Stresses Psychological Dangers

Copyright 1979 - TRANSITION

Garrett Oppenheim, Ph.D.

***From TERRANET, San Juan Capistrano CA, 714-248-2836

"Should every patient who comes in asking for hormone therapy receive it? I used to feel that most of them should, but now I look at this request a bit more critically." The speaker is Dr. Charles L. Ihlenfeld, and the occasion is a combined meeting of Confide's crossgender counseling groups in Tappan, New York.

What has happened to modify the attitude of this well-known friend and adviser to the transsexual community? For one thing, a three-year residency in psychiatry, which Ihlenfeld completed last year. Previously, as an internist and associate of Dr. Harry Benjamin, the pioneering researcher in transsexualism, Ihlenfeld had for six years been administering hormone therapy to patients with gender problems. He found himself giving a lot of counsel as well, and in the course of his contact with some 500 cases of gender dysphoria he became deeply interested in the psychological aspects of transsexualism.

"I didn't want to be an amateur psychiatrist," he told the Confide group members, "so I decided to become a professional." That meant quitting practice and going into the long training program from which he has now emerged as a full-fledged psychiatrist.

"Perhaps my psychiatric training has made me more conservative," he remarked. "I hope it has made me more responsible."

Reasons for Caution

Among the reasons for exercising extreme care in giving hormones, according to Ihlenfeld, is the fact that 80 percent of the patients who want to change their sex shouldn't do it. "There is too much unhappiness among people who have had the surgery," he said. "Too many of them end as suicides." The transsexual candidate, he added, has been described as "the only patient who diagnoses himself and prescribes his own treatment."

Even though the physical effects of hormones are largely reversible, he pointed out, their psychological effects often are not. The very fact that a doctor clears the patient for hormone therapy, he said, can act as a self-fulfilling prophecy for that patient. It may signify to him that his fantasy has received confirmation from the medical profession and that there is now no turning back."

Hormone therapy also reinforces the tendency, common among transsexuals, to shy away from psychotherapy, Ihlenfeld continued. There is always the fear, he said, that if a doctor looks too deeply into their psyche, he will take away the dream of sex change that has nourished them all their life. "`No psychiatrist is going to change my mind,' they will tell you."

The Role of Anxiety

And once on hormones, the patient is likely to feel better and calmer, Ihlenfeld noted. In the male patient, he said, the sex drive quiets down, anxiety diminishes and he has a feeling of psychological well being. But anxiety, in the eyes of this psychiatrist, is a powerful stimulus to accept therapy; it also provides much of the material for the therapeutic sessions. "Without anxiety, the patient may be deluded into thinking he can go it on his own."

Yet therapy, according to Ihlenfeld, has an important place in the treatment of ALL persons who want to go the transsexual route. "It's not just a question of surgery or of screening out those who are psychotic or emotionally unstable; it's the question of what the patient is going to do with the rest of his life that has to be resolved. Therapy can give him insight into himself and into his feelings that he needs to change his anatomical sex."

That need, Ihlenfeld thinks, is most likely to stem from powerful psychological factors -- mainly from the experiences of the first 18 months of life. In the past, Ihlenfeld tended to attribute greater importance to prenatal biological factors that might predispose a child to transsexualism.

"Still, there must be SOMETHING inborn," Ihlenfeld conceded, "because when two children are reared in the same family, only one of them is likely to become a transsexual. We still have a lot to learn about the precise contribution of environmental and constitutional factors."

For reasons such as these, Ihlenfeld is against giving hormones to persons under the age of 18; in fact, he prefers that they be at least 20 to 21 years old before they start on this route. "I did have one patient who had surgery at 17 and is doing well,m" he said. "But in general, identity is still fluid in adolescence. There's a chance that gender feelings still might change."

Ihlenfeld cited the work of Dr. Richard Green, who has attempted to identify potential transsexuals before puberty and to alter their gender identity. But it's difficult to identify transsexuals when they are children, he added. "I feel that people even in their mid or late adolescence should look first -- with the help of psychotherapy. by contrast, if a genetic male living as a female came into my office and I learned she had been on hormones for 12 years, was mothering children and didn't want to live as a male, I would strongly urge surgery for that person."

Any psychiatrist, Ihlenfeld feels, can do a transsexual evaluation, "but the patient will probably be better off if he can find one who believes that hormones and surgery should be a therapeutic option for some patients."

Before making any final evaluation, Ihlenfeld likes to see at least one person who is close to the patient -- a parent, a spouse or lover, a brother or sister, perhaps. "It not only gives me a more rounded view of the patient, but it tells me whether I was right in believing everything the patient said -- which I tend to do."

Favors A Team Approach

Even when a patient has been cleared for hormones, he should go through the whole prescribed program -- two years on hormones and six months to a year living completely in the role of the other sex prior to surgery -- Ihlenfeld believes. During this period, he said, it's best to have a team of experts on his case. Although Ihlenfeld himself is an old hand at administering hormone therapy, he no longer does this in his psychiatric practice. "I don't want to take complete charge of a patient," he emphasized. "I think the different aspects of his treatment should be separated so that different people involved in the case can talk it over and arrive at opinions by consensus."

What about hormones without surgery? "In certain cases, that's a valid alternative. But on the whole, I like to feel that the candidate who's accepted for hormones will probably prove to be among the 20 percent who SHOULD have the operation."

Even for that 20 percent, Ihlenfeld feels, sex change is by no means a solution to life's problems. He thinks of it more as a kind of reprieve. "It buys maybe 10 or 15 years of a happier life," he said, "and it's worth it for that."

But statistics on postsurgical transsexuals are hard to come by, Ihlenfeld admitted. "People who have had the operation tend to disappear in their effort to be accepted in the world as women or men, rather than as transsexuals."

Hormones For The TV?

Turning to transvestism, Ihlenfeld offered a Freudian interpretation of its cause. The TV, he said, dresses up to reassure himself somehow that he is still masculine -- that his penis is still there.

Benjamin, he recalled, used to give a small dosage of female hormones to transvestites who couldn't control the compulsion to crossdress, the theory being that reducing the sex drive would also reduce the compulsion. "I treated a few patients this way," Ihlenfeld said, "and it did seem to help -- at least for a while. But for some, the resulting feminization was socially and maritally unacceptable."

TV's, he remarked, have a greater tendency than TSs to accept therapy, largely because crossdressing so often gets in the way of normal living.

Dr. Ihlenfeld is a valued member of Confide's advisory board and the author of several widely quoted papers on transsexualism. He has a private psychiatric practice in New York City.

Reprinted from TRANSITION, No. 8 - January/February 1979 Copyright 1979 - TRANSITION/Garrett Oppenheim, Ph.D. SOURCE: J2CP Information Services