Gendercare Gender Clinic

Gendercare Gender Clinic

5 years helping Gender Dysphorics

A Professional Web-Based Gender Dysphoria Counseling Service

Introduction

To a large degree, Gender Variance and Gender Dysphoria remain mysteries. Why would someone with the perfectly-formed genitals of one gender feel that he or she might belong to the opposite gender? Many theories have been proposed to explain gender variance, some based on genetic and biological causes, others based on social and cultural causes, and dramatic clashes have often ensued among the proponents of different theories. Some experts believe gender variance is not inherently a problem for the individual, but is merely one harmless aspect of human diversity, whereas some mental health professionals classify it as a mental disorder. Scientific progress in this area has been slow, but the causes of gender variance are gradually being elucidated. In the meantime, irrespective of the causes, it has become evident in the past few decades that gender variance is far more common than had ever been believed in the past. Professionals and patients alike agree that people who suffer discordance between their gender identity and genital formation, due to multivariate factors, benefit from good medical and psychotherapeutic assistance, and often, hormonal and surgical interventions in order to achieve harmonious lives. However, such assistance is presently available to only a small fraction of the world’s population. Could we provide some of the assistance people with gender dysphoria need by means of the internet? Is it possible to provide adequate diagnosis of gender identity conditions without face-to-face interviews with patients who live far from any professional assistance? Could we provide gender transition counseling, hormone therapy letters and orientation, and even sex reassignment surgery referral letters through the Web? Gendercare Gender Clinic has been in existence since 2001 developing Web methods to evaluate and treat gender identity dysphoria. The medium of the internet may be the best way to provide people with help for gender identity dysphoria, and we propose to describe our methods and results in this paper[1].

Development of the On-Line Counseling Model

The first thing it is necessary to do in GID therapy is to understand the patient and learn his or her life story. In other words, the first step is always an anamnesis, which can be developed through a variety of means, including:

--Face-to-face interviews

--Phone consultations

--Video conference consultations

--Web chat consultations

--Web email consultations

Face-to-face interviews are ordinarily impossible as an adjunct to Web gender therapy. Phone consultations would be difficult in a foreign language, and the telecommunications costs would be prohibitive. Video conference anamnesis would be feasible only if the patient had the money for the required hardware and for a high speed connection, which is unlikely, particularly for many poorer patients who live far from good connection service. Web chat entails almost the same drawbacks as video conferencing. Therefore, the best solution for us, since the middle of 2002, has been the Web email anamnesis.

We have never had any problems or patient complaints in connection with our email anamnesis procedures, in large part because we have taken the following precautions:

1. The exercise of total discretion, using the emails only within the clinic, with the most absolute ethical principle never to share any anamnesis data with any person besides the patient.

2. The installation of a tracking IP system in all of our web pages allows us to know the point of origin of all visitors to our website, so we can be certain about who is communicating with us.

The anamnesis alone, however, does not furnish sufficient information to understand a patient’s reality. In traditional psychotherapy, face-to-face interviews provide additional information—including what the patient tells us, the way in which he or she tells us, and WHAT WE SEE AND WHAT WE FEEL ABOUT the patient, whereas through emails we feel almost nothing and see nothing. In our early experience with conventional face-to-face gender therapy, we recognized the bias of WHAT WE SEE and the significance of WHAT WE FEEL. When we see a person’s appearance, we judge immediately: “This guy looks like a truck driver and says he is a woman! This woman is so beautiful and says she is a man!” We understood that we were not immune to these effects with face-to-face therapy, and that they could lead to an immediate bias in our judgment.

The Web mail anamnesis removes this bias. On the other hand, for the patient and even for the therapist, personal contact may be very useful, and it is essential in any psychotherapy. If the patient needs psychotherapy, such as analysis, psychodrama, etc., obviously emails will never adequately provide for it. But an anamnesis is not psychotherapy--an anamnesis is a history, in which the less bias the better. Nonetheless, a careful anamnesis via email proved to be insufficient for developing a complete picture of the patient and for proceeding to an accurate diagnosis; we needed additional tools.

