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Gendercare Gender Clinic

5 years helping Gender Dysphorics

 

A Professional Web-Based Gender Dysphoria Counseling Service

*That is a part of a full paper that is still in preparation*

Copyright ©2006: Gendercare.com

 

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].

 

Abbreviations used:

CD- crossdresser

DHT- di-hydro testosterone;

FMX- female to male unexpected gender Gendercare test;

GI- gender identity;

GID- gender identity disorder;

GIDNOS- gender identity disorder not otherwise specified;

MFX- male to female unexpected gender Gendercare test;

SRS- sex reassignment surgery;

T- testosterone;

TG- transgender;

TS-transsexual;

 

 

 

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.

 

Most patients after the first 6 months continue on their own way for some time without purchasing a second Transpack from Gendercare, either due to lack of resources or due to relying on local supervision. Then one day they usually return, saying, “Now I am ready for a secondary surgery or for SRS” (after their diagnosis with us, they gain THE RIGHT to purchase an SRS referral letter from us someday, after a rough verification that they are ready for it, through pictures and emails).  Some others continue for a year or more under our supervision, until they have SRS and continue until the end of the PostOpPack supervision.  A few patients decide to seek HRT supervision locally and a few change their minds and stop their transition (mainly due to lack of money or hope for professional advancement, or even from fear of starvation or misery).  Regardless of the patients’ decisions, we always try to maintain contact with them and help in any way possible.

 

Certain patients, at some point--even some from prosperous countries—indicate that they are experiencing extreme financial difficulties.  Even many TS and TG people in the U.S. are unemployed, homeless and without health care due to a lack of government social services. We do our best to accommodate them, sometimes at no charge.  This is most often the case with patients from India, Latin America and some African countries, but is also true for some U.S. citizens.

 

Sometimes in Brazil, or even in the U.S., some patients may not have access to local assistance or may have reasons for not wanting to utilize it. This is mainly the case when there are no local clinicians, psychotherapists or endocrinologists, or secondarily as a consequence of having had a negative experience with local health care providers.  When one of our patients is simultaneously receiving local counseling, we are always available to communicate through emails with any local professionals (the Brazilians are more open to us in that respect – probably because of the common language, and because they recognize they may be lacking in certain expertise) and sometimes they accept our suggestions and orientation.  There are other times when a patient will find it necessary to choose between local supervision and ours.

 

The MtF HRT regimen we recommend sometimes is not the most conventional one.  In Brazil the usual anti-androgen is cyproterone acetate (Androcur), while in the US it is spironolactone.  Sometimes we do not use either, and instead recommend Depo-provera (injections or tablets), which is inexpensive, reversible and effectively nullifies androgen production (this is the recommendation we received from Dr. Dorina Quaglia, MD, PhD, an endocrinologist and psychotherapist). We sometimes refer to the use of Provera in this way as “chemical castration.”   In addition, we also generally recommend for MtF’s a simulation of the female hormonal cycle (men are linear, women are cyclical), mainly using medications commonly used for HRT by post-menopausal women.  Sometimes, when the patient cannot afford the pills, we recommend injections (including for patients with liver problems, for whom oral hormone administration is too risky), and other times we recommend estrogen patches, which are too expensive but are better for the liver. For FtM patients, HRT is much simpler, but it can also be very dangerous. We suggest testosterone patches if possible, or injections. The lowest possible level that will produce the desired physical changes is best, because it will minimize the possibility of circulatory and cardiac problems.  We always try to find the best balance for each patient between the health benefits, the pace of transition we and the patient think is best, and cost-effectiveness.

 

When it is needed by a local clinician or other local authorities (including law enforcement), we send the patient a letter with our complete evaluation, setting forth our diagnostic process and explaining that the patient has GID and is undergoing a supervised gender transition.  Later, if the patient needs any surgery and if the time is appropriate, we will furnish referral letters, and we suggest the best techniques to achieve the results the patient desires as well as provide information about the limitations of those techniques.  During any surgical process, we remain in contact via email with the clinic and the surgeon, as we do with the patient during the recovery phase.  Finally, we continue communicating with the patient after recovery from SRS to help him or her attain a normal life as soon as possible.  All these activities are conducted effectively by means of the internet.

