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Gender Dysphoria Program Guidelines

Notes on Gender Role Transition
By Anne Vitale Ph.D.

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Gender Dysphoria Program Guidelines
-- as used in my practice.
My Philosophy:
There is no clearly understood cause for Gender Identity Disorder. However, we have enough information about fetal and childhood development to implicate a complex interaction of events.

Nature starts out the human developmental process by using the female schema as a base. For a male embryo to develop, something must be added. That something must be a Y chromosome inherited from the father. Further, that Y chromosome must contain a gene known as the Testes Determining Factor (TDF), telling the embryo to differentiate along male lines and develop male genitalia. All embryos without the factor (even if the Y Chromosome is present) continue to develop undifferentiated as female. (More info about this)

Nature takes male differentiation further by having the newly formed male genitalia flood the brain with androgenizing hormones at around the third month of pregnancy. This sudden surge of brain masculinizing hormones -- the creation of the male gendermap -- occurs again in males somewhere between the second and twelfth week after birth. Importantly, there is no corresponding feminizing hormonal surge sequence observed in females.

This leads one to consider the possibility that male hormonal surges must occur not only in sufficient amounts, but also during a short window in time, to cause masculinization of the gendermap. If there is insufficient androgen, or the surge comes too early or too late, the gendermap may be only partially imprinted as male. Another factor that needs to be accounted for is that masculinizing hormones are available to every developing embryo through a variety of other sources. A partial list would include a disorder in the mother's endocrine system such as a hormone secreting tumor, common maternal stress, maternal medications, or some other toxic substance yet to be identified.

Although further studies are necessary, scientific confirmation of this hypothesis was revealed in recent post-mortem studies done on transsexuals, non-transsexual men, and non-transsexual women that show a significant difference in the volume of a portion of the hypothalamus which is essential for sexual behavior.

In essence then, the absolute binary (male/female) structure society imposes on gender role behavior is inconsistent with the possibilities of human development. Instead, gender appears to be a continuum with most people gathered at either end, the rest being somewhere in between. Feelings of discomfort or complete inappropriateness about one's assigned sex does not mean the individual is wrong or ill. It simply means that the original assignment was made solely on the shape of the genitalia without consideration of any internal differentiation.

Psychotherapeutic Orientation:
My therapeutic approach is Existential-Humanist. That is, I am interested in the process of being. I believe that how we live our lives is ultimately who we are. I also firmly believe in providing complete and compassionate psychotherapy for all my clients.

I will not decide if sex reassignment is the proper course for anyone: only the client can make that decision. My job is to keep the exploration well informed, honest, and thorough. Obviously, gender clients have many of the same issues regarding living life that others have. I try, therefore, to serve not only as a sex transition guide, if sex reassignment seems appropriate, but as a full issues therapist as well. I expect each of my clients to take full responsibility for their progress. I believe that the more responsibility the individual takes for their transition the more successful and more fulfilling their life in the new sex will be.

In accordance with my agreement to uphold the WPATH Standards of Care, my ethical and moral obligation to maintain a responsible level of professionalism, and the experience of years of first hand involvement in the sex reassignment of many people, I have developed a short list of expectations.

Therapy Sessions:
The number of psychotherapy sessions necessary prior to making a joint decision to start hormone therapy depends on the needs of the client. An earlier version of the Standards of Care required a minimum of 12 sessions. Although I continue to think that 12 hours of careful consideration is certainly worth taking prior to making such a big decission, the actual hours we spend together will probably vary. A modified meeting schedule can be negotiated to accommodate people who must travel long distanced to my office. I am also willing to spread the sessions out over a longer period of time if you desire.

Hormone Therapy:
Hormone therapy is to be administered and regularly monitored by an endocrinologist recommended by me or someone of your choosing that is familiar with the possible physiological difficulties enherent in taking cross sex hormones.

Continuing Psychotherapy Throughout Transition:
The number and frequency of visits is to be determined by the degree of difficulty the client is experiencing. The minimum frequency of visits, if the client is not in one of my groups, is one hour of therapy every other month. Keep in mind that transition may be the most demanding and psychologically difficult experience anyone will ever have to face. It is common for critical and totally unexpected issues to arise that may tax any client's very ability to cope with life.

Real Life Experience:
Every gender client wishing to go on to sex reassignment surgery must live full time in the gender of choice for at least 12 months prior to SRS. When the client decides to start living full time in the gender of choice is strictly up to the client. Keep in mind that full time means living and working, 24 hours a day, every day. This is a real life test! By definition, there can be no exceptions. Every client who reaches this stage will be expected to resolve not only their inner sense of gender identity, but all of their associated social identity documentation such as driver's license, Social Security registration, and bank accounts to reflect the new gender. I will, of course, be glad to assist with letters or any other documentation that may help this exciting but often frightening process.

Sex Reassignment Surgery:
Over the course of transition, I will provide as much current information as possible to help the client make an intelligent decision regarding which surgeon and what surgical procedure to choose. Every surgeon of established reputation requires at least two letters of recommendation, one from the primary therapist (in this case me) and a second opinion letter from another therapist qualified in gender matters. I will be glad to provide a list of qualified therapists to choose from. Keep in mind that many surgeons also want a current letter from the endocrinologist that states the particulars of the client's health status.

Business Arrangements:
I expect every client to adhere to a standard Client/Therapist Contract. In addition, every client must either keep their account paid in full or arrange a monthly payment schedule with me. Letters of Recommendation for SRS will not be sent until the account is paid in full. There are no pre-visit screening procedures or enrollment fees. Simply call (415) 456-4452 to make an appointment. If you get the 24-hour answering service -- which is most likely -- leave your name and phone number and a good time for me to return your call. If there are any special instructions you would like me to follow, please tell the answering service. I will, of course, try to be as discreet as possible. I can also be reached via email at anne@avitale.com Please put INQUIRY in the subject field.

Anne Vitale, Ph.D.
October 7, 2000 / Updated November 29, 2011


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