Book Review: Transgender Care: Recommended Guidelines, Practical Information and Personal Accounts

Author: Israel, Gianna and Tarver II, Donald
Title: Transgender Care: Recommended Guidelines, Practical Information and Personal Accounts
Call No: 362.108 ISR

Transgender Care is a rather different kind of book–not just among books by, for, or about the transgendered, but among nonfiction books generally. It is both a personal statement and a collection of diverse viewpoints; it is both an advocate for a new policy of healthcare and a polemic against that same policy (as being insufficiently revolutionary); it is both a dry, almost academic, detailed description of that policy, directed largely at healthcare providers, and a collection of impassioned voices, both raw and educated, strident and well-modulated, speaking out of the depths of that healthcare clientele.

This book is an important new resource for the transgender community; it may form the basis for an expansion of humane care of all segments of this diverse population. Gianna Israel is a well-known gender therapist, working with Dr. Donald Tarver (public sector and private practise psychiatrist) in San Francisco.

Ms Israel (herself a transgender woman) describes herself as both principal author and “project administrator” of Transgender Care. For this book is partly the work of Ms Israel and Dr. Donald Tarver as authors–Part I, “Recommended Guidelines”–and partly their work as editors in compiling Part II, “Essays”. In addition, most of the essay writers, with a few other people, served as a sort of review board for Part I, making the entire book a complicated process of give-and-take. There is a loss of a single point of view in such an undertaking; but that multiple-voicedness is one of this book’s special strengths.

The intended audience of this book is as complex as the book’s structure: It is largely intended for care providers in the field of transgender health, mental and physical, as suggested by both the content–suggested directives on the care of the transgendered–and the sparse, sometimes unforgivingly technical prose in which Part I is often voiced. But it is also of substantial interest to the transgendered, who should not only be aware of these recommendations for their care, but may take great interest in the essays on facial and genital surgery, insurance matters, intricacies of the client-therapist relation, personal stories of the transgendered, and even the philosophy of what it means to be transgendered.

What does “transgender” mean for this book? It is another of the book’s particular strengths that it is quite inclusive–crossdressers, transsexuals, transgenderists, drag queens and kings, MtF and FtM and androgynes and all. Although the bulk of the book is devoted to guidelines and essays concerning transsexual men and women, at every stage of the Guidelines, care is taken to address the needs of every stripe of transgender person.

Part I consists largely of an extended gloss on the Recommended Guidelines for transgender care. In brief, these Guidelines are the authors’ answer to the Harry Benjamin International Gender Dysphoria Association (HBIGDA) Standards of Care, but they are far more extensive than those SOC: They start with Guidelines for the placement and care of transgender people in residential environments, whether in social service, mental health, or correctional facilities. Next are Guidelines for hormone administration; then for aesthetic surgery (meaning anything non-genital–including, for instance, breast augmentation or mastectomy); and then for genital surgery. There follow Guidelines for the treatment of transgender people who are HIV-positive, Guidelines for treating those of different cultural background from the care-provider, and Guidelines for treating transgender youths.

The philosophy behind the Guidelines developed here can be gleaned from a few quotes–basically, a very positive outlook on what it means to be transgendered, as opposed to the overly pathologizing language characterizing much of the SOC:
“Irresponsible usage of labels [such as “transsexual” or “transvestite”, etc.] may result in … Care providers who stop listening once they decide an individual falls within a subpopulation. Encouragement of an individual to conform to models that are inconsistent with that individual’s needs or self-identity. … Transgenderists or transsexual individuals who feel pressured to conform to stereotypes…” (p. 14)
“Many transgender persons do not evidence gender-associated confusion or emotional distress.” (p. 24)
“There is no reason why psychiatrists and other mental health professionals cannot be charged with the responsibility of recognizing gender-identity issues without the necessity of labeling them as disorders.” (p. 25)
“Care providers and surgeons are … advised that in some circumstances a real-life test may be physically impossible prior to surgical intervention.” (p. 79)
The actual Guidelines are recognizably derived from the Benjamin SOC, but with a human face–the very name, “Recommended Guidelines”, instead of “Standards of Care”, bespeaks the principal difference: For instance, there is the familiar requirement for a three-month relationship with a Gender Specialist before hormones are to be prescribed (Guideline 1, p. 71), but then there is Guideline 1b: “Exceptions to the three-month assessment period may be considered by the evaluating Gender Specialist or the prescribing physician if a well-established transgender identity exists and other aspects of the Recommended Guidelines for Hormone Administration are observed.” Other Guidelines are similarly hedged about with warnings to be flexible and take individual differences into account. In short, the Guidelines are not legalistic Rules of Conduct, but considered suggestions addressed to care-providers who are expected to exercise careful judgement.

