January 25, 2014
From a TransBlog post titled “The Feelings We Feel” by Angus “Andrea” Grieve-Smith:
“Here, then, is a first attempt at cataloging transgender feelings. Essentially I’m writing down feelings associated with transgender events or thoughts, or with trans people. If I’ve written about that feeling before, I’ve tried to link to that post. This is not meant to be an exhaustive list, just a starting point. Please feel free to point out any that you think I’ve missed.
I recently wrote that everyone’s actions are non binary in that they cross somebody’s line between men and women. Trans feelings are similar: as I write down the feelings I’ve felt and heard and read about, I realize how many of my friends and family have had similar feelings. Not all trans people have all these feelings.
It’s important to remember that feelings aren’t always logical. They’re responses to things that happen to us. Sometimes they’re rational, and sometimes they aren’t. That’s okay.
A lot of these feelings are superficial. That’s in part because I’ve focused on specifically transgender feelings, and some of them are superficial. It’s not that I don’t have deeper feelings, it’s just that those feelings are more universal and less trans-specific.
Sometimes I feel sad. I feel sad that when I’m naked and I look in the mirror I don’t see a beautiful woman. I feel sad that I don’t always see a beautiful woman when I’m wearing women’s clothes, and sometimes I don’t even see someone who looks like a woman. I feel sad when I hear women admiring each other’s clothing or grooming, but I’m afraid to tell them about my own women’s clothing or grooming, let alone show them. I feel sad when I see women being admired, but I don’t see any reason for anyone to admire me.
Sometimes I feel frustrated. I feel frustrated when I spend an hour on my makeup and am told to try on clothes in the men’s changing room. I feel frustrated when I’m in a room full of women who are attracted to women, and none of them show an interest in me. I feel frustrated that I have to spend an hour on makeup before I can look in the mirror and see a woman.
Sometimes I feel anxious. I feel anxious about being a man, because men are the dangerous ones. I feel anxious about being perceived as a man in a dress, because people are rude to men in dresses, and often hurt or even kill us. I feel anxious about attracting people that I’m not attracted to. Sometimes I feel anxious about just plain being noticed.
Sometimes I feel longing. I long to be sexy, to be attractive, to be stylish. I long to be admired, to be loved, to be accepted.
Sometimes I feel desire. I want to be a woman. I want to wear women’s clothes, to be seen as a woman. I want to be accepted in women’s roles, with the status of woman. I want someone to tell me I look pretty, or sexy. As Rick Nielsen said, I want someone to want me.
Sometimes I feel sexually aroused. I feel aroused when a sexy person desires me. I feel aroused when I look in the mirror or at a picture of me, and see someone who looks sexy. I feel aroused when I wear sexy clothes. I feel aroused when I imagine myself looking sexy.
Sometimes I feel excited. I feel excited about people seeing me as a woman. I feel excited about people admiring me. I feel excited about trying on new clothes. I feel excited about losing weight.
Sometimes I feel happy. I feel happy when my gender presentation looks good. I feel happy when I get comments on my looks.
I would be very surprised if any of you reading this feel the exact same mix of feelings I do. That’s normal. We’re all snowflakes. There is no one way to be trans. But from conversations I’ve had and descriptions I’ve read, I know that a lot of you have similar feelings. Please do let me know if there are feelings you’ve had that I haven’t covered.”
November 1, 2013
Guest Post from Gregory:
I have tragically come to realize my story is fairly typical of most MtF persons. I was molested by my “trusting” grandfather at age 3, father was killed at age 5 and while my mother remarried; you could essentially say I grew up without a “father figure” or role model. By 10 or 13 years old; the gender confusion had begun. Only I didn’t know its origins. I was frequenting the gay neighborhoods by 16; assuming this emptiness and sexual craving was a signal of who I was. But, it wasn’t gratifying; and always left me disgusted. By 25, I was cross dressing in earnest. Buy, purge, buy, purge this repetitive cycle of self hatred continued unabated. For the next 15 years I was married and divorced twice. The root of the failures I believe some bent up anger and feeling of inadequacy stemming from a childhood I had no control over.
