An Argument for Ethical Treatment of Sex and Gender-Diverse People by Professional Caregivers

Originally appeared in Transgender Tapestry #101, Spring 2003.

By Tracie O?Keefe

I remember April Ashley, the famous English woman of transsexual origin, saying to me: ?I just don?t understand it, darling. All those professionals are just poking their noses in your business. In my day, you just took hormones, had an operation, and that was it.? April, as anyone who knows her will tell you, has always been an individual in her own right. Because all her life she has had to be a groundbreaker, she took a lot of flack, so she had to create her strong survivor persona.

Of course, there have been many people who have adjusted their sex and gender identities with minimal professional help, and done very well in their lives. However, for most people who undergo some kind of sex and gender transition, it can at times be difficult, confusing, isolating, and overwhelming. Truth be told, even April, when she was barricaded above her restaurant in London?s Knightsbridge, hiding from the press, could probably have done with some help.
Professionals who care for sex and gender diverse people have to be sure that when they put their names and signatures to a referral within their clinical practices, it doesn?t backfire and haunt them at a later stage. There have been several court cases against surgeons who have performed sex reassignment surgery by individuals who later changed their mind. A lawsuit for negligence can ruin a professional?s reputation, stop them from helping others, bankrupt them, and put their family out on the street, ruin their life, and even stop them from practicing medicine. It?s right and proper that all professionals helping sex and gender diverse people be sure they are assisting their clients to do the right thing?for that person. Caution andconsideration have always been my bywords as a professional therapist?fashionable or not.

There have been many suicides of people who have made some kind of transition and found life was too much for them to cope with. The issues facing them had not been carefully gone into in therapy, and they believed the transition would solve all their problems?not so. There have also been cases of intersex people and other sex and gender diverse people who have committed suicide because of what has been done to them by professionals without their permission. Many suicides have occurred when a
person has undergone surgery because of advice given to them or pressure put upon them and their relatives to carry out surgical treatment. Sometimes this has happened when the person was a child, and sometimes during adulthood.

It is a fine power balance that must be sought between professionals and those who want, need, or desire to alter their physical, psychological, and social identities. In different cultures, the power balance translates differently, throughtradition and varying intellectual and social equations.

For me, as a psychotherapist, I enter into a power-sharing relationship with the client, in which we mutually try to find the best way forward. I try not to set myself up as gatekeeper. I believe it?s never my place to tell a person what they are. I don?t live in their bodies, look out of their eyes, or feel what they do, and I also won?t have to face the consequences of their actions. I try to think of myself as a hat-check attendant?I just hold their coat while they figure things out. I might point people in a direction in which they can find answers themselves, but I try not to shove or push, and never prevent them from moving in the direction they want.

I?m a great believer in holding people responsible for their own actions. I always tell people we?ll talk a great deal, though at the end of the day it?s their decision and they can choose. If they get it right, the glory is all theirs, but if they get it wrong, that?s also down to them. I refuse to take the responsibility of making choices for my clients. Even clients who have emotional or social problems can be given the freedom to choose. I?m not a coward, just a facilitator. If someone has a mental illness, that?s entirely another scenario, but the majority of gender-variant people are quite sane, given the chance.

When I write a referral for hormones or surgery, I don?t say what the person is, just that they?ve told me what they think they are. My observation is that they seem to have explored their issues sensibly and reached some kind of rational understanding of their situation.

Medicine, psychology, and social work are, however, often shrouded in mystery and secrecy. The wishes of the central component?the client?are often left out of the decision-making
process, or ignored purposefully. The hierarchy of knowledge and access to services can easily be abused by professionals, even though that isn?t always the intention. It?s often due to ignorance of the professionals involved.

Unfortunately, some professionals, whether for the sake of their own egos or fear of being sued, don?t let their clients make decisions of their own free will. I see these clinicians as dangerous. They generally belong to the old school of medicine, seeing themselves as godlike figures and believing they know better than the rest of us. They will protect their power bases at any cost.

One of my great friends, a Native American, described them as forked-tongued. ?Is their mouth opening when they speak?? she asked me. ?Yes,? I replied. ?Believe at your own risk,? she proclaimed. ?They used to have rifles. Now they have letters after their names. They?re the worst kind, because at least when they had rifles, you knew when they were going to shoot you.? Science and research are the new religions and demigods... pay your money and take your chances.

I remember sitting next to a psychiatrist at an international conference on gender dysphoria in 1994. He told me he treated his patients with the Bible. Being a confirmed atheist, I wondered what he did with it?get them to sell Bibles so they could pay for their surgery? Nothing so harmless, I?m afraid. His idea of treatment was to make his patients recite Bible passages in his office. He told me he was the leading authority in his country.

When I moved to Sydney in 2001, I met clinicians who were still trying to deny that transgenderism is a reality; they still believe everyone should fit stereotypical transsexual profiles. They couldn?t get their heads around the idea that someone may just want an orchidectomy or to have their breasts removed, or to crosslive without hormones or surgery. Choice can be just as legitimate as necessity, but that was not pathology, so they couldn?t accept those concepts.

So what am I talking about? Well, I?m talking about removing the need to imbue people with pathology just because they wish, need, or desire to alter their sex assignment or appearance. That, of course, would mean changing the name of the Harry Benjamin International Gender Dysphoria Association, replacing gender dysphoria with something like ?sex and gender diversity.? Ideas like these are popular with many gender-variant persons. Many are even members of HBIGDA, but they?re afraid to put their name to such a motion until the ruling faction of the HBIGDA indicates it wouldn?t be upsetting to key members.