 

The Necessity of Local “Face –to-Face” Psychotherapy

 

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.

 

Psychotherapy is not required to treat GID, but it is needed to deal with related or concurrent problems such as depression, hysteria, paranoia, schizophrenia, OCD (obsessive-compulsive disorder), BAD (bipolar disorder), etc.  When a patient has any of these problems in addition to GID, our procedure is to treat the GID in a light way, which generally involves a very slow transition and a low level of HRT, in order to give the patient time to show us his or her adaptation to the changes, including those psychological changes that are likely to happen. At the same time, we request that the patient find local support for the other problems. The problems we find associated or concurrent with GID are rarely serious, and so we often suggest art therapy, occupational therapy, and in addition most of time we suggest that the patient study for at least a university bachelor’s degree in order to build a productive career. In general, we do not particularly favor psychoanalysis for people with GID, nor do we ordinarily recommend psychiatric medications such as for depression or for any other GID-related psychiatric condition.  In this respect we prefer softer therapies such as occupational therapy and art therapy, for example.  In Brazil and elsewhere, occupational therapy is very common, and is even utilized in prisons.  Working in a garden or on a small farm, or doing handcrafts or even sports, can be very healing for some conditions. Art therapy can be equally helpful in many cases, as is also true for some techniques of Asian origin that now are well-known around the world, such as yoga and tai chi, among others.  In the end, of course, the decision about the treatment modality depends on the patient and on the available local resources.

 

Integrating Web and Face-to-Face Procedures

 

Gender counseling via the Web has now developed to the point that it can be integrated advantageously into a more traditional psychotherapy practice.  The value of the MFX and FMX tests is not limited to the internet--they can augment any anamnesis and face-to-face evaluation.  The same is true of the Game Tests for children.  For example Gendercare developed a partnership with the Hospital de Base de São José do Rio Preto (Dr. Cury’s hospital), whereby the patients may try our MFX/FMX tests at a 20% discount to complement the local conventional diagnosis.  Other therapists, clinics, hospitals and institutions from other countries are also invited to establish similar arrangements. To discuss conditions for a partnership with Gendercare, please access www.gendercare.com and use the contact page.

 

The Inadvisability of Web Psychotherapy

 

We are not advocates of Web psychotherapy. Our position is that true psychotherapy should only be conducted on a face-to-face basis.  Our service is not psychotherapy—it is gender therapy, and these are two completely different things. We have never recommended Web psychotherapy and have no intention of doing so.

 

SRS Follow-up through the Web

 

We are virtually always in communication with our patients and the surgical staffs during surgery and recovery. Only one U.S. patient, who had MtF SRS with Dr. Kunaporn in Thailand, expressly declined our assistance during this period, and only wanted the SRS referral letter (which was serving as a second opinion, since she already had another SRS referral letter). All of our other patients have asked for our assistance during their surgeries. We believe our help is important for all patients, but particularly for our Portuguese-speaking patients to have more support when they are in a foreign country such as Thailand for MtF SRS for example, or the U.S. for FtM metoidioplasty, etc.

 

Of course the surgeons and clinics are not always perfect.  On one occasion we had a very small problem with a Swiss patient of Dr. Suporn.  For some time after her surgery, she said she could not urinate on her own. Dr. Suporn explained to both of us that hers was a psychological problem arising in part because she was not waiting for her bladder to fill, and later reality showed that Dr. Suporn had been absolutely right.

 

A Brazilian patient of Dr. Kamol had a wonderful SRS, and she also simultaneously had rhinoplasty, but did not like the size of her new nose, although today she is very satisfied with the results of both procedures (she didn’t wait until the swelling receded fully before evaluating her new nose, but at the time she would not accept our explanations nor those of Dr. Kamol).  In Brazil some patients of Drs. Jurado and Cury have expressed complaints related to the depth of their neovaginas, but an improved dilation regimen solved those problems with minor effort.

