Читать книгу Transgenderism: A Case Study of the Movie TRANSAMERICA - Francine R Goldberg PhD - Страница 7

The setting is southern California. The opening scene introduces Bree Osbourne, a transgendered person who is in the process of transitioning from male to female (MTF). This means that she has been presenting herself as the opposite sex and living as a woman. As part of the transitioning process she has been working on developing her voice to sound more feminine in pitch and inflection, she uses feminine cosmetics and make-up, wears female clothing, including female under garments and accessories to exaggerate her breasts and hide her penis, and she slouches to appear shorter than the average man.

Bree’s transition process appears to be ongoing, for at least three years, during which time she has been through electrolysis, three years of hormone therapy, facial feminization surgery, brow lift, forehead reduction, jaw re-contouring and a tracheal shave. She is in psychotherapy where she feels support for her transition, but is unable to identify any family or friendship support.

Bree says that her parents are dead but later in the film it is learned that this is untrue. Perhaps Bree has become estranged from her family so that she does not have to announce her transgenderism. Perhaps she is estranged from her family because she has announced her transgenderism and has been rejected by them. Lev (2004, p. 299) reports that clients are afraid to disclose to their families of origin. Disclosure of transgenderism can result in excommunication and ostracism from family, which can also be difficult to manage if someone is close to his or her family, but can also be difficult to manage if someone is estranged from family.

Some transgender people have never come out to anyone. It is unknown how many people harbor unresolved feelings and thoughts about their gender but remain completely reticent about these feelings, perhaps never acting on them, even in secret. Others might cross-dress, publicly or privately, and even have an active support system within the transgender community, and keep this information hidden from their significant other. In other cases, only the significant other knows and the secret is kept hidden from the rest of the world. The advent of the computer age and online communication has created a vast support network for people who might otherwise be isolated. Many people are only “out” online, or have opposite sex personas online, although they have no other real-life experience (Lev, 2004, p.293.)

Many transgender people are socially isolated as expressed by Riki Wilchins (1997), a MTF transgendered person who is an internationally known gender activist and advocate, in her book, “Read My Lips: Sexual Subversion and the End of Gender”:

Loneliness, and the inability to find partners, is one of the best-kept secrets in the trans community… Transbodies are the cracks in the gender sidewalk. When we find partners, they must be willing to negotiate the ambiguity of the terrain.

Bree is at the point in her transition process where she is seeking written consent from a psychiatrist to have SRS, to physically become a woman.

Requests for SRS began escalating in the early 1950’s after a young G.I. left the United States to go to Europe and become a female named Christine Jorgensen. Thousands and thousands of letters were written to Christine for support and guidance by individuals who identified with her. Others who did not write, many of who were simply too young to contact her, were indelibly marked by her courageous public disclosure of her transition from male to female. Christine Jorgensen’s story shocked the world, and generated dilemmas and controversies in psychiatry, medicine and law, that persist today. But above all, it gave hope and inspiration to many that perhaps anatomy was not destiny after all (Ettner, 1999, pp. 16-17.)

During Bree’s interview with the psychiatrist, Bree poses the question, “Don’t you find it odd that plastic surgery can cure a mental disorder?” Bree’s sentiment seem to be in congruence with Harry Benjamin, an Endocrinologist and pioneer in the compassionate treatment of gender variant people. In discussing a male-to-female transsexual Benjamin stated that, “Psychotherapy with the aim of curing transsexualism, so that the patient will accept himself as a man…is a useless undertaking…the mind of the transsexual cannot be adjusted to the body, [thus] it is logical and justifiable to attempt the opposite, to adjust the body to the mind (Benjamin, 1966, p. 116.)