There is a counter argument, however, to taking that route. Some people propose that such a name change will give the insurance companies a let-out from paying for treatment, letting them argue treatment is elective and/or cosmetic, and not necessarily life-saving. The same is also said of government funding for treatment. Those who have not already had surgery become nervous for fear insurance coverage might be denied, leaving them without options. However, women receive funds for abortions without having to be pathologized. Some women in the high-risk cancer group choose to have their breasts removed; they aren?t pathologized. Men have vasectomies and circumcisions without being pathologized. So why should people who are gender-variant, those who wish, need, or desire to change themselves, be treated differently that the rest of the human race?

On Clinical Abuse and HBIGDA

Some of you reading this will have heard before about clinical abuse by
professionals. I wish I would no longer have to write about such things, but such abuse is ongoing. Writing about it has made me unpopular with some professionals who would prefer these sort of matters stay buried and never come to light?and this includes members of HBIGDA. Although clinicians say they don?t consider transsexualism and gender variance a mental illness, the vast percentage of clients are indeed treated as if they are mentally ill.

When, at the 1999 HBIGDA conference, I spoke of such abuse, board
member Leah Schaefer asked surgeon Michael Brownstein to form an ethics committee. I attended the first meeting of that committee around a dining room table in London and it was said it would set out to do great things. Certainly, a code of ethics was wheeled out, which, to be honest, could have belonged to any professional association?but it has never been implemented.

In the latest HBIGDA members-only newsletter, it was announced that the ethics committee had been reduced to an educational committee. Ethics committees are not set up to be educational, even though that may be part of their criteria. They are set up to tell members of professional associations how they must and cannot behave. They are regulatory bodies that assure the public that their members will behave in an ethical manner.

When I asked that committee to support a motion that clinicians should not be allowed to withhold treatment after a three-month assessment period, I was told the committee didn?t want to get involved with controversial issues. This proposal went down like a lead balloon, and members of the ethics committee ceased to communicate with me. The reality, in my opinion, is that at the moment the ethics committee is little more than window dressing.

In fact, I was excluded from that committee without ever being informed, and I found out only when I received the latest HBIGDA newsletter. I asked Michael Brownstein to place me back on the committee, but he refused. The ethics committed has been reduced from around 20 members to a select three, or maybe four, as I was told by President Eli Coleman. But it has been made clear that in no way was I allowed to be the fourth, even though I also represented many views of the gender community, as well as being an experienced clinician. What I was also told was that no one can sit on the HBIGDA committees unless the board approves them?so much for democracy.

I?m aware some members of the HBIGDA hierarchy consider me a live wire or loose cannon and that many of my ideas threaten to upset their apple carts. The old power base at HBIGDA is
diminishing, and they fear their demise. Jamison Green, the trans activist on the liaison committee, recently circulated an e-mail that requested members to be more open and honest about the running of the organization. That?s unlikely to happen until the membership and leadership of HBIGDA is predominately
gender-variant people and the old-school members are placed in a position of
service rather than dominance.

There?s no doubt in my mind that there is much transphobia within the HBIGDA, based on the fear that the lunatics are taking over the asylum. Well, for those of you who are afraid, let me tell you that we, the trans, androgyne, and intersex people of the world, are taking back control of our own lives.

I have heard from some clinicians who haven?t joined HBIGDA because of the way some members treat their clients. I?ve witnessed wonderful work done by dedicated professionals who are members; there are clinicians to whom I would give medals if I had them.

The intersex community is deeply paranoid that they may end up being treated as badly as the trans community if they allow the central core of the HBIGDA to dictate treatments for them. I understand exactly where they?re coming from. There?s no doubt that the way some of the members treat their patients/clients violates human rights.

I believe HBIGDA is worth fighting for, but in an altered form from how it is presently run. I may not survive that transition, since my bridges are well and truly singed with the current HBIGDA board. As I?ve said, there are many fabulous members of the association who treat their clients amazingly well and who are prepared to listen to what sex and gender diverse people want. Of the clinicians in the world who are highly abusive to sex and gender diverse people, some aren?t members of HBIGDA, and some are. If HBIGDA refuses to take responsibility for monitoring and directing its members, then it begs the question: why should anyone trust its members?

It?s time for big changes. First and foremost, the name of the association needs to be changed. Gender dysphoria must be removed from its title, as it is no longer applicable. We are sex and gender diverse, and the professionals need to catch up with us. Remember, dinosaurs are a long time dead.

HBIGDA must not only stand for ethical treatment of people who are sex and gender diverse, but also stand against unethical treatments of the very same. To do otherwise is less than professional and responsible. Turning up at a conference every two years and patting each other on the back was not why I joined HBIGDA, and certainly not what I pay my membership fee for. I want change and I want it now?my
fellow sex and gender diverse peers have suffered enough.

If you?ve thoughts on or support changing the name of the HBIGDA, or if you wish to see clinicians prevented from withholding treatment, please write to me directly.

Dr Tracie O?Keefe, DCH is a clinical hypnotherapist, psychotherapist and counselor, originally from the UK and now living and practicing in Sydney, Australia. She can be contacted at 27 Meymott Street, Randwick, Sydney, NSW 2031, Australia or by email at Website: