Since it’s pretty clear you people really like reading about all things tangential to sex, I don’t mind indulging your secret freaky sides every once in a while. Hey, far be it from me to deny you! So in that spirit, this week’s topic is….
wait for it….
The Oxford Dictionary has this to say:[sey-doh-mas-uh-kiz-uhm]
interaction, especially in sexual activity, in which a person enjoys or derives pleasure from inflicting or receiving physical or mental suffering upon or from another person.
Abbreviation: S&M, S and M
The shrinky dink version from the American Psychological Association Dictionary version:
1. sexual activity between consenting partners in which one partner enjoys inflicting pain (see sexual sadism) and the other enjoys experiencing pain (see sexual masochism).
2. a paraphilia in which a person is both sadistic and masochistic, deriving sexual arousal from both giving and receiving pain. —sadomasochist n. —sadomasochistic adj.
The Mark G. Agresti version:
deriving pleasure or gratification from inflicting or experiencing pain.
It’s important to note that both the pain and pleasure given and/ or received in sadomasochism can be physical, emotional, or both. In addition, when it exists in the strictest definition, it is considered a mental illness, but there are all sorts of conditions and considerations- and controversy- that go along with that. I’ll elaborate a little on that later. No matter who you listen to or what you believe, sadomasochism tends to be a rather delicate topic, and strictly speaking, not exactly one you’d discuss in “polite society.” Whatevs. I’m all about taking deep dives into that kind of stuff- it’s actually one of my missions in life- and in fact, my entire profession centers on helping people with delicate issues that aren’t talked about in “polite society.” Despite not being coffee talk, there’s a lot to be said about sadomasochism… including the fact that many people exhibit sadomasochistic tendencies, which is not to say they regularly wear black leather gear or want to tie their partners up and beat them btw. I’d even venture to say that most people, eapecially when in romantic love relationships, exhibit characteristics of sadomasochists. How does that grab you? If you’re thinking Ineed my head examined right about now, then keep reading about the psychology of sadomasochism.
But first, I have to get into where the term sadomasochism comes from, break it down (pun intended), look at its nominal derivation, and how it’s been viewed and analyzed throughout the ages. Let’s just say that shrinky dinks have had a lot to say on the subject.
Captain Obvious says that sadomasochism is the mashup of sadism and masochism, terms coined in the late 1800’s by an Austrian psychiatrist dude named Richard von Krafft-Ebing, who believed that the natural tendency of the male was toward sadism, while the natural tendency of the female bent toward masochism. What!Everrr! In reality, studies show that sadistic fantasies are just as likely to occur in females as they are males, though the masochistic bend definitely develop earlier in males. We now know that, like many things, sadomasochism knows no gender. When you break it down, sadism is defined as pleasure or gratification gained from the infliction of pain and suffering upon another person, while the counterpart, masochism, is the pleasure or gratification of having pain or suffering inflicted upon the self. At the simplest, most basic level, you could say that sadists get off on dishing it out and masochists on taking it. Now, how often are things that simple? Like never, people. And believe me, that’s the case here. But this generalization works just in terms of remembering which is which. That said, there are no clear lines dividing the two, and in practice, they’re often interchangeable and may even coexist in the same individual at different times.
Krafft-Ebing named sadism after the 18th century Marquis de Sade, a French nobleman, revolutionary politician, philosopher, and writer. He is most famous for his libertine sexuality, and he ‘graced the world’ with novels, short stories, plays, and dialogues, including Justine, which is basically about a woman with the same name who travels around the world getting the crap beaten out of her as she goes, and Les prospérités du vice, which roughly translates to something like the pleasures of vice, in which he said:
How delightful are the pleasures of the imagination! In those delectable moments, the whole world is ours; not a single creature resists us, we devastate the world, we repopulate it with new objects which, in turn, we immolate. The means to every crime is ours, and we employ them all, we multiply the horror a hundredfold.
Two of his most commonly annotated quotes:
“It is always by way of pain one arrives at pleasure.“
“I’ve already told you: the only way to a woman’s heart is along the path of torment. I know none other as sure.“
Sounds like a great guy, right? Evidently, his current day ancestors have been very busy trying to rehabilitate their great great great whatever’s image by creating a line of gourmand treats: wine, pâté, cheeses and such; and supposedly had pitched a Sade line of lingerie to Victoria’s Secret. Another fun fact, the film Quills, starring Geoffrey Rush, Kate Winslet, and Michael Caine, is inspired by the story of Sade.
Krafft-Ebing was a busy guy, naming masochism for a contemporary of his, 19th century Austrian nobleman, writer, and journalist Leopold von Sacher-Masoch, who gained renown for his romantic stories of Galician life. He also authored Venus in Furs, in which he wrote:
Man is the one who desires, woman the one who is desired. This is woman’s entire but decisive advantage. Through man’s passions, nature has given man into woman’s hands, and the woman who does not know how to make him her subject, her slave, her toy, and how to betray him with a smile in the end is not wise.
