POSTOPERATIVE TRANSSEXUAL

“A study of Integration”

By Ms. Marty M Hagglund R.N.

SUMMARY BACKGROUND, HISTORY AND GLOSSARY

Historically Transsexual persons have returned into society after their final surgery and very little has been heard from them. This study attempts to answer some very basic questions of that integration into society these persons experience. During the period from May 1998 to November 2000 a study was conducted in Maine, U.S.A to provide not only information, but to provide postoperative medical and psychiatric care as well. We will explore five stages of integration I have found in the time I spent with this group and beyond. These stages are as follows. Socialization, Physiological, Spiritual, Sexuality and Intimacy, and finally Gender congruity.

Data gathered by personal care provided by a registered nurse providing counseling, and surgical care. All clients but one were fully compliant with the standards of care of the Harry Benjamin society. Clients also had private therapists, and evaluations from a psychiatrist, prior to surgery. Considering the lack of data to work from, this is certainly not a definitive study but the purpose is rather to provide the reader with enough questions so as to stimulate further study. Although this study focuses on the male to female transsexual the information may be informative in relation to the female to male transsexual as well. Let me begin with a “glossary” of terms that may not be familiar to all of you.

In the two and one half years I spent with this group, doing direct care and follow up contacts, some basic observations are relevant to report. Age characteristics. Four individuals were in their 4^th decade of life. Two individuals were in their 5^th decade, and one in their 3^rd decade. All clients were of middle class incomes. All were in or divorced from relationships with genetic females. One out of six has professed an attraction to their same gender after surgery. I began to observe these clients in close proximity from several days after their surgery. All patients experienced similar responses initially to bodily changes and tissue recovery. All clients received similar levels of nursing care in a specially prepared environment for their recovery.

INTEGRATION

It seems necessary to define what integration is and why it is important to this study. For the purposes of this study, integration means ones ability to cope with, and adjust to citizenship in a new gender role. References to barriers are meant to provide the reader with understanding of the Stages of development necessary to complete the task of integration. Changing ones gender is as much a developmental task as any one seen in childhood or adulthood. As seen in my study certain barriers have produced an almost standstill of development. To clarify this we must understand that integration is a process much as any other major change in someone’s life. Events seen or unseen can have disastrous effects on ones progress towards fulfillment.

ASSESSMENT

Gender identity disorder had been diagnosed in all clients. Early childhood memories, as well as an unceasing desire to be rid of anatomical sex organs are milestones of this disorder. All clients seen were living a life that they describe as painful, fake, with constant referrals to trying to live up to the ideals of that birth gender. Attempting to explain all the facets of this disorder is beyond the scope of this study. Suffice it to say that these persons were experiencing a total and unrelenting “allergy” to their assigned birth gender. After spending a minimum of several years [with one exception] fulfilling the requirements of the standards of care, these individuals were deemed ready to complete gender reassignment surgery. These requirements outline the steps to be taken to manage the psychiatric, Psychological, Medical, and surgical management of Gender identity disorder. Among this group, depression is the most common pre operative mental health issue. One of the six experienced a bipolar diagnosis. One other experienced obsessive-compulsive disorder. Physical assessment was quite extensive prior to hormonal reassignment, during the real life experience, and again at the time of reassignment surgery. The reader is pointed to the “standards of care “ for further information on “the real life experience” and “Hormonal reassignment”. The individuals’ physician performed the Monitoring of blood for anomalies. Most clients received services from an endocrinologist. These physicians were familiar with all necessary issues to be monitored i.e.; Estrogen levels, testosterone levels, blood clotting factors, and a list of other tests .The reduction of dysphoria and subsequent integration after G.R.S. is the next subject I will report on.

Gender identity disorder has long been considered a mental health issue, denying many other individuals access to properly qualified medical care, unless they are able to pay for it with out of pocket expenses. Many other individuals have chosen to use black market hormones and less than qualified medical and surgical care to relieve their symptoms and refrain from suicide.

OVERVIEW "STAGES OF INTEGRATION"

I have identified five stages of integration. These stages may be experienced in any order, except the stages specifically related to the postoperative individual. As I have seen with this study group, variations exist in the person’s reaction to the events they have experienced, but the difference is in intensity only. Everyone has their own way of coping with life altering events, and this group is no different in these matters.