By my late thirties, this feeling of a “feminine core” continued. It led me to purchase online and experiment with Estrogen and an Anti-Androgen. My body slowly started to feminize. I dieted and exercised feverishly and got my body down to an acceptable female weight. I felt great; this must be who I am?
I remarried again in my early forties to a wonderful woman. Yet, the programming in my mind was so scrambled by then that it was difficult to differentiate between reality and fantasy. By the time I started seeing a gender therapist and a surgeon they were as convinced as I was that I was female.
Since I was already on estrogen, the endocrinologist felt morally/ethically obligated to continue that same protocol and at least monitor it and prescribe it legally. I received my first letter for surgery after a year and the second after two years. My childhood issues were jotted down by the therapists almost as if a side note. (A very common failure in approving surgery.) At no time did I tell my family, consider my career or even consider talking to the love of my life of my plans. This “sickness” and it is a sickness, consumes and takes over your life! You will lie to everyone around you as you continue to lie to yourself to get it done.
The first six months post-op SRS were wonderful. By the eight month, things were changing. Now my interest was finding out how to end my life. That is called REGRET. How long it takes you to come to this point is subjective; probably once the excitement wears off. You realize this was completely wrong. You have destroyed everything in your path to get it done and no-one in the medical community will stop you. How can they? You lied to yourself for so long. Fooling them was the easy part. Or did they even care? “When would you like your next appointment?”
The recently published WPATH Version VII has simply allowed the medical community to open the “floodgates” for this very tragedy to unfold. To get on cross gender hormones and then have surgery has become almost as simple as going to the convenience store for a pack of gum. If the client wants it, give it to them. “Real Life Test”? Maybe, maybe not, depending on your circumstances, occupation, etc. It is a billion dollar industry that thrives on your illness.
Get help. Don’t mutilate your body. The psychiatrist, psychologists, and surgeons will enjoy a wonderful life. You, however, could end up with a tortured life, ending up penniless, possibly unemployed, without family or friends and maybe even homeless. And that’s if you haven’t tried or committed suicide by then! All so you can become the girl you “think” you are inside and wanted to be! People, God or whatever you believe in made you in the correct gender. It is encoded in your very DNA. If you think differently, get real help; but, DON”T CHANGE IT.
This essay was previously published on REtransition.Org.
Thank you Gregory.
May 5, 2013
Motherboard: When does a paraphilia become a disorder?
Blanchard: There are two ways by which a paraphilia could be converted into a paraphilic disorder: the individual is distressed by their desires, or they are acting in a way that is noxious to people. So a pedophile could have a pedophilic disorder if the guy is tortured by the fact that he is a pedophile, or he is perfectly happy with the fact that he is attracted to children, and he is molesting a lot of them.
So if someone cross dresses and they are cool with it, then they don’t have a disorder, correct?
Yes, under my proposal you can now be a happy transvestite, or you can have a transvestic disorder.
You coined the term autogynephilia, which refers to a man who is aroused by the thought of himself as a woman. This term is kind of your baby. Is it going to make it into the DSM-5?
That comes under the heading of what I can’t tell you, because of the confidentiality agreement I signed with the APA.
Do you think autoandrophelia, where a woman is aroused by the thought of herself as a man, is a real paraphelia?
No, I proposed it simply in order not to be accused of sexism, because there are all these women who want to say, “women can rape too, women can be pedophiles too, women can be exhibitionists too.” It’s a perverse expression of feminism, and so, I thought, let me jump the gun on this. I don’t think the phenomenon even exists.
Some trans activists object to the inclusion of transvestic disorder in the DSM because they feel it pathologizes gender non-conformity. How do you respond to these criticisms?
To say that transvestic disorder pathologizes all trans people is rhetoric with no logic behind it whatsoever. If you actually open the DSM-4, it’s very explicit that it applies to people who get sexually excited by dressing in women’s clothes. They really object to the fact, (which is a fact established beyond any conceivable doubt), that in a lot of men there is some connection between cross dressing and sexual excitement.
Is the objection based on the idea that it fetishizes gender non-conformity?
Some activists are trying to sell the public on the idea, “We really are women where it matters–in our brains–and women don’t get sexually excited when they put on their bras and panties, so we don’t either.” And for a lot of them that’s just a lie.
So you don’t see a male-to-female transsexual as being female?
I think that a transsexual should be considered as whatever their biological sex is plus the fact that they are transsexuals. That’s how you would do research on them. There’s no other way to do it. If you’re interested in whether the brains of transsexuals are different in some way, you’re interested in seeing if they differ from other individuals with the same biological sex.
So in a way psychiatric research is inherently gender normative?
I would say medical research is inherently gender normative.
Some members of the trans community object to the stigma they feel accompany DSM diagnoses, but because of the impact of the DSM on insurance payments, it’s necessary they be labeled mentally ill. To what extent is a diagnosis from the DSM necessary to receive reimbursement for gender reassignment therapy?
In the US I would say most insurance companies probably require a DSM diagnosis. The point that sticks in the craw of a lot of activists is that in order to get sex reassignment surgery paid for by a third party, it has to be deemed a disorder. The transgender community has tried to get around this in a way that they seem to think is very creative.
Their argument is, “Well, public health insurance plans pay for the cost of child delivery in a hospital, and childbirth is not a disorder. Therefore transsexualism could be covered under public third party health insurance payers without it being a disorder.” That’s how they’ve tried to square the circle.
And have they been successful?
No. How many people do you know regard sex reassignment surgery as part of the life cycle like having a baby?
Do you think that classifying transgender people as having a disorder does contribute to stigma against the trans community?
No. I mean how many people who make a joke about trannies consult the DSM first?
Do you think that transgender identity might get to the point where homosexuality is now, where it is considered offensive and inaccurate to call it a disorder?
I think there are some glaring differences between acceptance of transsexualism and acceptance of homosexuality. Let’s say that a friend comes to you and says she’s a lesbian, you aren’t seeing your friend performing cunnilingus on her girlfriend. All this requires is acceptance of what you don’t have to see.
With transsexualism, if a friend comes to you and says I feel like I’m actually a woman, and starting tomorrow I’m going to be showing up wearing dresses, this is not happening offstage, you are now part of their movie.
[Images added to this post by me- GM]
February 27, 2013
Heart-wrenching post by a man coming to terms with the fact that he drank the gender Kool-aid, got swept up into the “Transsexual Empire” of the psychiatric and medical sex-change industry, and now needs to come to terms with it all.
At the start of the piece Carolynn asks why there are not more voices in the transgender community expressing doubt before undergoing profoundly reconstructive cosmetic surgery on their genitalia? And why are there not more voices expressing the regret and despair that follows?
The answer, he shows us, is clear. Once you have gone that far into the process there is “no going back”. His only choice is to make the best of his life now that what’s been done, cannot be undone. There is no benefit to wallowing in despair. Rates of suicide for post-operative transgenders are high. The only sane choice is to accept what has been done and make the best of it.
From the piece, titled “Did I Make a Mistake?”:
“DID I MAKE a mistake? Am I doing the right thing? Is this the path for me? These are questions we usually ask and, if not, should be asking ourselves. Gender transition is not for the faint of heart. Early in my transition from male to female, I gave little thought to those questions. I was very busy buying new clothes, coming out to family and friends, and getting ready to return to work after a lengthy absence.
I was working on name changes, birth records. I was preoccupied early in my transition. There was a lot of ground to cover if I was to come out and be my true self. Endless doctors’ appointments. Sometimes I felt as though I should have had a tube from my arm connected directly to the blood lab. I had more blood drawn from me in my first year of transition than I had in my entire life, and I was under the microscope of psychiatrists, every move scrutinized. Should I sit in the blue chair in the doctor’s office? Should I sit in the pink chair? I felt like I was under constant surveillance, and worried my male side would pop out. It didn’t. I did a very good job at covering the male side of who I was. After a few years of this—the real life test—I received a letter saying that I was eligible for and had met all the criteria to move forward and have gender reassignment surgery. To say I was happy would have been a gross understatement. There it was in my hot little hands, the brass ring! The letter I had been working toward for the last four years.
For a brief moment, I hesitated to pick up the phone to book my surgery date. I read and re-read the letter countless times. Then it went into my file, and I didn’t look at it again for at least three months. Those three or so months were when the questioning began. I tried approaching people in my support system. Each of their answers was almost scripted: “Well, if you have any doubts then you’re not really trans!” I thought to myself that “You’re not really trans” was an odd thing to say. My question was still not being addressed. I had a new brass ring to reach for. “Is there anyone who has any doubts or second thoughts?”
One would think this would be a very easy question to have answered. It was my experience that it was the hardest question that I ever asked to find an answer for. It would appear that by the time I reached that stage in my transition, the medical community felt I was ready to move onto the next stage—surgery. I was supposed to be ready to take the final plunge into the mystery of becoming a woman. Hard as I looked for one person to say, “Yes, I had doubts; yes, I was terrified; and yes, I questioned if I made a mistake,” I never found them. That one person never appeared.
I knew they were out there. They didn’t speak. Now I had a new question. Why weren’t they coming forth with their experience? Shortly after I pulled the letter from my file again, I made the call to the surgeon and booked my flight. I was very excited to be on my way to have this correction taken care of, but that one question still haunted me. What haunted me even more was where were the ones that had gone before me, that were supposed to help guide me through this rocky period. It wasn’t long after I had returned home from the surgery that I found the answers I was looking for. I found where most brothers and sisters had gone; I found the answers to those nagging questions. The real work began upon my return home. The rigid schedule of dilating, the inability to get to the bathroom without assistance, the blood, the pain. I’ll never forget the pain. My hips and halfway up my stomach were yellow and black from the bruising. The simplest act of trying to watch television became agony. The deed had been done; there really was no turning back. I couldn’t go home now .
I was now in this surgically created wonderland that I called my female body, laying awake at night still asking, “Did I make the right choice?” Right choice or not, this was where I was! Life carried on seemingly uneventfully, get-well cards came, flowers arrived, people phoned. It was almost like I had celebrity status, but that was short-lived. Then again I was alone with my thoughts. That one nagging question rang through my head. Did I make a mistake? I felt a bit depressed so I made a couple of phone calls trying to find a counsellor to speak with. Oddly no-one would accept me. I called my old shrink and he said, “Our work was finished. I was only there to help you until you had surgery. You’ll need to find another doctor.” The hunt began for another psychiatrist. I thought it would be easy, but it was not. Depression by this time had taken deep root; eventually I was diagnosed with chronic depression. What followed was not at all what I had expected. I stopped going outside, I quit playing softball, I closed my kickboxing gym. I became a recluse, subjugated in my own home by no one other than myself. My depression deepened. My rigid schedule of postsurgical care went out the window. Then another nail struck into my coffin of depression! My surgical area had grown shut!