Interestingly, evidently Masoch did not approve of this use of his name. Bummer that somebody names something after you and you don’t approve of it. My suspicion is that it’s more likely that he didn’t approve what it was used for, as Krafft-Ebing essentially outed the guy as a masochist. Sadly, no word on a lingerie line for Sacher-Masoch, but I’ll keep you posted.
Sadomasochism as a mashup term was actually coined by none other than Freud, the mother-loving, father-hating Austrian neurologist and psychologist who is widely regarded as the father of psychoanalysis, a therapeutic process designed to make the subconscious conscious by releasing repressed emotions and experiences.
Even The Kama Sutra, which dates back to second century India, includes an entire chapter devoted to “blows and cries.” According to the Hindu text, “sexual relations can be conceived as a kind of combat… For successful intercourse, a show of cruelty is essential.” Seriously?
Now that you’re good to go for the daily double on historical literary references to sadomasochism…
Most of the time, for obvious reasons, we think of sadomasochism and it’s nominal components in terms of sexual behavior only, but they can have broader applications, and this is especially the case in sadism. The quality of being sadistic is most applicable to some notable autocrats of the past and present, and these are actually the first thing that comes to mind when I hear the word. When no other single word could possibly encompass the horror of their being, sadist just works. Think Stalin, Pol Pot, Hitler, Saddam Hussein, and the Kims. I was surprised to even see our 45th President’s name included while looking up a statistic. Hmmm… wonder who submitted that? (Dr. Mark Agresti is not making a statement about any person’s sexual inclination or mental status and is not claiming any political affiliation; this advertisement is brought to you by the equal opportunity offender party.)
Okay, I have no clue how that dude got in here, but you get the idea about sadism. On the other hand, masochists enjoy receiving pain, which, again, may or may not be sexual. Strangely (?) I couldn’t find much in terms of famous or known masochists. The best I could do was a British artist I actually remember from some required art “appreciation” class freshman year, a painter named Keith Vaughan. Evidently, he purpose built some kind of gizmo contraption to electrocute his own genitals. They definitely didn’t cover that part in my class though, I’m pretty sure I’d remember that.
Sexual sadism and masochism can actually be considered to be psychological disorders, as each are categorized by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) as paraphilias, which are sexual disorders that are characterized by socially unacceptable preoccupations or behaviors. Some other examples of paraphilias include voyeurism, exhibitionism, and fetishism, to name just a few. There’s a great deal of controversy on this topic, and at first glance, I generally think of sexual sadism and masochism as quasi-disorders at best. Proponents of the ‘disorder theory’ claim that because sadism involves causing physical or psychological pain or suffering to another human being, anyone who enjoys it is mentally ill. Opponents say that it doesn’t involve pain or suffering in the ‘classic sense,’ (say whaaat??) and that as long as it occurs with a consenting partner, it should be argued that it is not a psychological disorder.
I say that there are many factors to take into account, but that it should definitely be considered a psychological disorder in certain cases: if and/ or when it causes anxiety or depression to that individual, causes problems that interfere with work, social setting, or family, and obviously when it poses, or is likely to pose, a potential danger to another individual person or group. And in fact, more recent versions of the DSM back me up, asserting that it must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” in order for sexual sadism or masochism to be considered a disorder. I’ll spare you the markers that must be considered to establish that distinction. And you’re welcome for that.
When applied to sexual relationships, sadomasochism is generally termed BDSM, or Bondage and Discipline, Dominance and Submission, and Sadism and Masochism. BDSM is generally considered to be an “alternate” sexual preference that includes a variety of sexual identities and activities. Mainstream culture often represents it as reckless, dangerous, and unhealthy; a dark, non-normal kind of sexual preference which typically forces its players to retreat into carefully curated communities alienated from the majority of society. If you actually paid attention to Fifty Shades of Grey, you might have understood that Christian Grey’s reasons for enjoying kink stem from a childhood filled with abuse. Television crime dramas often portray fetishists as seedy, unethical lawbreakers, and that’s probably as a result of the psychological disorder theory more than anything else. Participants or “kinks” often make the argument that dominance and submission are more a power dynamic than a punisher-punishee relationship; and they usually identify themselves in one of three main ways: dominant, submissive, and switch, though the identities are fluid and continuous, and can change depending on the participants’ mood or partner. But if you consider the fact that the terms sadism, masochism, and sadomasochism were coined in the late 1800’s, pop culture wasn’t responsible for making kink the latest fad… it seems some humans have long had a penchant for adventurous sex. Even way back in 1956, when the Kinsey Institute was in its heyday, a study revealed that 50% of men and 55% of women enjoyed erotic biting, evidently as racy as they got when describing kinky sex. Considering all of the historical evidence taken together, I can only surmise that we’re not necessarily having more kinky sex than we always were, but we’re just talking about it- or admitting it- more than before.
Bondage: A form of restricting a sexual player’s movement, ie by ropes or handcuffs, to increase pleasure.
Discipline: A series of rules and punishments typically used by a dominant partner to exert control over their submissive partner.
Dominance: The act of dominating a sexual partner, during or outside of sex. This can include dictating sexual behavior, food habits, and even sleep patterns.