Dr. Benjamin’s interest in what he himself came to call “transsexualism” began after he became acquainted, through Alfred Kinsey, with a young patient who was anatomically male, but insisted that he was really female. His interests have led to what is known today as The World Professional Association for Transgender Health (WPATH), an international interdisciplinary, professional organization whose mission is to further the understanding and treatment of gender identity disorders by professionals in medicine, psychology, law, social work, counseling, psychotherapy, family studies, sociology, anthropology, sexology, speech and voice therapy, and other related fields. It was originally named after Dr. Benjamin, as it was first known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA.) It provides opportunities for professionals from various subspecialties to communicate with each other in the context of research and treatment of gender dysphoria including sponsoring biennial scientific symposiums. WPATH publishes the Standards of Care (SOC) and Ethical Guidelines, which articulate a professional consensus about the psychiatric, psychological, medical, and surgical management of gender identity disorders, and help professionals understand the parameters within which they may offer assistance to those with these conditions (WPATH, 2007.) The SOC are clinical guidelines that are intended to provide flexible directions for treatment with eligibility requirements that are meant to be minimum requirements. They include standards for professional involvement with patients; the roles of the mental health professionals with the gender patient; standards for the training of mental health professionals; the differences between eligibility and readiness criteria for hormones or surgery; the mental health professional’s documentation requirements for the differing letters for hormones or for surgery; standards for children with Gender Identity Disorder (GID); standards for treatment of adolescents; standards for psychotherapy with adults; standards for the real-life experience; and requirements for genital reconstructive and breast surgery (Ettner, 1999, pp. 139-150.)

It appears that Bree, thus far, has been treated according to the SOC and that is why she is in the psychiatrist’s office being assessed for (GID.) The SOC outlines five elements of clinical work, the first three, i.e., mental health diagnostic assessment for GID, a minimum of three months of psychotherapy to confirm that the client has GID and real-life experience living in the social role of the opposite sex for one year, determine the client’s appropriateness for the last two, i.e., hormonal therapy and, perhaps, surgical therapy. To be referred for the latter two the client must have a letter from the psychotherapist and countersigned by a psychiatrist or psychologist stating that the client fits the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnostic criteria for GID or the diagnosis of transsexualism outlined in the World Health Organization’s International Classification of Diseases, Tenth Revision (ICD-10) (Lev, 2004, p. 45 and Herman, 2006.)

Joanne Herman (2006), a transgendered member of the advisory board of the National Center for Transgender Equality, writes about the trans catch-22 faced by trannsexuals. “The SOC represents a “medicalized” approach, involving hormone therapy or surgery. And yet, because of the stigma from the DSM-IV, most health insurance plans will not pay for any treatment for a GID diagnosis code. This means that a patient who is diagnosed with GID may end up without access to treatment solely because he or she cannot afford to pay the costs out of pocket. The exclusion in health plans of all treatments related to SRS is terribly unfair and unjustifiable. Insurers will cover a hysterectomy for a female who has uterine cancer, but they won’t cover the same surgery for a female-bodied person who is transitioning to fit a deeply held male gender identity – even when it is recommended by a doctor for the psychological well-being of the transgendered patient…There’s another, more fundamental problem with the GID diagnosis…what if you don’t happen to desire hormone therapy or surgery to feel comfortable expressing your gender [variant] identity? You likely will not be diagnosed as having GID, meaning you too will be denied treatment. So why not remove GID from the DSM-IV? Aside from its existence as the linchpin of the SOC, some believe that its presence gives doctors a basis for providing hormones and surgery for us when they might fear being accused of malpractice otherwise. For those of us who truly need(ed) and want(ed) hormones and surgery, the prospect of having no doctors available to carry out the treatments is downright scary…”

It is worth noting at this point in the discussion that insurance reimbursement for SRS procedures has become extremely rare in the United States (Wilson, 2005.)

However, there is ongoing controversy as to whether the GID diagnosis should remain as the DSM-V is now going through the planning stages, especially since homosexuality, which was once included in the DSM, was deleted in 1973( Hausman, 2003, Herman, 2006; and Wilson, 2005.)

Some point out that American psychiatric perceptions of etiology, distress, and treatment goals for transgendered people are remarkably parallel to those for gay and lesbian people before the declassification of homosexuality from the DSM as a mental disorder in 1973 (Wilson, 2005, Herman, 2006.)