 

The only difficult situation we have been involved with occurred some time ago when a patient of Dr. Cury had a small problem with some sutures that became loosened in the interior of her vagina. She became desperate and refused to ever again see Dr. Cury.  We arranged for Dr. Jurado to correct the problem, which he easily did.

 

In summary, we have had nothing but success with our SRS referrals, with only the rare problem that has been easily remedied every time.

 

Acceptance of Gendercare SRS Referral Letters

 

We have never had a problem, either in Brazil or in Thailand, with our patients obtaining SRS with our referral letter alone.  Dr. Kamol in Thailand generally requires a second opinion, but he accepts SRS and FFS patients based on the Gendercare referral letter alone.  Because I am a professional practicing in a country foreign to many patients, many (including some in the U.S. and Canada) express the fear that what we do is not acceptable in their own countries. We generally have no problems, but even in Brazil there have been occasions when a local practitioner would not accept Web documents originating from a distant professional.  We understand this situation, and it is a relatively new one.  In part this is a manifestation of market protection, with some health care providers disliking the idea of having “outsiders” trespass in their territory.

 

Post-op MtF SRS Patients Have Normal Lives

 

After surgery, some patients continue to communicate with us when they have a problem or an idea, but most of them simply begin living as normal people.  Having changed their names and papers, they then go about their new lives.  Our significance to our patients is transitory, during their time of need.  This is the best outcome for our patients, and we hope that they will gradually forget the difficult times they experienced.

 

After SRS and a normal post-op period, generally less than a year, almost all of our GID patients want to live normal lives.  We respect that.  Some of our patients eventually marry.  Two of our MtF patients, one European (after SRS by Dr. Suporn) and one Brazilian (after SRS by Dr. Kamol), told us they had gynecological examinations, and in both instances the gynecologist had a difficult time believing they were not born women. The European patient today operates a small business enterprise with her husband, and the Brazilian patient is currently an English teacher. Both of them are legally documented as women, and they lead women’s lives.

 

Regarding Gendercare’s Adherence to the SOC-6 of HBIGDA

 

The HBIGDA principally has a symbolic influence on GID health care.  In Latin America, with several hundred thousand or possibly even millions of potential patients served by a mere two or three full members of HBIGDA, the Standards of Care—even when they have been heard of--are almost universally ignored, and the same is true in most countries around the world.  In Brazil we suggested to the CFM (National Council of Medicine) that they consider adopting a form of the SOC of the HBIGDA, but they only adopted selected aspects, and they made no formal reference to the SOC or to the HBIGDA.  Their main objective appears to have been to protect the health care market for Brazilian medical doctors, which is what usually happens all around the world.   In the U.S. and Canada, home to most of the directors and membership of the HBIGDA, the SOC is taken far more seriously, but the document is not truly “international.” Not even all the European nations follow the SOC closely, other than Great Britain, Holland, and sometimes France, Germany and Italy.  However, we do consider the HBIGDA SOC-6 an important document and we do take it into account even though we do not follow it to the letter. In general we do follow the SOC-6 of HBIGDA, even though nothing is written in the document that pertains explicitly to Web GID Diagnosis.  This will need to be included in the SOC in the future, and such a revision will need to be conducted with the participation of people who have experience in this emerging field.

 

Our principal disagreement with the SOC-6 of the HBIGDA concerns the necessity of the “REAL LIFE EXPERIENCE” of approximately one year.  Our transition strategy is different.  After diagnosis, the MtF body will need one to two years to change sufficiently to be ready for possible SRS. The same delay is necessary for the FtM body. The SOC-6 mandates that this period be one of full social exposure in the new gender role, EVEN WHEN THE PATIENT RISKS THE LOSS OF EMPLOYMENT, FAMILY, AND EVEN VIOLENCE.  We do not agree with this procedure. We recommend instead that during the physical transformation process the patient not transition socially but rather prepare himself or herself for a new professional life in the new gender role, i.e., IN STEALTH MODE WITHOUT ANY SOCIAL EXPOSURE DURING TRANSITION.  We call this transition strategy “THE BUTTERFLY STRATEGY,” to allow adequate time during transition for the complete alteration of the body and for preparing a new life and very possibly a new career.

 

My personal history offers a good example.  As a male I was a well-regarded engineer in Brazil. I was a director of some companies, a manager of others, and was responsible for some of the largest industrial plants in the Brazilian fertilizer industry. I was often a project manager or the manager of technology development for a project.  As of the day I began MtF transition, because of social ostracism it was no longer possible for me to work as an engineer anywhere in Brazil.  It was necessary for me to develop a new profession, and I chose psychotherapy, gender therapy, sexology, and began studying for my MSc and a new career.  It required a number of years to transition into my new life (I needed 5 years to develop my new professional career and eight months to develop my “new body”).  During this period a useful strategy is to hide temporarily and appear later as a “butterfly”, after some time has passed.  The beginning of my transition was not the proper time to expose myself to society (especially to family and co-workers), and I also think this is true for the majority of my patients.  Accordingly, we do not use that strategy unless the patient requests it.  And almost all of our patients prefer our strategy and decide to follow it.

 

Some patients younger than 30, sometimes because of romantic involvements, attempt a faster transition with less preparation, but more mature people almost always prefer our “butterfly strategy.”  In parts of the U.S. and some European countries where anti-discrimination laws have been enacted, and where society has otherwise become less hostile to gender transitions, the “real life experience” is more practical.  In many other places in the world, and even in some European countries and in certain areas within the U.S., the one year “real life experience” may mean death by murder or starvation, or criminal prosecution for prostitution.  To live under the European Human Rights Court, which allows a TG or TS starting transition to obtain a legal name change, and later after surgery a change of gender on all legal documents, is one thing; to live in a place where one personifies shame and defiance of God and society, without being able to change one’s name and with no protection, may amount to suicide.

 

The mandatory complete “real life experience” is not a proper strategy for the majority of our patients. We are certain that a period of one to two years spent preparing for a new professional career and transforming the body is sufficient for any patient to adequately adapt to life in the new gender.  Sometimes, the RLE procedure is more reflective of the uncertainty and ignorance of the therapist—who will never have to experience the RLE--than of the needs of the patient.  We prefer to do all we can in a patient-centered fashion, preserving the patient’s opportunities—and his or her life--to the maximum extent possible.

 

We also do not agree with the HBIGDA SOC-6 requirement of two approval letters for SRS, which is good in principle, but in practice is sometimes used to needlessly extract money from poor patients and close doors to others. What is important is not only the number of letters, but also the quality of the diagnosis each represents.  It is a well-meaning procedure to require two letters showing good diagnosis, but surely one letter from an excellent clinician is far preferable to two letters from poor clinicians.

 

Over time the impression has built that the mandatory requirement of two referral letters is mainly a feature of U.S. surgical practice.  In Brazil, where there are few services for GID patients, such requirements are absurd.  In the small Brazilian public health care sector dedicated to GID patients, all of them must be supervised by the same group of therapists for at least two years, and are allowed HRT and surgical treatment only by doctors who are part of the program.  These surgeons will not accept referral letters from “outside” therapists, nor will they refer patients to other surgeons.  Even more absurdly, a patient’s record of therapy is non-transferable from one local public program to another; someone moving from São Paulo to Rio de Janeiro, for instance, after a year and a half of therapy, must begin all over again.

  

In actual practice, many SRS surgeons around the world do not require two referral letters, or commonly make exceptions to the requirement.  In Brazil, Dr. Jurado, in private practice, requires one letter from an endocrinologist and another from a gender therapist.  Dr. Cury, also practicing privately in Brazil, has his own psychotherapy staff to evaluate patients, and also accepts letters from Gendercare.  In Thailand, Dr. Kamol prefers his patients to have two referral letters, but accepts only one if it is ours, because of the richness of information it contains and because he knows how closely we monitor each patient’s progress.  Dr. Suporn requires letters only in specific situations, in part because he has his own local psychotherapy staff to evaluate patients, and he waives local psychotherapy for patients who have our referral letter. Dr. Kunaporn also suggests two letters, but does not make it an absolute requirement.

 

Thanksgiving

 

We would like to thanks Sonia John for her edition and English revision of our text.