Saturday, December 13, 2008

Whipping Girl - Commentary II

I've tried to write this commentary several times, and each time that I have written it, I have found myself getting bogged down in the details and quid pro quos.

Through to Chapter 7, Serano speaks quite harshly of the treatment that a lot of transsexuals experience at the hands of therapists. She comes very close to advocating for removal of the condition entirely from the DSM, but stops just short of that.

Let me start off by saying that I am sympathetic to those who have experienced the kind of hostile treatment that Serano describes, and has often been attributed to the dubious methodology of people who follow J. Michael Bailey's theories. There is nothing more damaging to someone's sense of self than finding a therapist who claims that they are lying at every turn.

However, I disagree quite strongly with the idea of simply removing transsexualism from the DSM. Transsexualism is a somewhat unique condition in the world of mental health concerns. Unlike a lot of situations that lead people to seek out a therapist's help in life, the transsexual's situation actually will ultimately lead to bringing the services of multiple professionals into the picture - including psychologists, physicians and surgeons; but also can involve lawyers, public service officials and other individuals. There can be little question that some kind of common lexicon is useful in facilitating communication between these varied professionals.

The physician that is prescribing hormone therapy may be quite comfortable monitoring the response of the body's endocrine system to the hormones, but may well not feel that he or she has the appropriate training and background to understand whether the patient is adapting to the changes that the hormones bring with them appropriately. When one considers the legal and ethical bindings placed upon medical practitioners, it should come as no great surprise that many are reluctant to get involved in a situation that they do not feel they understand.

Quite rightly, the WPATH Standards of Care demands that the various professionals involved in an individual's transition be in regular communication with each other.

As Radha points out in her post 'Gaming Therapists, Gaming Ourselves, the therapy process can be a catalyst for learning a great deal about oneself. A positive relationship with a therapist can be an amazingly constructive process - one which enables an person to move beyond their immediate assumptions about themselves and to be completely honest with themselves - both in terms of their strengths and weaknesses (and yes, there is an amazing amount of strength to be found in the vulnerability of admitting to your own failings - the reality of that is left as an exercise to the reader).

I would like to see the definition of transsexualism (or more broadly transgenderism) in the DSM to continue to evolve. In the DSM IV, it is only in its third incarnation, and it has morphed considerably from the original definitions in the DSM II(?), mostly in response to the emergence of more data that has broadened the range of experiences that clients have described.

It is unfortunate that there are so many who mistakenly assume that the presence of a diagnostic category in the DSM means that someone is 'ill'. A more reasonable view of the DSM is that it describes psychological conditions - a lexicon more than anything else. In fact, if one peruses the chapters of the DSM for a while, it is not difficult to understand that it contains a great many conditions which we would agree do not constitute a serious impairment of an individual's ability to function, but may need to be described in order to draw a complete picture of the factors an individual is facing. Here, I believe the APA and related professional bodies have a significant amount of 'marketing' work to do. Society still bears a surprising degree of fear and stigma to 'mental illness', and the professional societies involved have not been very successful in breaking that pattern. One of the key things they could - and should - do is spend some time explaining the DSM's purpose and intentions in layman's terms. (There are only a few of us outside the mental health world willing - or able - to wade through the dense terminology of that book's prefaces)

The transsexual bears a responsibility to find a therapist that they can work with. We are all individuals, and it is no surprise that not everybody can work effectively with every therapist. Therapists and medical professionals are responsible for ensuring that they become educated about the treatment of transsexuals - the transsexual should not be the person trying to educate the professionals; and similarly, finding a therapist should not be an 'underground experience'. Too few therapists publicize that they are willing and experienced with transfolk, which often makes the process of finding a therapist traumatic in its own right.

Those professionals who see themselves as 'gatekeepers' rather than as partners with their clients need to adjust their perspective. In the case of transsexuals, the client is usually quite aware of their condition and what they need to achieve. Gatekeepers are not what is needed - constructive help is. Sometimes that may mean pointing out the 'cracks' in the patient's plans or timelines; but more often than not, it means helping the patient piece together the resources they need.


Anonymous said...

I feel obligated to make two points regarding your post.

First is regarding your statement ".... there are so many who mistakenly assume that
the presence of a diagnostic category in the DSM means that someone is
'ill'." You seem to neglect the fact that the DSM is the Diagnostic and Statistics Manual of Mental DISORDERS (sorry to yell, if there's a way to italicize here, I'm not savvy enough to work it.) With a name like that, it's bound to be seen as "illness".

Second, the fact that a constellation of professionals is required to proceed through transition is monetarily out of the question for many, dare I say most, people who are interested in transition. It's gatekeeping by finances.

MgS said...

You seem to neglect the fact that the DSM is the Diagnostic and Statistics Manual of Mental DISORDERS

That is part of the general misperception of the DSM in popular culture. I addressed what I believe needs to be done later in that same paragraph - namely that the professions involved have a certain amount of marketing to do to get the reality of their worlds understood. (In many respects, the DSM is a 'manual of jargon' - unlike a lot of other domains (like medicine), the DSM has become fairly widely available outside the professions involved.

With respect to the 'gatekeeping by finances' issue, I agree that is a problem, but then transsexualism is a multi-axial condition that requires treatment in multiple dimensions. In only a few cases will an individual practitioner be capable of being a 'one stop shop'.

In both Canada and the US the problem exists for anyone who is considering treatment that is not funded by whatever public health care funding is coming. In my view, this is much more of a matter of public policy, rather than a fault to be laid at the feet of the practitioners involved.