Submission: The act of a submissive partner following a dominant’s actions or dictates.
Consensual sadomasochism should not be confused with acts of sexual aggression. While sadomasochists do seek out pain in the context of love and sex, they do not do so in other situations, and typically abhor uninvited aggression or abuse as much as the next person. Generally speaking, sadomasochists are not psychopaths, and thankfully, the opposite is usually true as well. Also contrary to popular belief, evidently submissives have just as much control over deciding what happens to them as their dominant partner does, and sometimes even more so. Communication between the dominant and submissive is of utmost importance, as that’s where boundaries are set, desires are shared, and permission is given. Consent, in the form of a formal contract, a verbal agreement, or a casual conversation, is the key to healthy expression of BDSM and sadomasochism. There is typically an understanding between all partners that activity could stop at any moment should they be uncomfortable with the intensity of play; this can be done through the use of previously agreed upon safe words that signal others to stop when uttered. I’ve seen references to layers of safe words that are like a traffic light: green means good to go, yellow means proceed with caution, and red means get the hell away from me. That’s sure different than the “red light-green light” we played as kids.
Speaking of games….
Maybe you think that this sort of stuff only applies to a small number of “deviants,” but the truth is that many people, if not most, do actually harbor sadomasochistic tendencies. For example, many casual, “normal” behaviors, like infantilizing, tickling, and love-biting, could be considered as containing traces and elements of sadomasochism. In addition, sadomasochism can play out on a more psychological level- sadomasochism on the DL if you will. Consider the fact that in almost every relationship, one partner is more attached than the other. This phenomenon is just accepted as fact without much discourse, so commonly that it has even been the subject of poetry and philosophy, with the more attached partner being referred to as “the one who waits.”
In 1977, A Lover’s Discourse: Fragments philosopher Roland Barthes writes:
Am I in love? —yes, since I am waiting. The other one never waits. Sometimes I want to play the part of the one who doesn’t wait; I try to busy myself elsewhere, to arrive late; but I always lose at this game. Whatever I do, I find myself there, with nothing to do, punctual, even ahead of time. The lover’s fatal identity is precisely this: I am the one who waits.
When this asymmetry is examined, the less attached partner (A) grows dominant, while the more attached partner (B) becomes infantilized and submissive in a bid to please, coax, and seduce them. Sooner or later, (A) feels stifled and distances themselves, but if he or she moves too far away, (B) feels threatened and may go cold or give up. That in turn prompts (A) to flip and, for a while, to become the more enthusiastic of the two. But the original dynamic soon re-establishes itself, until it is upset again, and so on, ad nauseum. Domination and submission are elements of every relationship (or nearly so) but that does not mean that they are not tedious, sterile, and immature, as Freud points out…endlessly I might add.
Rather than playing cat and mouse, couples need to have the confidence and the courage to rise above the game playing. True love is about trusting, respecting, nurturing, and (healthy) enabling, but not everyone has the capacity and maturity for this kind of love. I see this domination-submission phenoma nd game playing a lot…like a lot a lot, and it can be quite the mess to rectify, as people get comfortable in their roles, whetjer they’re conscious of them or not.
Sadomasochism, BDSM, kink…they aren’t really my thing. Then again, neither is sociopathy, but I can still effectively diagnose and treat patients with it. That said, sadomasochism as a practice is definitely harder to understand than just grasping it as a general concept. I classify it as one of those great mysteries of the human condition that give me a headache when I try to completely untangle them. I’ve of course had patients into all kinds of kink and BDSM, and then again, I’ve also had some who are more “classic” practicing sadomasochists, who can be more challenging to treat. Everybody’s got a backstory that I may or may not be privy to, so I don’t judge and I think I do a pretty good job of treating everybody fairly. I figure that understanding, or at least the most earnest attempt at it, is the best way to deal with anything we may not ascribe to, even as we wish to respect the person who does. Along that same vein, if you’re curious about BDSM and kink, there are websites galore with tips and tricks, even online “academies” where you can learn to be a dom or a sub, or BDSM groups for the over 50 set…you name it, it’s there for your perusal. If you do decide to partake, I can only suggest to communicate, communicate, communicate; be safe, establish a safe word and safe boundaries, and have fun people.
I hope you enjoyed this blog and found it to be interesting and educational. If you did, let me know. If you didn’t, let me know that too!
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Thank you and be well people!
The Truth About Gender Dysphoria
Gender dysphoria is basically a mismatch between a biological sexual assignment, i.e. the gender one is born into, and what gender they feel they are psychologically and desire to be physically. Until several years ago, it was termed “gender identity disorder,” but, for three reasons, I never liked that nomenclature: first, it was/ is not a disorder, second, the term ‘disorder’ was further stigmatizing to a group of people who frankly were already dealing with such huge stigma by simply existing, and third, the term ‘dysphoria’ is a more accurate term, for reasons I’ll explain shortly. So, good riddance to bad rubbish.