Note, also, that the prescribing physician is a formally addressed subject of the hormone administration Guidelines; thus do these Guidelines address the reality of the context in which they will be followed–or ignored, if they did not address that reality.

The Guidelines for genital reassignment surgery are not very different from those of the HBIGDA SOC; the two letters and one year’s Real Life Experience are still there, though there is more flexibility in the nature of the required relationship between client and counsellor.

But besides the raw Guidelines, there is much discussion of the issues involved:
a discussion on when and how to make disclosures of transgender issues to one’s family, children, or colleagues (with considerations for those contemplating or not contemplating hormones, transition, or surgery); an introduction to the usage of hormone therapy, both MtF and FtM, including typical blood-levels; an extensive section on Consumer Preparedness for those looking for genital surgery; a basic discussion of how hormones and surgery are and are not complicated by HIV; a nuanced discussion of the special problems of transgender youth, including some special solutions: “…allowing the child to dress androgynously for school and peer activities … encouraged to adopt an androgynous name until they are old enough to be certain they want to change their name permanently” (p. 138); an entire chapter on Support Tools, including a suggested Gender Identity Profile form; a series of Support Scenarios, illustrating the various modalities that may be useful for different types of clients in different contexts.

There are some issues missing from the discussion of Part I that it would have been well to have included. For instance, there is virtually no mention of the psychoactive effect of hormones, which a great many transsexual men and women have remarked upon. It may be idiosyncratic, perhaps placebo in nature, but it is so commonly reported that it deserves more than passing mention. Then there are the Guidelines for aesthetic surgery, with a recommendation for a six-month period of consistent desire for such surgery before a referral letter to a surgeon is issued; it would be nice to see a discussion of the reasoning behind this, but very little is given. And why not a discussion of the reasons for a full year’s Real Life Experience and two reference letters for genital surgery? There is some tension in the authors’ description of an individual’s having a self-defined transgender identity–defined to mean, among other things, “the ability to stay consistently within one’s chosen presentation” (p. 8); does this mean that if one is unable to “pass” then one does not have a transgender identity? This cannot be what the authors mean, but it’s unclear what they do mean; closer discussion is called for.

The thirteen essays of Part II include some notable names: Dr. Eugene Schrang, e minent sex-reassignment surgeon, speaking of his surgical techniques; Dr. Douglas Ousterhout, famed plastic surgeon, discussing techniques for gender-reassignment facial surgeries; Dr. Anne Vitale, well- known transsexual psychotherapist, discussing the complex nature of the client-therapist relationship; Rachel Pollack, transsexual activist, issuing a strong critique of the Recommended Guidelines from Part I. These and other essayists are part of the Review Committee for Part I. Other essays also criticize the Guidelines for maintaining something of a gatekeeper role for the therapist; another discusses the possibilities of legal challenges to insurance companies’ practices of excluding coverage for transsexual care.

One of the most hopeful-sounding passages in this book is that the authors intend future editions of the book, to include updated and additional information. I look forward to seeing this text evolve into an even more helpful and thought-provoking aid to the entire transgender community.

Source: Steve Harris, Gianna Israel Gender Library (