I had less than two inches of depth. I was horrified. What had become of that soulful, full-of-life woman that I had known at the beginning of my transition? Where did she go? How could I get her back? The question of whether or not I had made a mistake was secondary at this stage; my priority now was to find the real Carolynn again. This was a daunting task to say the least. I was lucky enough to have been referred to a doctor by a dear friend of mine. He saw me, and I would love to say that we got off to a great start. We didn’t. He called me obese and said I needed to exercise. I didn’t see him again for at least a year. When I finally did return to see him, I was a complete train wreck. I had put on 40 to 50 pounds, and I was depressed. I still had the problem of the surgical area having grown closed. After some time with this doctor, things started to look a little better. Over the next few years things began to change. I felt my old self returning, I re-opened my kickboxing school, and started to socialize again. Then my doctor threw this at me one day in a session. He said, “Carolynn, you know you can go for a surgery revision and get that fixed.” My jaw hit the floor. I was in shock. I thought it was a one-time shot, and if, like me, you screwed it up—well, you were screwed forever after.
I felt this little fire of hope begin to burn in me again. I had purpose in my life again. This time, I wasn’t going to screw it up! I jumped through all the hoops, made all the phone calls, and reattached the tube from my arm to the blood lab. Honestly, I felt happiness shine again in my life. Finally, the day came for me to head off and have my surgery revision. I remember arriving at the recovery house and seeing another group of me’s from six or seven years ago. They were all driven. They were all happy and they all had no clue what was going to happen after.
Not from a place of ego, but rather a place of a caring sister, I took it upon myself to inform the other guests that this was not my first time. I had to go around and return their jaws to the closed position. I became very close with two of the girls there. One very young woman was maybe 17 and there with her mother, and another was my own age and all the way from the U.K. They listened intently as I told them my story and the pitfalls to be aware of. My young friend even went so far as to take notes. Our surgery days came and went. We all returned to the places we respectfully called home. A few days later, I got a phone call from my friend in the U.K. She was in tears and panicking, saying, “I don’t know what I have done.” We talked for what seemed like hours until she said she was feeling better. It’s been some time since I have heard from her. As for my young teenage friend, I got a call from her mother on several different occasions telling me what her daughter was not doing, and how she was feeling depressed. Considering myself somewhat of a hip person, I started to text my young friend. We worked out some things via texting and email. My life continued fairly normally. I was again into my routine of dilating and postsurgical care. Only this time I had a new-found appreciation for what I had been given, and the question had finally been answered.
Did I make a mistake? The answer is No! I did not make a mistake. Do I have regrets? Yes, of course, I have regrets. I do not feel I would be classified as human if I didn’t. Do I miss my old self? Sometimes. The question of whether or not I made a mistake at this stage is irrelevant. The more pressing and more important question is, am I able to be happy living as I am? At time of writing, I have an afternoon appointment coming up with a personal trainer at the gym. Later this evening, I’m going out for dinner with some friends and there is this very handsome man I met who asked me on a date.
The answer is, yes, I am happy and can live this way. The question I had chased and tried to have answered was the wrong question. After a few years of wrestling with it, the question “Did I make a mistake?” became irrelevant. The question I should have been asking myself all along is, “Can I be happy after I have made these final choices?” People have surgery everyday. Most don’t ask themselves, “Did I make a mistake?” If my own personal experience is of any use to anyone, then ask yourself the right questions first. Don’t ask “Did I make a mistake?” or “Am I doing the right thing?” Ask yourself, “Can I live happily once these decisions have been made?” That question is far easier to answer than the others.
November 21, 2012
Bailey, J. Michael.
Perspectives in Biology and Medicine, Volume 50, Number 4, Autumn
2007, pp. 521-534 (Article)
A COMMON UNDERSTANDING OF male-to-female transsexualism is that all
MtF transsexuals are, essentially, women trapped in men’s bodies.The standard
narrative of men who become women goes something like this: “I have
always felt that I was born in the wrong body. I have always been feminine in
my interests and feelings. My desire to change sex is about my gender identity
and not my sexuality.”This narrative, which Dreger (2007) has termed “the feminine
essence narrative,” represents both what most laypeople believe to be true as well as
what transsexuals are likely to say publicly.The narrative has been extended to an
etiological theory, which Lawrence (2007b) has called “the brainsex
theory of transsexualism.” The transsexual advocacy website, transsexual.org,
puts this theory succinctly: “A transsexual is a person in which the sex-related
structures of the brain that define gender identity are exactly opposite the physical
sex organs of the body.”