And speaking of rubbish, we’ve all heard people say how this “phenomena” is a “trend” and how “these young people think it’s cool to say they are something they’re not.” Can I just say, I’ve found that anything following “these young people…” is bound to be crap 99% of the time, and this is just another perfect example. A lot of people also say that “it’s a phase” and that kids will “grow out of it.” To be clear, GD is not acne or puberty or a shoe size. It is not a phase, not a growing pain, not a cool trend, and most certainly not a choice. But what it is, is a very confusing, very painful, very disturbing state of being, especially when first realized and explored. In my experience, the later in life that the realization happens, the greater the pain, ramifications, and complications that will manifest in the person’s life.
First awareness of gender dysphoria historically begins around the age of four, but can be even earlier. In some people, it might be more into early adolescence, and in a very small percentage, even into young adulthood, though I believe those are likely cases of severe repression and/ or denial. Regardless of the age, it is always very psychologically distressing to the person with GD and their parent(s)/ family, but for very different reasons that are age dependent: if a five-year-old has enough awareness to tell their parents about it, his/ her parents will react very differently than parents of a nineteen-year-old. It’s potentially the difference between the six-year-old maybe being ignored or hopefully going to a physician for discussion, and the nineteen-year-old possibly getting thrown out of the house. And of course the potential parental and/ or family reactions to the news vary widely across a huge spectrum, regardless of the age of awareness or realization; and those reactions can either encourage the process or forbid it, or anything in between.
Some people find it very difficult to believe (read: don’t) that a child of four could ever have the awareness of GD, or of being in the ‘wrong’ body, but they absolutely can. Let’s be clear, a four-year-old girl doesn’t look in the mirror and think “Gee, I hate this dress; I’d rather wear jeans. Hmmm, I must have gender dysphoria. I’ll tell the parental units, riiiight after I finish my chicken nuggets.” It doesn’t happen that way. GD is also not about little girls refusing tea parties in favor of tonka trucks or little boys preferring their sister’s tutus to GI Joes. If only it were actually that simple and easy to diagnose! In reality, gender dysphoria can be a confusing conglomerate of signs that can be very misleading. Depending on the age and psychological state of the child with GD, it may be less confusing and more acceptable to them, because younger well-adjusted kids typically have greater acceptance of things they feel but haven’t seen or had exposure to…nobody has tainted them, inoculated them with cynicism, self-doubt, or guile; in short, they’re innocent. If they’re of an age that Santa and the Tooth Fairy are real, how much of a stretch is it to honestly feel they belong in a different body? I know all the questions from listening to the parental/ familial perspective for years. They always wonder if their child is lying. The truth is that children under age ten to twelve-ish likely don’t even know about the existence of GD, much less enough to lie about it. And if they’re asking about older children, adolescents, or even young adults lying, I always wonder (and ask) why on earth anyone would want this, or intentionally insert themselves into this situation? Who would relish this scary, confusing, and troublesome state of being? The answer is no one. Parents exploring GD want to know when “it” happened, like it’s the big bang. They wonder aloud when a girl child is more Tom than just tomboy, what are the signs, and how do they recognize and read those signs? The problem is that they’re usually looking for proof in a situation that is inherently difficult to prove without a crystal ball and related accoutrements. I generally tell them to not try to read any signs; that it’s much better to simply listen when a child speaks. Invariably, it comes down to this: “But how does my child know they’re not the gender they were born, or that they’re in the wrong body? How does my daughter know she’s not a female/ my son know he’s not a male?” I always answer that question with a question: “How do you know you are a female/ are a male?” The answer is that you just know. It’s an inherent thing. Children more readily accept it because they don’t have all of the hang-ups that come as standard equipment with adulthood. But please don’t misunderstand, when I say that children more readily “accept” it, I don’t mean that little Johnny realizes he doesn’t belong in the body he was born in and then he skips off in bliss. Not at all. With gender dysphoria, there is plenty of angst to go around, and every person in the family gets a heaping helping. It is difficult on the person with GD because they were born, named, and recognized as one sex, but have always known they were supposed to be the other sex. It is difficult on the parents and on the family system, because someone who was born, named, and recognized as one sex, (seemingly) suddenly wants to be the other sex. And all of them must choose to adapt to it or fight it, neither of which are easy roads to hoe. And what seems to the parents and family to be a snap decision on the gender dysphoric person’s part is actually anything but; this knowledge came only after long and serious consideration and great internal debate, relative to, but regardless of, their age at the time. In any case, it’s an inherently difficult situation to adapt to for everyone, and that’s one of the main reasons why gender confirmation (aka gender reassignment) is a multiple years-long process, not an overnight thing. Incidentally, the preference was changed from gender ‘reassignment’ to gender ‘confirmation’ by leaders in the field because they (and people with GD) say it isn’t reassigning another sex to the person, it is actually and truly confirming the sex the person was meant to have been in the first place. But both terms are still used interchangeably for the most part.