Gendercare MFX and FMX tests

We therefore started, at the end of 2001, to develop gender tests designed to elicit data from patients with reference to a number of specific periods of their lives. The first test (MF1) was produced only in Portuguese for use by male-born Brazilians. Hundreds CD’s, TG’s and TS’s took that test, as did many non-GID men, both gay and heterosexual. We have been constantly improving this test since 2002, and presently use the ninth version of it.

We found that all “normal” men (hetero, bi and homosexual) showed a very low level of unexpected femininity (hetero near 10%, bi/homo between 0 and 20%). CD’s tested in the 20-50% range, TG’s at 40-65% and TS’s at greater than 70%. These were global scores, which we define as the combined result for all stages of a patient’s life. Later, after we had thousands of results, we devised a mathematical criterion to differentiate between normal/CD/TG/TS for MtF evaluation and we began to approach FtM evaluation in the same way.

However, we then realized that a single global score was too crude to adequately describe a GID patient’s life, and so we defined four more specific scales:

--The Unexpected Gender Scale

--The GID Scale

--The Sexual Orientation Scale

--The Sexual Action Scale

In addition, deriving four global scores for each of these scales would still be insufficient to fully define a GID patient’s life; what is more important is an evaluation of the dynamic development through time of each of these scales.

In the beginning we calculated by hand a score for each scale for each patient, and we then developed the MFX and FMX test concepts with the intention of understanding the dynamic formation of Unexpected Gender Identity and the other scales. We expressed the patient’s age in terms of weeks after conception, and proposed the following ages as critical inflection points for gender development:

1. During week 1 (the chromosomes)

2. At week 2 (gonadal development)

3. At week 16 (genital development)

4. At week 24 (basal brain development)

5. At week 36 (cortical brain lateralization)

6. At week 414 (childhood self definition, measured by the MFX/FMX tests)

7. At approximately week 550 (late childhood definition, also measured by the MFX/FMX tests)

8. We took into account later ages when the MFX/FMX tests generated significant additional data.

The Unexpected Gender Scale is a measure, at a variety of different ages, of the unexpected femininity (for MtF patients) or masculinity (for FtM patients), with reference to behavior that is typically considered either to be male or female (for example, liking to “play house” is female, while fighting is classified as male). The GID Scale refers to the distinctions between TS, TG and CD. For example, an MtF TG desires breasts, while an MtF CD does not. The Sexual Orientation Scale pertains to the patient’s preference in sexual partners—men, women, both or none. The Sexual Action Scale refers to the patient’s preferences in sexual behavior with a partner, regardless of that partner’s sex.

All the data is extracted from the single test, and so one test answer can affect multiple evaluation scales FOR THE SAME AGE. Next, we plot a trajectory for each scale that reflects the patient’s data for every period in his or her life.

For the Unexpected Gender Scale we analyze the data one step further, subjecting that trajectory to a curve-fitting procedure and generating a phase space diagram to try to understand the attractor and transient stages of the system. For the other scales we study each trajectory directly.

The test result therefore consists of plots of five principal curves:

--- The Unexpected Gender Trajectory plot;

--- The Phase Space Diagram and Attractor Gender plot;

--- The GID scale trajectory plot;

--- The Sexual Orientation trajectory plot;

--- The Sexual Action trajectory plot.

From these plots we may conclude whether the patient shows a typical TS condition, a typical CD condition or a typical non-GID condition. Furthermore, we will be able to see whether the patient reveals any special GIDNOS condition or any ambiguity between TS and TG. We will also be able to detect any inconsistencies between the Phase Space diagram and the GID Scale trajectory, between the Sexual Action Scale and the Phase Space diagrams, and between the overall test results and the earlier email anamnesis.

Comparing numerous patients’ unexpected gender trajectories was not an easy task, and so we developed software to simplify the work. This basic software is applied to the test results and calculates all age scores, all scale scores, all global scores, and yields the phase space data[2] for each patient.

Based on the results of the detailed anamnesis generated by email, and the supplemental information derived from the MFX/FMX tests, we will have a very strong idea about the patient’s need to transition, to change his or her body through hormone therapy (HRT), to need secondary surgeries (breast implant surgeries and facial feminization surgeries for MtF’s and mastectomy for FtM’s, for example) in the future, and even whether the patient will one day need to undergo SRS[3].