The standard, feminine essence narrative, and the associated brain-sex theory,
are incorrect, in the sense that they do not represent reality, even if they do correspond
with many transsexual individuals’ beliefs and identities. The best scientific
evidence (discussed below) indicates that there are two distinct subtypes of
MtF transsexuals, and that the feminine essence narrative at best approximates
the life history of only one subtype. Paradoxically, this explanation of MtF
transsexualism persists because it is the explanation preferred by the other subtype, to
which it does not apply at all. The popularity of the feminine essence narrative
reflects factors other than the strength of scientific support. Its persistence has
likely had negative consequences for both science and transsexuals themselves.
November 13, 2012
From today’s NPR article “Inmate Sex Change: Should We Pay And Does The Surgery Actually Work?” by award-winning journalist and syndicated health columnist Judy Foreman:
“As the controversy continues to swirl over sex change surgery for convicted murderer Michelle Lynn (formerly Robert) Kosilek (there’s a hearing this month on whether taxpayers should pay for her electrolysis), I got to wondering about some of the questions this case raises.
Certainly, prisoners are entitled to basic health care. But do we really owe her a sex change operation?
Especially if — as some of the evidence I uncovered suggests — it wouldn’t leave her in substantially better mental health than she is in today?
I confess: I’m not sure I would even ask this question if I were sympathetic to her in the slightest. But I’m not. She is a convicted murderer. She is in prison for a reason, and a very good one.
But, that aside, back to my quest for facts: How well does sex reassignment surgery (SRS) work in the first place?
Here’s some data: There was a major study in 2011 by the Karolinksa Institute.
Using data from Swedish registers, they studied 324 people — 191 male-to-females and 133 female-to-males — who had SRS between 1973 and 2003. For each SRS patient, the researchers randomly selected 10 people from the general population who had not had SRS. From this group, two control subjects were matched to each SRS patient — one with the same sex and age as the patient at birth and the other, with the same age and sex as the patient after SRS.
All-cause mortality was three times higher for people who had SRS and deaths by suicide were also higher. People who had the SRS were also at higher risk for hospitalizations for non-gender related psychiatric problems. It’s not totally clear why people who get the surgery get worse. But the authors conclude,
“Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behavior and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism…”
So, in other words, the surgery does get rid of “gender dysphoria,” meaning deep unhappiness with one’s biological sex. But it doesn’t seem to help much with other mental health issues, including suicidality.
If that’s true for Kosilek, I wondered, why should taxpayers foot the bill?
The Karolinksa researchers did caution that for SRS patients their findings didn’t necessarily mean the surgery didn’t help at all: “Things might have been even worse without sex reassignment.”
I wouldn’t be so swayed by this pessimistic study except that it’s methodologically much better than previous research, including an oft-cited 2010 Mayo Clinic study.
Researchers performed a systematic review and meta-analysis of 28 studies of hormone therapy and sex reassignment involving 1093 male-to-females and 801 female-to-males.
The studies were observational and most lacked controls. Overall, in the Mayo review, 80 percent of people who had the sex reassignment reported significant improvement in gender dysphoria, as well as significant improvement in psychological symptoms and quality of life.
But, as the Mayo researchers themselves note, all of these conclusions were based on “very low quality evidence due to the serious methodological limitations of included studies.”
In data-speak: garbage in, garbage out.
Ben Klein, senior attorney for Gay and Lesbian Advocates and Defenders, doesn’t see it that way. “All studies have limitations,” he told me, “but if you look at the overwhelming trend of a significant number of studies, all point to the same conclusion – that sex reassignment surgery is the only effective treatment for gender identity disorder.”
But I’m not buying that — pooling a bunch of bad studies doesn’t yield good data.
It makes more sense to wonder why the surgery doesn’t have better long-term results. One reason, suggests Renee Sorrentino, a Harvard Medical School psychiatrist who runs the Institute for Sexual Wellness in Quincy, is that by the time a person seeks sex change surgery, gender dysphoria has usually been a problem for a long time and is often accompanied by significant traumatic experiences, including bullying. Those deep psychological wounds may not be so easily healed.
That said, I know a transsexual woman, Sara Herwig, who has been helped by the surgery and now feels like a “congruent person.” So I called her.
“The thing to remember about SRS or general reconstructive surgery is that it is not a silver bullet,” she said. “You still have to deal with everything in life that everybody has to deal with. It’s not going to have a big impact on clinical depression or other kinds of mental illnesses.”
Fair enough, but did she believe taxpayers should be on the hook for Kosilek’s surgery?
Herwig has mixed feelings, “My initial reaction is that nobody paid for mine. Health insurance doesn’t cover it. I understand her desire to have the surgery, but … vast numbers of other people I know have had to pay for their own. I do think there need to be reforms in health insurance so such surgeries are covered. But I don’t think the taxpayers should pay for someone to have that kind of surgery.”
In the end, I concluded, neither do I.
And as for this month’s hearing regarding hair removal?
Give me a break. I have a couple of eyebrows I’d like taxpayers to have waxed for me.”
July 6, 2012
Excerpts From the APA Task Force on GID report issued this week:
Edgardo J. Menvielle, M.D., M.S.H.S. and Richard R. Pleak, M.D.
The optimal approach to treating pre-pubertal children with GV, including DSM-defined GID, is much more controversial than treating these phenomena in adolescents and adults for several reasons. Intervention, or the lack thereof, in childhood as opposed to later may have a greater impact on long range outcome (Crouch, Liao, Woodhouse, Conway, & Creighton, 2008); however, consensus is lacking regarding the definition of desirable outcomes. Further, children have limited capacity to participate in decision making regarding their own treatment and must rely on caregivers to make treatment decisions on their behalf. An additional obstacle to consensus is the lack of randomized controlled treatment outcome studies of children with GID or with any degree of GV (Zucker, 2008b). In the absence of such studies, the highest level of evidence currently available for treatment recommendations for these children can best be characterized as expert opinion. Such opinions do not occur in a complete vacuum of relevant data, but are enlightened by a body of literature (mostly APA level C and lower), including systematic experimental single-case trials as well as both uncontrolled and inadequately controlled treatment studies, longitudinal studies without intervention, and clinical case reports.
Opinions vary widely among experts depending on a host of factors, including their theoretical orientation as well as their assumptions and beliefs (including religious) relating to the origins, meanings, and fixity/malleability of gender identity. For example, do gender variations represent natural variations, not assimilated into the social matrix, or pathological mental processes? Even among secular practitioners there is a lack of consensus regarding some of the most fundamental issues: What are indications for treatment? What outcomes with respect to gender identity, gender role behaviors, and sexual orientation are desirable? Is the likelihood of a particular outcome altered by intervention? What constitutes ethical treatment aimed at bringing about the desired changes/outcomes? Adding to this complexity, service seekers as well as providers differ in their religious and cultural beliefs as well as in their world-views regarding gender identity, appropriate gender role behaviors, and sexual orientation. Primary caregivers may, therefore, seek out providers for their children who mirror their own world views, believing that goals consistent with their views are in the best interest of their children.
We begin by examining the natural history of GID as defined by outcome without treatment. We then discuss the goals of interventions in treating these children and the factors that influence clinicians in goal selection. Next, we describe various interventions that have been proposed. The empirical data available to inform the selection of goals and interventions are then reviewed and an opinion is offered regarding the status of current credible evidence upon which treatment recommendations could be based.