subject. Now I will seek out my next victim – watch this space.

[Adrian]

Thanks for all the input on this tricky topic.

I find it disturbing that the WPATH guidelines attempt to address the challenges of co-existent mental health issues, but yet rarely, if at all, does the topic appear in the chronicles of girls transitioning. From the perspective of the doctor calling out such issues it is a no-win situation. Transitioning girls are now well versed in the available procedures through information available on the internet (as Peter Benjamin admits). The result is that they approach the medical profession with demands rather than seeking advice. If the professional were to advise caution because of some physiological or physical issue then the patient will just go and find another doctor more compliant with their perceived needs. Perhaps this explains why Peter Benjamin got such an easy green light for transition.

Looking back on my own history of dealing with gender dissonance I was surprised to find how it affected me mentally without my being aware. So I don’t think it is reasonable to expect those seeking to transition to self-diagnose any significant mental health issues. We won’t know when we need to seek out a doctor, and even if we did, we would probably suppress the information as it would likely stand in the way of us getting the hormones and surgery we seek.

I share Caroline’s scepticism about the motives behind sensational reporting of transition ‘failures’. Because we know hard right groups will pounce on any evidence that being transgender has challenges to advance their cause of labeling the whole thing an abomination. The trans-warriors on the sidelines enforce this media block-out by pouncing on anyone who reports anything other than the official transitioning nirvana. But in hiding the challenges from society at large we also hide it from those setting out on their gender journey, and from the doctors who we entrust to advise us. That said I’ll be happy to not see the individual transgender regret stories. Isolated glowing reports of life after transition, and sensationalised cases of failure, neither are a valid indication of the reality.

[Adrian]

Good peer-reviewed studies on transgender mental health are few and far between. I have a few that I’ll post on this thread to illuminate the issues we face, both in understanding the challenges, and also helping people through them.

Levels of anxiety and depression in transgender people
accessing services: A large matched control study.

This paper presented at the 2017 2nd EPATH conference: Contemporary Trans Health in Europe has an abstract on-line.

This paper looks at mental health of people seeking to transition. It is a BEFORE study so tells us nothing about what happened AFTER.

Quote:

Background
Anxiety and depression are serious disorders which significantly impact upon a person’s wellbeing and quality of life. The transgender population is reported to be at an increased risk for such disorders, with symptoms often associated with other difficulties such as discrimination in employment, abuse and harassment, and lack of gender confirming treatment. While studies that have sought to investigate the prevalence of these disorders in the transgender population have offered valuable insight, the data are often limited by small sample sizes, the lack of control for known factors that affect symptomology (age and gender), and the selection of non-homogenous groups of transgender people; that is, those at varying points in their treatment.

The study looked at 913 people attending a UK gender clinic. It only looked for evidence depression and anxiety. These were matched with individuals from the general population by age and experienced gender. Analysis revealed that transgender individuals were significantly more likely to have anxiety disorder and/or depressive disorder compared to cisgender individuals.

In the group low self-esteem and interpersonal function significantly predicted both anxiety
and depressive symptoms, while less social support also predicted the latter. The study also (rather unsurprisingly) found that the use of cross-sex hormones was associated with lower levels of anxiety and depressive symptoms in transgender individuals.

The study concluded:

Quote:

Conclusion
This large scale, matched control study confirms that non-treated transgender individuals are at an increased risk of disorders that impact upon their wellbeing. This risk is predicted by other factors indicative of reduced quality of life, such as low self-esteem, poor interpersonal skills and lack of social support. Interventions aimed at developing interpersonal skills, increasing self-esteem and improving social support may prepare the individual for a more successful transition.

[Deleted User]

Such an interesting topic..

Most of us have been very adept at concealing our “other identity” from our Partners with varying degrees of success . In my own case , the success lasted about 20 years before I was caught out and had to explain everything. Fortunately all good now as some of you know

Those 20 years or so took an enormous amount of energy. as Dr Phil said in a program with a transgender person .. he said to the SO “Do you realise how much energy is burned keeping something like this concealed”.
That statement caused me to have a a bit of a meltdown at the time when I realised how true it was in my case.
The act of concealment is not good for anyone and I think that was the reason I was at times tense and anxious with my partner when I had no idea how to deal with this “identity crisis’. I hadnt heard of the term transgender but was aware of persons calling themselves Transexual. I had no idea how to handle my thoughts and never ventured towards a Psychiatrist for any help. I was far to shy and scared to think about doing anything like that.

So that indeed was a mental health issue for me at the time but Id feel more comfortable these days seeking help than 20 years or so ago. times have changed and Clinicians are a bit more aware of us .

Adrian raises the valid point that we are pretty good at presenting ourselves to professionals
in a way to achieve our objectives whether that be CGHT or GRS.
Clinicians are people just like us and they can be persuaded to act in the way we might wish.

The whole problem with Clinicians exercising duty of care and identifying mental disorders that should preclude medications or surgery for some is that we are generally so damned good at presenting with all the right answers.

[Martina]

Perhaps a consultation with a psychiatrist who is also transgender might provide a more empathic reception. I wonder.

I actually have a French friend who fits that bill and have been passing on parts of our discussion here. Her first response (in fractured English) is as follows:

“I read your email at the middle of night, I was still working finishing to
write a chapter on Emotions and cognitions in bipolar disorder.
First of all I agree with the document there are more psychiatric
illnesses in “transgenders, transvestites ” mainly bipolars.
On the other hand I was as psychiatrist in GRS several time but never in
my patients they wanted to go back as they were previously.
I took a lot of time to help their decision, most of them do not have GRS
but only feminine hormones and anti androgens, and ask to change identity.
It is very often the right solution.”

(I have made some minor amendments to correct the spelling.)

[Deleted User]

http://lgbtqpn.ca/wp-content/uploads/woocommerce_uploads/2014/08/Guidelines-mentalhealth.pdf

This is an excellent document even though its 13 years old

[Martina]

Caroline, I tried to access your link three times but each time got a warning saying “This website has been reported as unsafe”.

[Deleted User]

Martina
I’ve not had any problem either on PC or phone
I’ll see if I can send to you as a pdf file later

[Deleted User]

Adrian

Can you check if you get same response as Martina?

[Adrian]

No problems for me loading under Windows or Android and NBN.
I guess I’m running with running with my shields down – all this paranoia about websites is enough to give one a psychiatric condition…