STAGE ONE: "SOCIALIZATION"

Usually this stage is begun before G.R.S. however, overcoming societies stigmas can take many years to adapt to. Leaving ones own gender role can and will produce some barriers. One of my clients found that they felt abandoned. They saw that some persons that knew them prior to G.R.S. would not treat them as the woman they now are. Surprisingly the support they received from the gender community was very poor as well. As I have seen again and again many postoperative persons lead a somewhat solitary life. Sometimes, because of discrimination and sometimes because the individual is not adjusting well, they wind up leaving many of their old friends and striking out to make a new life for themselves. One of the goals of this stage is to “Establish meaningful relationships”. This is an important stage for, if a person does not establish supportive relationships they can fall into isolation and are at high risk for suicide. The basis for this is found, in my counseling of the group postoperatively, and follow up individually. Approximately one third had expressed suicidal ideation to me. Almost half of the group had feelings of isolation. At times this feeling of isolation had been misinterpreted by others to mean the individual may have made a “mistake” in having their surgery. Fear of the future is also a very real experience, and usually stems from the fact that the clients spend a great deal of time preoperatively on issues of meeting the requirements for surgery. I have seen [with the exception of one individual] that the social role of conforming to a woman’s world can produce some loss of “power”. One person found that she always felt competitive in the work place and postoperatively she found her social role to be different, and needed to adjust to that new role. This is not to say she felt poorly about her decision, but this remains a very important barrier to cross. Another issue is, socialization within a persons own peer group. Whatever age the person is, their remains a psychological need for acceptance among an outside group such as support group, friends, etc. Much as a teenager looks to find their own identity by proximity to a peer group Transsexual persons look for their own identity As well. Lack of experience coping emotionally with different Brain chemistry can result in Emotional immaturity. This can mean the difference between successful integration and Isolation, Depression and Happiness. The change in social roles of these individuals, and the subsequent isolation it can produce makes this stage a very important one to be monitored by a professional person familiar with Transsexual issues. Comfort in ones gender roll is learned over a great deal of time when we are in our formative years. The time frame to learn this new role is greatly shortened after G.R.S.It is my dream to see more therapists and clinicians available to deal with this issue and to provide these persons with a strong basis to finally obtain the peace of mind they deserve.

STAGE TWO: "PHYSIOLOGICAL STAGE"

In thinking how to address this stage of integration, I can see using words like physical changes, hormonal changes, but the word that most suites me is simply “change”. Hormonal changes starts when the client begins hormonal reassignment. There is also a peak, directly after surgery. When I say directly I mean at the time of surgery. Most postoperative persons begin a process of withdrawal that causes varying amounts of discomfort. These people I have worked with, found rather serious sweating and certainly emotional changes. Although welcomed in most cases they are still a force to be reckoned with. Varying humorous cartoons and quips have been seen regarding women and their emotional stages. Depending on the type of person, and how they see this change, some of these cartoons seem appropriate. It is at this exact time I saw some of the strongest persons break down in tears. Not just some tears but buckets of tears. Although some of their tears were due to hormonal changes, some were also due to spiritual experiences as well. I will address spiritual changes in the next stage. Physically, changes seen are overwhelming. A total change in not only hormones, but in the person’s urinary tract, and the appearance of the persons new vagina. I use the example of a new mother bonding with a brand new infant. This total change needs to be absorbed and seen as familiar to the individual. The individual will need to integrate this new chemistry and body together to be able to properly care for themselves. The goal of this stage then becomes “ physiological stability”. I cannot stress enough the absolute need for proper after care of the surgical patient. Without this, the person runs into another barrier of integration, fear of his or her own body.

STAGE THREE: SPIRITUALITY

I must begin by saying that spirituality, in the context of this study is not meant to imply religion in any way. It is a fine line as to describe the spiritual experiences of these individuals with out references to a person’s soul, spirit, and beliefs. To begin with, most of my patients needed to begin to address this issue privately long before their final surgery. One of the barriers at this stage can be the person’s inability, to resolve a basic conflict of changing their body to meet what they feel in their hearts. The barrier exists simply because most of us were raised to believe that the gender we were born into is final. A dysphoria exists because of the conflict between the persons perceived and actual gender. The person who does not resolve this conflict at least somewhat before surgery can run the risk of feeling that they made a mistake in having the surgery. Can you imagine, even for a moment waking up after G.R.S. and feeling that you have made a mistake? Maybe this is a part of counseling that should be explored more fully after G.R.S.

