The most common person who comes to see me is someone who says, I don't know if I'm a TV (transvestite) or a TS (Transsexual). "I thought I was a TV and now I'm wondering." That's very typical . There are a lot of other people who come to see me too, but for this audience I am gearing it toward gender issues.
Crossdressers who are not uncomfortable with crossdressing generally don't come to see me. I think a lot of people like that are members of ETVC. I'm talking primarily about people who do come to therapy.
Many people who are seeing me feel confused. One day they think they're one way and one day another, and it's shifting and fluid and there are a lot of variables and a lot of things happening in your life that can change what direction you want to go. That's why it is usually a developing diagnosis.
That's not always the case. I do see people who know for sure they're crossdressers who are not leaning toward transsexualism and people who know they're transsexual and have never had any crossdressing associated with sexual arousal, or any crossdressing that is a response to any kind of trigger, the way TV's do. In terms of complexity, the most complicated situation is when you don't know, and that usually takes the longest, and is very common.
Why is this so complicated?
Sexual identity is broken down into biologic sex, sexual orientation, gender identity, and gender or sex roles. We know almost nothing about any of those four.
We know very little about etiology, about how they develop, and in this community we see fluidity and change in all these areas. So you can see how, in each person sometimes, you can have one gender identity or two gender identities, one gender role or two gender roles.
Sexual orientation can be towards men, it can be towards women, and it can be towards your image of yourself as a woman. And it can be changing. So it's complicated. How do you get static, so you can settle down, so you know who you are and what you want?
There's a lot of controversy, too, as to how crossgender identity develops. Is it nature; is it nurture? Again, nobody knows. So we just have to start with you, and what you want and what direction you want to go, because I don't have the answers. Nobody does.
What classifications do we have within transsexualism? There are in my practice over the years essentially three types, and if you look in the one author, and primary and secondary by another author, but they are talking about two different phenomena, so you still get confused.
So I am going to describe the three types and see if anything rings a bell. Some of you may exhibit characteristics of more than one type, so if you're confused about yourself, that's also common.
One type is early onset crossgender identity. The person is pretty much asexual. There is almost no sexual arousal associated with crossdressing. The person is usually a loner as a child, somewhat inhibited, may have tried marriage and family. Their presentation in the male gender role is not particularly effeminate. They are quiet people, and their sexual orientation seems to be changing, but really they are pretty much asexual . A lot of their psyche is taken up by crossgender identity.
So these people have one gender identity, and that is female. Two gender roles, though, with the male presentation seeming like a guy, and the female presentation seeming the same, like the same person, but also seeming like a woman too, someone who is sort of androgynous, but not in the Michael Jackson sense--someone who is undifferentiated. Their sexual orientation can change as they shift roles, as they start living in the female gender role.
Another type is someone who appears in the male gender as an extremely effeminate homosexual.
They are the sissy boys, who have always had a crossgender identity at the extreme end of effeminate homosexuality. They seem like girls, and they are very talkative and uninhibited and talk about sex all the time. They have always been interested in men; there is never a change in their sexual orientation.
The third type is a person who starts out as a transvestite. The [Image] crossgender identity is a late onset one. The person for many, many years has assumed he was a garden variety crossdresser, whose crossdressing was associated with sexuality, sometimes tranquillity, but there were triggers to it. Maybe he didn't know what the pattern was, but when he undergoes therapy he realizes there were triggers to the crossdressing.
What happens as he gets older is that the female gender identity, which used to be a subordinate part, starts taking over, and he becomes she. There were two gender identities that were quite split, with sexual orientation usually toward women. As the female identity takes over, whereas he originally thought he would be a lesbian, she goes into the female gender role, and often, with time, she becomes interested in men, but never has been before. This is the late onset. A lot of these people are at ETVC.
In terms of outcome with these three, I can't tell any difference. All three types do just as well following sex reassignment surgery. At least that is what I've seen in my clinical practice, but many researchers disagree. Many refuse to authorize surgery for secondary transsexuals because they fear that the chances of making a mistake are too great.
Then there's the person who comes in and says they're transsexual and they're not, or I don't think they are, and what I have to do with that group is set up a therapeutic alliance with them, otherwise they will just leave therapy. In other words, help them to realize that I am on their side, and that my job is to help them even though they might not be transsexual
What is sometimes going on in this case is a multiple personality disorder, which I see infrequently but I do see. There are usually several personalities, with at least one a male and one a female, so the experience is that I might be transsexual ." Another possibility is a psychotic experience.
Stress and Thoughts of Transsexualism
More common though is the crossdresser who is under extreme stress, has a big loss in his life, and then escapes into the female temporarily.
That's where he is used to going for comfort, safety, and security, and he believes then that he is transsexual, and what happens over time with psychotherapy, and just time really, but the push is an internal push, is that he eventually realizes he is still fundamentally a crossdresser.
So if you are a crossdresser one thing to be careful with if you find yourself moving in the direction of the feminine is to see how much stress you are under; see if you've had any experiences that could be causing you to want to escape Into this other identity.
Treatment for transsexualism is supportive psychotherapy and help with referrals for hormones and sex reassignment surgery--if that is what you want. A lot of people don't; a lot of people just crosslive and feel comfortable without changing their anatomy. Such people are often termed transgenderists, although the term is a relatively new one.
One of the things I can do for clients is be a female role model for them. I was raised as a woman and I can refer you to image consultants, electrologists, endocrinologists, surgeons, speech therapists, and other providers to help you with your socialization into the female gender role.
The Standards of Care are essentially that you be in therapy for three months before getting a referral for hormones and for six months with the same therapist prior to surgery, and that you cross live for at least a year, preferably two, so you can go through a transition similar to adolescence, the way that I did, to find out what it is like to be a woman full time.
Dr. Lin Frazer is a therapist in San Francisco
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