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Published on Tuesday, 01 November 2011

Written by Peter Burnett

If you’ve known from an early age that you are a man living inside a woman’s body, or a woman living inside a man’s, you’ll be aware that in the reassignment process, changes are going to be made both outside and in — and when we say inside, we mean to the very core of your being.  There are a few basics you’ll have been aware of for as long time, but if you’re starting to make decisions, you’ll want to find a health professional who is experienced and aware of the issues at stake.

Dr Lyndsey Myskow is a sex therapist and one of very few practitioners in Scotland to deal with the issues trans people face. The fact is that there isn’t a website or book large enough to list every peril, pitfall, question and challenge — which is why experienced practitioners are so valuable.  If you think you’ve thought of everything, you’re wrong — and just when you think that things are on an even keel — that’s when the mopst unexpected difficulties can pop up.

Every case of gender dysphoria is quite unique and on top of that social attitudes are not only unpredictable but in constant flux.  What people think and how they react varies hugely, but ultimately, the reason that these questions are so important is because the issues which arise from a dysphoria are so all-encompassing that they will be felt in every aspect of your life — every hour of every day of every year — until you can achieve some kind of resolution.

‘Generally, people will begin to realise that they have been born into the wrong sex at the age of three or four,’ says Dr Myskow.  ‘Biologically, it is sex hormones, sex chromosomes and physical appearance which determine who is a man and who is a woman — but in my experience, children who are going to experience dysphoria will start hinting to their parents that they are not who they think they are, at about that age.’

This means that the journey is much longer than many might think.  If you tell your friends that you are experiencing dysphoria, they may assume that it’s a recent thing, or something you developed at adolescent — but it rarely if ever is.

‘The thing is,’ says Dr Myskow, ‘that although children may have these feelings, they needn’t necessarily be an issue.  Children’s bodies, pre-puberty, have less sexual differences than they do post-puberty — and on top of that, particularly young children don’t make the same gender differentiations that a grown-up will.  Thus, if you’re a five year old girl who believes she should have been a boy, she can quite happily gather young male friends and play with them in preference to the girls.’

Dr Myskow became interested in human sexuality at medical school and had an opportunity to train as a sex therapist with Dr John Bancroft, who at that time often worked with transsexuals.  When Dr Bancroft left the UK to become Director of the Kinsey Institute for Research in Sex, Gender and Reproduction in 1995, Lyndsey continued this work and is now one of three practitioners on Scotland who have experience and expertise in this field.

‘There have been big changes since 1989, when I started,’ says Dr Myskow, ‘most notably in the field of legislation, which is much better now, and which aims at least to protect and nourish lives.  There are still problems in the working and personal lives of many transsexual people, and we still hear of physical attacks, although fortunately it isn’t nearly as common as it once was.  The ability to change one’s birth certificate has been great — and in many areas transsexual people are quite protected — which is as well, because I think the majority of people don’t realise the incredible strain trans people are under.’

It’s Dr Myskow’s appreciation of these strains which makes her not just a leading therapist, but a campaigner for legal and social equality for transsexual people.  At present the NHS waiting list to tackle Sex Reassigment Surgery is 20 months, but we are delighted to say that Dr Myskow is a campaigner to have that reduced, and that she meets the Scottish Government to tackle this.

Society divides people into either boy or girl, depending on the male or female appearance at birth, although intersex conditions may arise due to certain congenital disorders or hormone imbalances in the foetus or placenta.  Anatomical sex at birth may differ from the chromosomal or gonadal sex and genitalia may be ambiguous, but can often appear totally female or totally male.  In the case of gender dysphoria a person may feel a consistent and overwhelming desire to transition and fulfill their life as a member of the opposite sex — and although this can arise as early as three or four years old, many people just assume that their body will change accordingly at puberty, and are shocked when it doesn’t.

‘Puberty is a great time to act,’ says Dr Myskow, ‘and the basic rule is that the longer one waits, the more complicated the surgery will be.  If a person is properly diagnosed before puberty, they can be given hormone blockers at this time, which will give them more time to mature and decide.  This can be a great help, because the decisions involved are obviously momentous.  Some people are sure of what they want and have had family support from an early age — but others aren’t so clear.’
Many, says Dr Myskow, can now be left to be content and to live their lives as anybody else might — although some, because of appearance, may never be able to blend in.  However, anyone who assumes that the challenge lies in learning to dress properly and to use make-up to good effect is really only scratching the surface.

‘Of course, social attitudes and popular opinions can be quite misleading and even dangerous,’ says Dr Myskow.  ‘One thing that must be made clear is that Gender Dysphoria is not a psychiatric issue.  It’s true that people proposed for surgery must be vetted, because whereas Dysphoria might have a psychiatric definition, the symptoms can very occasionally appear as part of the psychosis of someone who is merely extremely confused.  These people are not transgendered however — far from it.’

Aside from the long waiting list and the social stigma attached to SRS, poverty is another major problem that faces many transgendered people.  ‘The fact is though,’ says Dr Myskow, ‘that for just about everyone I have treated, the need has been so great and so all-encompassing, that they are willing to throw all their resources into it.  If you are 21 and seeking surgery, you may have known about your condition for up to 18 years, so you’re going to be prepared to give it all you’ve got.  The two things that get in people’s way the most are finances, and the educational level, particularly of their own family background.  Thus if you are a Gender Dysphoric child from a middle-class family today, the chances are quite high that you can have a relatively stress-free transition when it comes — and the life you want to lead after that.’

Although the lengths of time taken to transition and the costs and times involved may vary, with MTF (Male To Female transition) being easier to achieve on the whole than (FTM).  ‘Many FTM patients chose to live without a penis,’ says Dr Myskow, ‘but there are increasingly more and better options if they would like to.  The real problem here however is that FTM surgery is not funded in Scotland, and this has been the case for four years, and this is because there is only one surgeon who will do it, and they are private.  That is very discriminatory, and something I am also campaigning to have changed — although all surgery varies from area to area.  In Lothian, for example, MTF surgery is funded, but this isn’t true across the board.  It just means that different treatment is available in different places — which is something that really needs to change.’

So how much does it all cost, and how much time will it take?  These are the practical issues that the huge majority of transgendered people face, and of course there is no fixed answer.  Generally however, a person undergoing a MTF transition will involve at least two years of both state and private treatment, involving speech therapy, hormone treatment and counselling, with genital surgeries costing around £12,000, and breast augmentation — if it is required — costing another £4,500 or so.  In all, the bill may be between £25,000 and £30,000, and of course, getting a loan for this will be far from straightforward.  Although it is much harder, FTM surgery is do-able, but also more expensive.  The NHS will fund a lot of private things, but as I’ve said, at the moment, not this.’

‘To begin with, a friendly GP is probably a transgendered person’s best friend, because a transgendered person needs good support.  The service in Scotland has gone through stages where it is better than it is now, and some level of consistency and on-going support would be invaluable.’ Knowing this, and from the experience of her patients,  Dr Myskow also makes a point of encouraging all the GPs she can to be aware of the issues and not shy away from finding the best support and advice. 

Speaking to Dr Myskow was an inspiration, not just because of her enthusiasm and her efforts to change social and in particular, government views, but because it’s clear she’s been an inspiration and a huge help for so many people.  While she agrees that a lot of progress has been made since the 1980s, Dr Myskow is firm that there is still a long way to go, and we are delighted that she is consulting with the Scottish Government in an effort to change funding patterns and attitudes. 

Dr Lyndsey Myskow is one of the founders of Medicalternative.  Link to Medicalternative.