The next part of this stage involves the sense of congruity, which most patients begin to experience after G.R.S. and during the recovery period. I have seen a time frame of two years to become totally comfortable with the persons new gender role. The experience of finding your body in agreement with your mind is truly a wonder. I have heard it described as a “coming home” a time when the spirit and the body meet. The goal of this stage is “self acceptance”. All of the clients in this study experienced some form of this growth. By the nature of what we are discussing here I must note an emotional tone to this stage. Recovery involves having the right people around the patient to illicit a feeling of acceptance and understanding Of all the stages of this remarkable experience this is perhaps the most difficult to explain. The miracle of seeing your self in a mirror complete and whole, has been a point I have used in lecturing on G.I.D. Waking in the morning to see a stranger looking back at you is the nightmare, many of these people have lived with. The period directly following G.R.S. has found many clients saying hello to the little girl they have never known. Of the group I worked with, not all of them would have benefited from in depth psychotherapy, as they were able to work this stage out on their own. Suffice it to say the clients [two] who did look for this help found it just about impossible to find anyone qualified to even understand it let alone counsel someone in dealing with it.

STAGE FOUR “SEXUALITY AND INTIMACY”

As I begin this fourth stage I feel confident that the reader is familiar with differences between gender/sex/, and some terminology concerning transgendered individuals. I take this liberty because I assume some understanding brought you to read this study. Sexuality as seen with my study group proved to me, to be more complex than I first realized.

As a person nears the end of these stages, and they are becoming comfortable with their new bodies, this stage becomes more important to them to ponder. Immediately following G.R.S. the issue of expressing sexuality is put off until full healing occurs. I have seen that out of the six individuals I studied, that two persons knew their attraction for a mate preoperatively. Such is not the case with all of the others. The other four have been slowly coming to their individual decisions as to a mate. In choosing a mate, they examined their preferences prior to, and post surgery. Some interesting patterns emerged, as I viewed the group as a whole .Of six individuals, all six were all married preoperatively to women. Most of the divorces had some elements concerning the spouses’ ability [or inability] to stay with the transsexual individual. One individual has married post surgery. I found the issues [concerning a persons attraction to either female or male partners] centered on the persons ability to integrate all aspects of their new bodies. And to resolve the dysphoria sufficiently to be able to make this choice clearly. As I have stated earlier, these stages can be experienced in any order. Some individuals were able to make this decision with relative ease, prior to G.R.S. One of the barriers to completion of this stage I have seen is, simply fear. Fear of ones own body and the inability to be intimate with themselves. As with any study of this type, I am sure there are other barriers that someone may encounter. The goal of this stage is “intimacy with self and others”. In order to be intimate with others, a person needs to be comfortable with themselves.

STAGE FIVE “ GENDER CONGRUITY”

This last stage of my study on integration is perhaps the one that will leave more questions than answers .I have found that a time does come when the individual achieves congruity. Simply put, nothing of the person’s surgery, transition, or in some cases past life remains as a barrier to them. They have been able to incorporate all the aspects of their new selves. I am not trying to say that the group I have studied, now are perfect, but just the same they have made progress towards congruity. As I stated earlier, complete recovery, both physically and emotionally can take several years to accomplish. I compare this stage to a typical task of adulthood. Thus the goal of the stage becomes: “MATURITY”.

*note* maturity means relative age of a subject to that of a young woman or man maturing normally in a normal gender roll.

 

SUMMARY

As I pull together all of these stages, a total picture emerges. From deep within a person’s psyche, a realization is reached. This realization at first is cloudy at best. As a person begins to fully realize the impact of their own thoughts, and feelings, they become overwhelmed with fulfilling a life long dream. This dream has become much more, and remains as a milestone in their lives. Some of the reality of this dream continues to be masked with euphoria. Changing ones gender is in itself, changing the most basic of human conditions. The drive to complete this change becomes an obsession unequaled. Working through these stages and barriers can provide the individual with enough inner strength and hopefully self esteem to endure their futures. Unfortunately most of society has little education or understanding of this process. This does cause varying amounts of discrimination and presents the person with not only internal barriers, but external as well. The stages outlined here can provide some formal basis in which to assess, and provide guidance to these individuals and their therapists.

All persons I have worked with during this two and one half years have become almost family to me. I have watched as they matured into making one of the most important decisions of their lives, to become the person they have always been. These stages represent a beginning to understanding more from these remarkable persons. The things we take for granted in our lives become familiar to us. What drives these individuals is for me, the most basic instinct we have as human beings. “ To love ourselves, to give love, and to receive love “.

" copyright 2002 transcare2000"