Darryl Hill, Ph.D., an assistant professor of psychology at Concordia University in Montreal, cites the lack of scientific reliability and validity studies supporting the GID diagnostic criteria and insists that GID is not a mental disorder, but that the criteria describes “the distress often experienced by parents” who have become “preoccupied with the negative aspects” of their son’s or daughter’s behavior as the child struggles to make sense of gender-related feelings. Thus, it is socially determined. In addition, Hill argues that “gender is not dichotomous” and everyone falls somewhere between the two poles, male and female (Hausman, 2003.)

In support of Hill’s argument, A. H. Devor, Ph.D. (2000) states in the abstract describing his work, “How Many Sexes? How Many Genders? When Two Are Not Enough,” that approximately a decade of his research with transgendered and transsexual persons is summarized in order to explore and illustrate some of the limitations in dualistic conceptualizations of gender, sex, and sexuality. In the process, he argues that increased descriptive power may be gained through the use of greater subtlety and nuancing of binary concepts of gender, sex, and sexuality. However he maintains that, ultimately, the dualistic paradigm is being stretched to the breaking point by the challenges raised by transgendered and transsexual people and that it is time for the development of new modes of thought.

Katherine Wilson, Ph.D., a founder of the San Diego-based organization GID Reform Advocates and former outreach director of the Gender Identity Center of Colorado, disagrees with Hill, insisting that it should remain in the DSM, but not as a disorder. She says that DSM fails to acknowledge that “many healthy, well-adjusted transsexual people exist”, and thus, GID should be replaced with a diagnosis of “unambiguously defined distress” rather than by “gender nonconformity. She would like to see GID replaced with a term like gender dysphoria, which would describe someone who is persistently distressed with his or her physical sex characteristics or with the limiting gender-based roles that society imposes on men and women (Hausman, 2003.)

Opposing the above arguments is Robert Spitzer, M.D., who chaired the work group that developed DSM-III and DSM-III-R. He maintains that cultures view gender as a dichotomy, certain behaviors “are part of being human – part of normal development” and it is legitimate for psychiatrists to identify a disorder in which persons of one gender reject these roles and behaviors and assume those of the opposite sex (Hausman, 2003.)

Also in opposition is Paul J. Fink, M.D., former APA president, professor of psychiatry at Temple University, and extensively experienced in working with transsexuals in the process of surgically changing their gender. He maintains that transsexualism is a valid psychiatric diagnosis, it “is not a normal sexual variant”, and although there may be a dearth of research on GID, he warns against correcting that situation by “legitimizing behaviors that are actually disadvantageous” to the person (Hausman, 2003.)

Ettner (1999, pp.61-73) offers diagnostic considerations regarding male-to-female issues. Only a certain percentage of individuals who disclose gender dysphoric feelings express a desire or intention to live full-time in the preferred gender. Many wish to maintain a partial or intermittent cross-gender presentation, or to live in an androgynous state. While some want or need only social or psychological interventions. Clinicians can help clients determine where they lie on the continuum of gender dysphoria. Many professionals have little knowledge about the nature of cross-dressing behaviors and assume they are entirely fetishistic in nature. Therefore, responsible diagnostic evaluation presupposes that the clinician thoroughly understand the difference between sex and gender…………………... …Female-to-male clients present far fewer diagnostic uncertainties than male-to-female ones. First and foremost, all female-to-male transsexuals “cross-dress”, but this behavior is not clinically remarkable as it does not violate social prohibitions. Neither is it fetishistic: Male items of clothing possess no erotic properties. Secondly, female-to-male transsexual persons often object to the term “transgendered”, which implies a periodicity or fluidity of the phenomenon, which they do not feel accurately describe the immutable nature of their experience.

As part of the psychiatric interview the psychiatrist asks Bree how she feels about her penis. Bree responds, “It disgusts me. I don’t even like looking at it.”

Dislike of the body and genitals is characteristic of gender dysphoria (Ettner, 1999, p.113.)

The scene ends by showing Bree at work as a dishwasher.