Chapter 1. Test1

Introduction

Written by Elaine Cassel, J.D., M.A.

Lord Fairfax Community College

(c) 2013 Worth Publishers (Photo Credit: John Knill / Getty Images)

1.1 Presenting Complaint

Charles is an 18-year-old Caucasian male. He has graduated from high school and put his college plans on hold while he undergoes treatment and preparation for male-to-female gender reassignment surgery. He has dealt with the feeling that he was a girl trapped in a boy’s body since he was a child. This was initially difficult for his parents but eventually they came to accept it and they have been generally supportive. Up to this point, Charles has tried to live as much of a normal life as he could engaging in activities stereotypically considered “feminine,” such as indulging his taste for nice clothes , taking dance classes and cooking. Charles has a sister, Amanda, who has been supportive of his desire to become a woman.

Eighteen years was more of a milestone for Charles than for most teenagers. Charles had to be 18 to be eligible for a radical course of medical treatments and surgery that would transform him into a new person. Charles was sitting in the Colorado office of a world-renowned surgeon who specialized in sex reassignment to discuss the steps he would take to turn him into the woman he had always wanted to be. Of course, it would be a long time before he could undergo what is known as “sex reassignment surgery,” a complicated reconstructive surgery to remove his male genitalia and build female genitalia. First, Charles would have to undergo several years of hormone treatment and start dressing and “living” as a woman. Working with a psychologist, Charles and the surgeon would determine when he was physically and psychologically ready to become a woman.

Sitting in the waiting room with his mother, Charles thought about when he first started to feel like he was a girl trapped in a boy’s body. He honestly could not remember when he first felt this way. All he knew was that he never felt like a boy, from the time he developed any conceptualization of gender. He remembers his father telling him at about the age of two, “Stop whining like a girl; be a man.” His father continued to reprimand him in this way for most of his life, until he finally realized that Charles was never going to conform to his idea of what a boy or man should be like. .

When he was about three, Charles remembered wanting to dress up like his sister, Amanda. No one (except his father and grandfathers) thought much of it. It was great fun for Amanda, who was five at the time, and his mother thought he looked cute in Amanda’s clothes. But when Amanda painted Charles’s toenails, even his mother was alarmed. Before that, the warning bells had sounded when Charles resisted potty-training. That in itself was not unusual, for boys often take longer to potty-train than girls. At age three, Charles was still wearing diapers at night, but that was not the problem. What was a problem was Charles’s refusal to urinate standing up. Charles’s father was flabbergasted that his son sat down to urinate like a girl. Try as he might, he could never get his son to change that practice.

When Charles was four, he attended preschool. His teacher, Mrs. Sabathia, almost immediately perceived that Charles was not like the other preschool boys. Charles wanted to play the “mother” when the children were playing “house.” He wanted to pretend to do the stereotypically feminine things that he saw his mother do at home (e.g., his mother did most of the cooking and cleaning, even though she also worked outside the home). Charles did not like the rough-and-tumble play of the boys. When the children went outside, Charles would prefer to spend time with the girls, and he typically played games like hop-scotch or jump rope. During preschool, his behaviors did not necessarily elicit any negative comments or teasing from other children.

But when Charles began first grade, his social difficulties began. The school had separate boy and girl restrooms, and he hated going into the boy’s restroom, feeling particularly uncomfortable with the urinals. He tried to be the first one into the bathroom so that he could get into a stall, where he hoped that no one would find him sitting down on the toilet. When he complained about other children playing too roughly and cried at recess and PE on several occasions, the other boys in his class started to call him a “sissy.” Although he preferred to play with the girls in the class, he also felt that the girls did not fully accept him. He felt ostracized by both genders. Charles’s mother made him wear pants and overalls to school which made him feel self-conscious and embarrassed. As soon as he walked in the door at home, he changed into shorts and hand-me-downs from his sister. He particularly loved wearing bright colors like pink and purple. Charles’s first-grade teacher, who knew about gender dysphoria, called his parents in for a conference. Charles did well enough in school, but his teacher was worried about his social development. His teacher expressed concern that the social pressures would only increase as Charles got older. The teacher suggested that Charles’s parents see a clinical psychologist about his behavior.

His parents sought help from a child psychologist. They attended the sessions alone first and then included Charles. Even at age six, the psychologist recognized that Charles might be experiencing gender dysphoria, although it was too early to be sure. She advised his parents to let Charles choose to behave as he wished as much as possible. With his mother taking the lead (although his father went along as well), they started family therapy with a therapist familiar with gender dysphoria. His sister also attended some sessions because the whole family had to be on board about how to deal with Charles’s insistence that he was not a boy. Charles had individual therapy as well which appeared to be helpful. Charles played out scenarios as a girl, and the therapist, who worked with him for three years until he was nine years old, helped Charles develop coping strategies.

Charles’s mother supported his interest in taking dancing classes. She reminded herself that football players bragged about taking ballet and the TV series “Dancing with the Stars” had created public awareness that dancing was not just for girls. Charles loved art and was good at it, so his mother and art teacher encouraged him to take up ceramics. Eventually as a teenager he became interested in metal sculpture and welding. His dad warmed to the idea of Charles working in a shop with welding tools. Charles also loved to cook. Charles got much pleasure from his leisure pursuits and he was a solid B student.

When he was about 16 years old, Charles started reading about sex reassignment surgery and hormone treatments at the suggestion of his therapist. In the United States, hormone treatments are generally not prescribed until after puberty, when the body’s hormones have stabilized. Charles began to grow his hair long. He despised his facial hair, but he was relieved that his beard was sparse and blonde. He had a slight build, so with his chin-length straight hair and designer jeans, tee-shirts, and flip-flops, he had an androgynous look that was popular among some of his peers.

When his peers started to date, Charles realized that he had feelings for guys. But he was not gay, he insisted. “I want to be a girl, and I want a boy to love me as his girlfriend.” That was complicated for everyone, including Charles, to understand, let alone explain, so he didn’t even try to date. His best friends were girls, and he was particularly close to his mother and sister. He felt lucky that his family was supportive during this confusing time.

Charles wanted to go to college and study art, but for now, college was on hold. The most important thing for him was to start to become a woman, and the first step was to develop a woman’s body to reflect the woman he felt was trapped inside. Today, after leaving the doctor’s office, he was going shopping with his mother for some more “feminine” clothes. He wasn’t ready to wear dresses yet, but he wanted some slim-fitting jeans and t-shirts, and some stylish shoes. He wanted to get a nice haircut and a manicure and pedicure. He thought he might even get his toenails painted pink or red, but he would still wear shoes so only he would know they were painted. His mother had said she would help him pick out some girls’ underwear. He would start taking better care of his skin, though he was not quite ready for make-up. Now that he was out of school, living at home and beginning his treatments, he felt ready to push the limits, so to speak.

Charles knew it would be several years before the surgery, but he expected to leave the doctor’s office with a prescription for hormones. After 16 long years of wanting to be a girl, he was on his way to becoming a woman. He thanked his mother for being there with him and asked “Would you mind calling me Cheryl?” She promised she would try, though they both knew it would take a while before calling him Cheryl would come naturally. Just then, a nurse came into the waiting room and said, “Charles, the doctor will see you now.” “My name is Cheryl,” he said.

“Cheryl it is then,” said the nurse. “Welcome.”

1.2 Social/Family History

Charles was born to college-educated parents. He lived in an upper-middle class suburb in a large metropolitan area. He went to private schools, beginning with pre-kindergarten when he was three years old. His sister, Amanda, was two years older. His father was an investment banker who had played lacrosse competitively in high school and college. Many considered him to be a real “macho” guy. Charles’s mother was a high school English teacher. Both sets of grandparents lived nearby, but Charles’s relationship with them became strained as a result of his gender dysphoria. His parents did not really understand these issues, but they had grown to accept him as he was. His grandparents, on the other hand, would probably never understand. To them, Charles was gay. How else could they explain his not wanting to be a boy? And to say that they were disappointed was an understatement. As the only grandson, his grandfathers wanted to hunt and fish with Charles, pursuits that held no interest for him. His grandmothers were less troubled by Charles’s behaviors. They enjoyed doing the things Charles liked to do, such as shopping and cooking. His sister, Amanda, could also share these activities with him, although she did not completely understand him either. It was also easier for her to think of him as gay. She had gay and lesbian friends, and she had no trouble with their sexual orientation. She understood that her friends were attracted to someone of the same sex. However, to want to change the sex with which you were born was confusing to Amanda, just as it was to her parents and grandparents.

As for his parents, Charles’s father had been, at the very least, upset about Charles’s behavior and his expressed desire to be a girl from the day Charles first started wearing his sister’s clothes and painting his toenails pink. He could now tolerate it, but he still found it difficult to accept. He loved Charles, but he could never bring himself to show affection to him. Charles felt the sting of his father’s rejection. Charles’s mother could accept the situation and she and Charles were quite close, especially since he started dressing as a girl when he was about 12 years old. Her biggest concern was dealing with the bullying and teasing and difficulty making friends that Charles had suffered from throughout his life. It would be a shock when Charles completed his hormone treatment and sex reassignment surgery; however, when Charles became Cheryl, his mother rationalized that even if she had lost a son, she would be gaining a daughter. She loved her child unconditionally and had worked hard to give him as normal a life as possible.

1.3 Multiple-Choice Questions