The Necessity of Psychiatric “Screening”

However, with only these two evaluation steps just described, we cannot be certain whether or not the patient might really need local face-to-face psychotherapy/psychiatric help. Therefore, as the third and final step of our Web GID Diagnosis we administer the MMPI (Minnesota Multiphasic Personality Inventory)[4]. If the patient shows serious psychiatric problems on this test, we have the option to suggest local psychotherapy or psychiatric consultation. Face-to-face psychotherapy can then be provided locally for the patient, but only if it is necessary. We make a clear distinction between the majority of mental illnesses and GID. MOST OF THE TIME GID IS NOT A PSYCHIATRIC PROBLEM but is a problem of inner harmony and of social recognition (just as alcoholism is not specifically a psychiatric problem, but is one for which psychiatric or psychotherapeutic consultation may be recommended).

Therefore, a patient will only require local psychotherapeutic intervention when our Web evaluation indicates that the GID is in fact a psychiatric problem or when he or she is experiencing serious concurrent psychological issues. Otherwise, the only local assistance needed by the majority of our GID TS/TG patients is laboratory blood analysis and the purchase of HRT medications.

Can We Trust Web GID Diagnosis?

Most critics distrust GID diagnosis via the internet, fearing the falsification of life history and other patient data. On the other hand, it is our opinion that it is very easy to deceive a therapist during face-to-face consultation. A patient’s voice, hair, makeup, clothing, mannerisms, etc. can be very misleading, but falsifying the facts of one’s life history is much less simple. The patient does not really know what is important to us or what we are looking for, whereas he or she may anticipate that a traditional face-to-face therapist is looking for certain obvious things that can be readily faked.

As an example, sometimes a patient will indicate a high level of homosexuality, and focus on his or her sexual drive, but that reveals nothing about gender. We may counter by asking questions about the patient’s gestation, and say we are not interested whether or not the patient prefers same-sex partners. How will a deceitful patient know the “correct” response? It is not easy to manipulate our anamnesis.

Our second step (the gender tests) is virtually impossible to manipulate. How could someone falsify a typical dynamic curve of gender development[1]? And even if it were possible, how could it be consistent with the email anamnesis? The rare patient capable of manipulating these diagnostic steps will have to be very intelligent. And let us not forget that later on the MMPI may also reveal patient deceitfulness. After diagnosis, in the few cases where we might have a slight doubt, we may elect to start HRT at a very modest level. Even so, proceeding this far in the process (in order to obtain HRT, for example) will have cost the patient some $400 to $600, which limits the number of people who will want to entertain themselves with this kind of trickery. In short, it is very improbable that a patient will try to deceive us, and it will be nearly impossible to succeed.

Gendercare Post-Diagnosis Patient Follow-up

A complete diagnosis, with its 3 steps, requires from two to four months, sometimes more. During the diagnosis phase, we discover the patient’s main problems and limitations. After the complete diagnosis, the patient will need to make a decision about a gender transition, and we assist in this process. For the most common TS situations, after a positive diagnosis we suggest our Transition Pack for the first 6 months, enabling the start of transition and HRT. At that time we request a scan of the blood test results (baseline levels, always, and after the start of HRT, at intervals when we deem it necessary), we request photographs or videos of the patients (in order to recommend HRT, beard and body hair removal, hair restoration, secondary surgeries such as breast implants and facial feminization for MtF patients and musculature development and secondary surgeries such as mastectomy for FtM patients), and we will sometimes request voice files to aid us in suggesting voice modification.

After the patient starts using our Transition Pack, what is most important for us is to gauge his or her response to the transition. Our principal objective is to know if the patient IS HAPPY with the transition and we listen closely to detect any APPREHENSIVE FEEDBACK. If any problems with the transition arise, we may decide to stop or slow it. During transition, regardless of whether the patient is following our “butterfly strategy[5],” we are continually evaluating his or her chances of surviving during transition, and of later surviving in the target gender as a stable person with a productive professional career and a normal life.