The Harris Institute says 0.3-0.4% of the US population, approximately 1.3 million people, are affected by gender dysphoria. That’s a pretty significant number; certainly high enough to deserve better care than what’s primarily available. There are a couple centers of excellence with a few big-shot surgeons that handle confirmation surgeries currently in the US, but there really should be several more in strategic parts of the country. I treat about three to four patients with gender dysphoria a year, so figure approximately 100 total throughout my career. To put that into perspective, I’ve treated about 20,000 depressed/ bipolar patients and 8,000 to 10,000 schizophrenia patients. It doesn’t come very close comparatively, but it’s enough to say that I’ve definitely seen an increase in the last ten years or so. And as attitudes change and acceptance becomes more widespread, I expect that trend to continue. It may sound strange to say, but I hope those numbers do continue to go up, because the alternative is frightening…it means that more people with GD are suffering silently, being marginalized, either severely in denial or repressed, hopeless and suicidal, mutilating, and ultimately, opting for suicide rather than confronting the issue headlong. And that is simply unacceptable if we are to call ourselves an enlightened society in this day and age.
As hard as it is on the parents and family, the most difficult path is that of the individual with gender dysphoria. This goes back to my earlier reference of dysphoria being a more accurate term than identity disorder. The reason why is because of the presence of dysphoria in relation to one’s gender. Dysphoria is defined as a state of unease or a generalized feeling of dissatisfaction with life; in gender dysphoria, this state of unease and dissatisfaction is caused by one’s gender, of being born in and living in a body of the wrong gender.
Let’s take my patient Thomas, who preferred to be called Tommy. Born male, Tommy was thirteen, and had started puberty several months before his parents brought him to my office. They said they were concerned because he “had stopped eating recently for no reason.” That piqued my interest, because I had a thirteen-year-old son once upon a time, and he never stopped eating “for no reason.” So I performed a stat parentectomy and brought Tommy into my office. Appearance-wise, he looked like any regular thirteen year old, but psychically he looked down, troubled, and on edge. I asked him what was going on with the not eating thing, and at first, he looked like he was running through a list of answer options, i.e. lies, and was trying to decide which would get him out of here with the least fuss. I quickly added, “the truth, Tommy. You’re never going to be done with me until you tell me the truth and we work through it, so you might as well start now. I can assure you that whatever you tell me won’t shock me.” After a long breath, he wisely chose the truth and started talking. For length’s sake, I’ll paraphrase what he said: he had stopped eating because he had hoped to stop puberty, basically to starve it of nutrition to try to prevent it, because it was so painful for him to gain weight and take on male characteristics. He was so distressed to see facial hair, pubic hair, muscles developing, his penis enlarging, and his voice deepening. He said it was wrong, he had known it was wrong since he was three, that this feeling was one of his earliest memories. Obvi, I had a good idea where he was going, but I had to encourage him to be more specific, and I told him that he couldn’t mince words, that he needed to voice it in his own words; so after a couple of beats, he did. With a few tears, he pointed to his lap and told me that he didn’t belong in “this” body. I really felt for this kid. He went on, the words choking him, saying that every morning he gets up for school and goes to the bathroom, and he looks down and has a panic attack. If I live to be 112, I’ll never forget the next thing he said; he tried to just slide it in, but it made my blood run cold. He said that he was going to find a way to cut it off, that he’d cut it with a nail clipper, but he didn’t have the guts to really do it. I had to bite the inside of my cheek. Every once in a very, very, very great while, maybe three times in my career, for a split second, I’ve thought to myself, “I can’t do this right now.” Looking at Tommy, I had that thought right then. It passed quickly, but the mental picture of what he was describing hit me like a ton of bricks. I asked him if he still had those feelings, and he said that he just didn’t know what to do. That was too vague for me, and in any case, it didn’t answer my question. I needed to know if he was going to hurt himself. I told him that I was going to help him, but to do that, he had to be 100% honest with me. When he agreed that he would be, I asked him point blank if he was going to hurt himself, cut himself, or mutilate himself in any way. He said no, and I believed him. Tommy was clearly depressed; it was clear to me that this scared little kid had the weight of the world on his shoulders. In his mind, he was female; his body disagreed, but he knew with every fiber of his being that his body was wrong. He wanted to be female. He wanted a female voice, a female body, a female top and a female bottom, to match his female mind. For Tommy, it was not a trend, not a passing thought, not a stage, not a lie, not a ploy, and nothing he asked for. This female being in a male body was a condition, one he had suffered with his entire life. He said he hadn’t told his parents, that he didn’t know how. When I asked if he needed my help to do that, he said yes. Tommy’s was my last appointment before lunch, so I had some time. When I asked if he wanted to tell them now or next appointment, he said now. I was on board, so I went out to the waiting room and called them into my office.
Once Tommy’s parents made themselves comfortable, I explained to them everything that Tommy and I had talked about. Suffice it to say there was shock, disbelief, tears, and many questions. Tommy answered some and I took the rest. I explained all about the diagnosis of gender dysphoria and the reason Tommy had stopped eating. There were some protestations and some denial that I did my level best to dissuade, or, if I’m honest, maybe something more akin to shut down. All in all, they took it relatively well, or at least better than some parents have at any rate. I explained that there is a very proscribed path to follow, and I made it very clear that Tommy’s physical and psychological well being was very likely at stake. I told them that he was very anxious and depressed, and that I could treat him for those things, but that I suspected that the only way to make him better was to fix the underlying issue, the gender dysphoria, through hormonal and surgical means. That freaked them out, but they relaxed a little when I said that today’s appointment was only the first of many steps that would be taken before that could happen. I still needed to talk to Tommy a lot more, as well as the entire family, before finalizing any diagnosis. I told them that today was a good start, that I was very proud of Tommy, and that they should be too. I gave them my cell number and told them to call anytime if they needed anything and suggested they go home and keep the dialog going. We made a follow up appointment for two weeks. I shook Tommy’s hand, patted him on the shoulder, gave him my card with my cell number, and looked him in the eye and told him to call me if he needed to talk. He got the message and said he would. He looked like twenty pounds had been lifted off his shoulders. I was hoping that the communication trend would continue when they were back at home. Lots of parents say they’ll do something in my office, but then don’t follow through at home. I didn’t think that would happen in this case. I really hoped for Tommy’s sake that I was right, and that in two weeks they’d say that they were willing to start on the long road to exploring Tommy’s issues, potentially with a view toward gender confirmation surgery. In two weeks, I’d know if they were willing to allow us to explore that potential diagnosis.
I have had a fair number of patients like Tommy, including genetically male patients of similar age who have been sent to me after attempting suicide and/ or mutilating their penises in a misguided attempt to fix themselves, or at least make life more tolerable. Unfortunately, that is not uncommon. It’s a very sad situation for all of them, but especially heartbreaking for the ones that have no support from their parents; or worse, the ones whose parents chide them, scold them, or do anything within their power to try to “change” them or make them see “the error of their ways,” including horrible and illegal things that make decent people want to vomit. I have had young female patients who, when they get their periods, develop severe anxiety disorders. For eight to ten days a month, they have a painful reminder of everything that is “wrong” with them and the bodies they are trapped in. When they start to narrow at the waist and get the weight distribution of a woman, they become intensely alarmed and anxiety ridden; and when their breasts begin to develop, they band them up or they tie them up so severely that they form a band of deep bruising, connecting continents of black and blue contusions. And sadly, breast mutilation in genetic females with gender dysphoria is nearly as common as penile mutilation in genetic males with gender dysphoria. It’s a devastating fact that most people would rather not consider.
Most of my practice is young people, so patients with gender issues, unknown psych issues, or even undiagnosed GD come to my office when they’re usually 12-15 years of age, a time when they are doing everything in their power to block puberty because it is so deeply disturbing to them. When I speak to them about it, I find that they are not afraid of changing their sex, they are not afraid of having top surgery, or of having bottom surgery, which is a major procedure, a very painful one with a long recovery period. What they fear is living in the wrong body, disappointing their parents, and feeling the wrath of siblings, strangers, bullies, and anyone who disagrees with their choices or state of being. Gender dysphoria is the only psychiatric condition that can be cured through surgery rather than through psychiatric intervention. My job is to guide them and treat the depression, the anxiety, and the panic of the unchanged being. Once they are on the introduced hormones and have the confirmation surgery, they do much better. It’s the only psychiatric condition that is like a broken bone, once it’s fixed, it’s fixed…it can never be broken in the same place ever again. Once you confirm the patient’s gender with surgery and change their outward appearance to match the sense of self they have always felt inside, they are dramatically better. They are whole, and they will not break in that place ever again. It is an amazing metamorphosis, one I have been privileged to be a part of many times.
Now, what is involved in this process of diagnosis and surgical intervention of gender dysphoria? I can tell you that it’s a long road, and not an easy one. Basically, there is a long list of criteria required to move forward on the path toward gender confirmation surgery. To meet the psychological criteria, there must be a documented history of gender dysphoria by a psychiatrist for a minimum of six consecutive months. By the time 90% of my GD patients get to my office, they have been tormented by the issue for years, and they are beyond ready to disclose it and take any steps necessary to move forward. I always make sure that the patient’s pediatrician is on board, and that they’ve done labs to look at general blood cell counts and hormone levels, and I also make sure there’s nothing significant in the medical history that might be pertinent to potential diagnosis. Assuming I make a diagnosis of GD, genetic females are put on testosterone, and they develop male characteristics: facial hair, a male weight distribution pattern, increased muscle mass with exercise, and lower voice tone. Then in due time (but never soon enough for them) they start having surgeries. The earlier surgeries are typically mastectomy (aka “top surgery”) and various facial plastic procedures, i.e. mandible (jaw) implants to square off the face and chin implant to accentuate the profile. Some may decide to break from surgery at this point and live this way for a period of time. Eventually, most genetic females undergo “bottom surgery” to complete gender confirmation. This is where female tissue is surgically altered and converted into a penis with varying sensitivity and functionality. Once healed, there can be numerous revisions to improve aesthetics and achieve better function over a period of several years if the person so desires. There can even be surgeries to alter the length of vocal cords to change the pitch and tenor of the voice to sound more characteristically male.
Post diagnosis, genetic males are put on female hormones estradiol and micronized progesterone, and these decrease the male penis, testes, and the sperm product. There are other drugs that can be used to demasculinize male facial features. Then there is laser hair removal for the face and body, and hair implants to lower the hairline to appear more feminine. There are many plastics procedures to make the face less masculine and more feminine, such as narrowing the nose, shaving down the forehead, reducing the chin, reducing the ears, adding cheek implants, shaving down the Adam’s apple, and all sorts of injections and fillers to feminize the face. Breast implants, various body implants, and liposuction feminize the body shape, and there are millions of different facial peels, laser treatments, and lotions and potions to remove the ruddiness that’s more typical of male skin and feminize skin tone. There are many procedures regardless of gender change direction, so a team approach with everyone on board and on the same page, and with constant communication is critical.
As with many medical issues, the sooner you can start therapy, the better. Hormonal therapy in gender confirmation is no different. The sooner you put a GD patient on testosterone or on estradiol/ progesterone, the better the result will be. But before that can start, many things have to happen, and those things take time. First, if the patient with GD is sub-adult (which they usually are), the parent has to get them to a doctor, which means that the child has either told them what’s going on, or the parent notices that there’s a problem, as Tommy’s parents did. That all takes time. Then, the next step is either a pediatrician’s office, who runs tests and then sends the patient to me, or the parent brings the child directly to me for evaluation first. More often than not, the entire process begins in earnest in a psychiatrist’s office. My problem as a psychiatrist is that children of age 10, 11, 12 do not yet have fully formed brains, yet they are asking to make permanent changes to their sexual assignment; to go from a genetic boy to a girl, or genetic girl to a boy. It’s best to start hormone therapy at this age, I know that, but what if you’re wrong? The odds of being wrong are pretty low because of exhaustingly thorough therapeutic examination of the issue, and the fact that really no one pretends that they have this problem, it’s not a fad, not a lie, not cool, not fake, etc. That is all plain to see in these patients. They are suffering and in great emotional distress. Their psychiatric problems are not about having the actual sex confirmation surgery or taking on characteristics of the opposite sex. Their problems either surround not being able to tell their parents, or dealing with family issues, of their parents rejecting them, siblings who may reject them, bullies at school, and/ or being isolated and depressed in their skin, thinking about not having friends, etc. These individuals have much higher suicide rates. The rate of depression, anxiety, and panic disorder are dramatically higher as well. So for the patient with GD, we have to intervene with parental counselling, and we have to intervene with family therapy. The whole family, as a unit, needs to process the potential changes in gender assignment. And of course there must be a great deal of individual therapy to help the GD patient navigate the waters of the process. As I mentioned before, the least of their worries is the surgeries; more importantly, they must learn how to tell people about their status if they wish, and learn how to deal with other people’s reactions, and with society’s reactions as a whole. For example, being forced to use the wrong bathroom, one that does not go with their true internal gender. Or dealing with someone using the wrong pronoun, referring to them as sir or mister when they prefer miss or ma’am. Driver’s licenses list the genetic gender that doesn’t match their true gender. These things are all very painful, very traumatizing for a person with gender dysphoria. Every stage or every place where society labels someone male or female is distressing for people with gender dysphoria. Even after they’ve had confirmation surgery, it can be painful. Obviously, Social Security records and birth certificates always list the gender a person was born under. If they want to change it, it’s not easy. They need lawyers for practically everything, they have to threaten to sue to go to the right bathroom, to get records changed, every little thing. But these things are very important to them, so they often choose to do them, no matter the expense or pain involved. And how do they apply for a job? What gender do they check? Because if that job includes health insurance and life insurance, it all has to match up. They can’t have their genetic/ birth gender on one document and confirmed/ inside/ new gender on another one. And speaking of health insurance, you can pretty much forget them paying for any of it, so you better hope somebody is independently wealthy or wins the lottery, because you’re looking at about a quarter million to get through just the basic therapy, testing, meds, and surgeries. Then tack on a lot more for potential revisions and all of the necessary plastics surgeries and other refining procedures and upkeep.
As a psychiatrist, I am usually the first hoop to jump through. I treat GD patients for depression, anxiety, sleep problems, addictions, attempted mutilation trauma, attempted suicides, and the physical/ emotional/ sexual abuse they may go through, as most do have harrowing abuse histories. I give my stamp of approval to move them forward on the gender confirmation pathway, and continue to follow them throughout. As the person that sees them first and last, I have a front row seat to before and after, so I have seen that things get much better for patients as their sexual transition progresses. It sounds like it happens quickly, but it doesn’t; even all the approvals can take years to put together, and then there are often surgical waiting lists, as there are only a few super-specialists who do the most major part of the process. It also has to be a team approach, with every physician trusting each member of the team. On that team, you need psychiatric therapy for the individual, parents, and siblings. You need a pediatrician for general medical, a pediatric endocrinologist to monitor hormonal changes, urology and urology surgery to deal with the plumbing, specialty surgery to do the actual reassignment/ confirmation, along with plastic surgery of all sorts to deal with function and aesthetics, the list is never ending. And again, you have to go to a center of excellence to find all of these surgeons, because these super-specialists don’t grow on trees…you’ve gotta go to them, for every procedure and every follow-up visit. With so few centers and so few super-specialist surgeons, that involves a lot of time in the air…lots of frequent flier miles. We desperately need more surgical centers and more super-specialists, and we have to maintain the team approach to treating GD. Because the psychiatrist is usually the first hoop to jump through, they lead the team. They are the ones to say “I have thoroughly evaluated this patient, and I certify that they have gender dysphoria and believe that they require gender confirmation surgery.” It’s really not so easy; it’s one thing to confirm a diagnosis, but it’s quite another to say “I am going to lead this team, and I am confident that making this permanent surgical transition is the only path to psychological health for this person. I will work with them, their parents and siblings, separately and together, for the duration.” To say that to a group of ten plus physicians, all of whom are counting on that original diagnosis, putting themselves on the line legally and ethically is a big deal, and not one I take lightly. I have to be pretty secure in what I’m saying, and to be honest, it takes me a while before I’m willing to make that play. I am required to certify the circumstances of GD for a period of six months, but it takes me a lot longer than that. I hate to say it, and maybe I should do it in less time, but it takes me over a year of working with that patient before I’m ready to lay it all on the line with a diagnosis of gender dysphoria. And patients get, ironically, well, very…impatient. Whenever I look back at my GD patients, I always think I should’ve pulled the trigger sooner. Sooner really is better in these cases, less traumatic, fewer mutilations borne of frustration, fewer attempted suicides, more effective hormone treatment, and with better final outcomes. I always say I’m going to shorten the time to diagnosis when I get the next case, but then I’m drawn in by an overabundance of caution. It’s not the worst thing ever, but maybe not the best? It’s really hard to say. Next time I have a GD patient, I’ll make a mental note to read this blog, and maybe that will decrease the length of time it takes for me to put my chips down on the GD diagnosis. A lot of it depends on the patient’s age of realization and their willingness, as well as their parent’s willingness, to undergo all of the therapy it takes to come to the diagnosis in the first place.
I’ve had a bunch of patients undergo these sexual reassignment/ confirmation surgeries, and I’ve had pre-op genetic males end up looking like post-op females and vice versa, and at every stage in between, so when they would come to see me during the process and would be in the waiting room, sometimes my secretaries wouldn’t recognize them. They would see a name they recognized on the chart, but sometimes not the face, which has led to some confusion…so these hormone therapies and procedures, when done well, can be very convincing. Over the years, some of these patients were thrilled when the girls up front didn’t recognize them! One such patient was Tommy. Remember him…the 13-year-old genetic boy I talked about earlier? Well, when her surgeries were all said and done, she looked amazing as a nearly 20-year-old woman. The day finally came when Tommy (she kept the nickname btw) caused a bunch of confusion with my secretaries. When she walked back into my office, she was smiling ear to ear because my secretaries didn’t have a clue who she was. It was pretty awesome to see, and I felt good being a part of something that was so clearly right. Tommy walked that long, and often dark, path to acceptance, and came out the other side beautifully, with all of her familial relationships intact. It doesn’t always happen that way. I’ve had patients who had to wait until they were out of their childhood homes because they were told they couldn’t have the surgery while they lived there. So they left as soon as possible. I recall even helping two GD patients emancipate themselves at 17 years old in order to get started that one year earlier. Ultimately, it comes down to the individual patient and the lengths they are willing and able to go to in order to feel comfortable in their own skin. As with any other aspect of life, we each have our own path to take, and I’m just privileged to be a guide.
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Transvestic fetishism is having a sexual or erotic interest in cross-dressing. It differs from cross-dressing for entertainment or other purposes that do not involve sexual arousal and is categorized as a paraphilia in the Diagnostic and Statistical Manual of the American Psychiatric Association. (Sexual arousal in response to donning sex-typical clothing is homeovestism.)
Transvestic fetishism refers specifically to cross-dressing; sexual arousal in response to individual garments is fetishism. Occurrence of transvestic fetishism is uncorrelated to occurrence of gender identity disorder. Most men who have transvestic fetishism do not have a problem with their assigned sex.
Some male transvestic fetishists collect women’s clothing, e.g. nightgowns, babydolls, slips, brassieres, and other types of nightwear,lingerie, stockings, pantyhose, shoes, and boots, items of a distinct feminine look and feel. They may dress in these feminine garments and take photographs of themselves while living out their secret fantasies. According to the DSM-IV, this fetishism has been described only in men.
There are two key criteria before a psychiatric diagnosis of “transvestic fetishism” is made:
- Recurrent, intense sexually arousing fantasies, urges, or behaviour, involving cross-dressing.
- This causes clinically significant distress or impairment, whether socially, at work, or elsewhere.
Thus, transvestic fetishism is not diagnosed unless it causes significant problems for the person concerned.Learn More