Prior to recognition of transsexualism as a disorder deserving medical and psychiatric attention many patients self-mutilated or committed suicide out of despair. (7) Transsexual patients are helped by sympathetic assessment and intervention. However, transsexuals can be difficult patients to manage or treat. It is a rare disorder in which patients make their own diagnosis, 'I am transsexual', and prescribe their own treatment, 'I want sex-change hormones and surgery'. Patients can be demanding and impatient for the therapist's acquiescence to their tailor-made programme. They may be resentful for having to see a psychiatrist, holding the opinion that the desire for hormonal treatment and surgery should be sufficient, and psychiatric agreement should be unnecessary.
Some patients are manipulative and will threaten self-mutilation or suicide if their demands and time schedules for demands are not met. Patients need to know that psychological stability is a key ingredient to successful negotiation of the cross-gender living trial period 'Real Life Test' (see below) and recommendation for surgery, and that suicidal behaviour is a contraindication to going forward.
During the past 30 years medical doctors and psychologists specializing in the treatment of transsexualism have worked to develop effective intervention strategies. Early on there was some optimism that extensive, prolonged psychotherapy could modify the patient's gender identity to conform to the patient's birth sex. However, in the vast majority of cases, this was not possible/20)
During the past 20 years one project undertaken by the Harry Benjamin International Gender Dysphoria Association, the professional body dedicated to the study and treatment of transsexualism, has been setting an extensive series of requirements for evaluation and treatment of gender identity disordered people. This set of guidelines is known as the Standards of Care.(21) Their principal purpose is to assure that people presenting with dissatisfaction continuing to live in the sex role to which they were born undergo comprehensive psychiatric evaluation and enter into an appropriate treatment programme. The programme includes, in addition to ongoing psychiatric or psychological monitoring, possibly endocrine therapy and, depending on the outcome of the graduated trial period of cross-gender living, possibly sex reassignment surgical procedures. The philosophy of treatment is to do reversible procedures before those that are irreversible. Thus clothing change, name change, and cross-gender role socialization, would precede, in selected cases, endocrine treatment with its gradual somatic changes followed, in carefully selected cases, by surgical treatment.
The crux of the screening and evaluation of those people given the opportunity to demonstrate that they will benefit from cross-gender living, perhaps culminating in surgical treatment, is known as the 'Real Life Test'. This requires that patients who state their need to assume the other gender role live full-time for at least a year and preferably 2 years in that role. The test includes high doses of cross-sex hormones and full-time employment or full-time student status in the new role for at least a year. If patients can demonstrate to themselves and mental health experts that they have successfully negotiated the 'Real Life Test' and are adjusting better socially in this new gender role, they can be referred for surgery.
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