Digest of recent discussions on ISSM mail (Sept 2009 - Dec 2009)

VIII

GABRIELLE MORRISSEY

Gender Dysphoria

                                                                                                                               October 30, 2009: 12 Messages

1

I have a client, David, who is seeing me for relationship and sexual function issues. David is in his 50s and has identified as gender dysphoric since early childhood. He has also seen a great number of experts on and off since his teens regarding his gender dysphoria. In his youth it wasn’t handled well by the expert doctors his parents sent him to. He remains traumatised by aversion and electro- therapies. He has spent the majority of his life as David, with some outlet episodes as Mary, and in fact at one point, some years of part-time transition living as Mary, and hormone therapy – all under the guidance of medical doctors and psychologists. He is in his second long-term marriage and has children from both marriages. Wife number 1 `allowed’ Mary some expression, as long as it was occasional and in a different town. Wife number 2 never knew about Mary when she married David, and upon finding out, has banned David from expressing Mary. David has always been very sexual in both his marriages, and with other previous partners, but finds now, in the last 5 years since the 2^nd wife has refused to acknowledge or accept the existence of Mary,  that his sexual function has been affected. Specifically: he cannot attain orgasm/ejaculate if vaginal penetration is involved. Masturbation, mutual masturbation, and oral sex all result in orgasm/ejaculation but if vaginal penetration occurs, he finds orgasm absolutely elusive. He has made the connection between the timing of this function issue and the issue with his wife finding out about it, and rejecting Mary, but is unwilling and currently unable to negotiate with her as he fears he will lose his marriage, family and his whole life that he has built and is attached to, and he’s made it clear he likes his life as David and he loves his wife but he’s in conflict about his situation. His ultimate goal, realistically at this stage in life would be to remain married, but allow Mary some expression, as he had in his first marriage, but his goal is not to transition fully to Mary – he feels he is too old, and there is too much in his life that he loves, to risk losing. He wants me to give him some advice or exercises (his phrase) to help him learn to orgasm during intercourse (again) with his wife. He says until 5 years ago, he was always able to. They have 2 children and have been married for 20 years. Without being able to integrate Mary into his life, even a little right now (he’s not ready to include his wife in sessions to discuss this possibility), I’m not sure how to proceed. What advice would you offer David?

                                                                         Gabrielle Morrissey (drgabrielle@bananasandmelons.com.au)

2

Gabrielle, you have provided a good summary of a complex and difficult presentation. On one level, this case, despite its other obvious issues, could be conceptualized as a presenting problem of a situation-specific `delayed’ ejaculation, which then suggests a potential treatment paradigm. Allow me to provide two concrete suggestions and then expand on one additional recommendation. 

1. Reassure him that men with a developmental history much less complex and variant than his own, may notice difficulty reaching coital orgasm as they age, compared to manual and oral sex.

2.  Encourage and educate him on how he might move his body during coitus in a manner that more closely duplicates the sensations that he experiences during oral and manual sex; thus increasing the quality of the friction. 

3. Does he allow Mary to be active in his own mind (not communicating this to his wife) when he is having coitus? I would predict that he does engage in some fantasy along those lines when he is experiencing manual or oral sex (which you say work fine), but is not doing so during coitus. The disparity in fantasy (especially as he ages, and his capacity diminishes) may be related to the current symptoms appearing. While the case is certainly intricate, he has been able to experience successful coitus in the past despite the complex life-long history you present. Check out the specific nature of his cognitions and his rationale for using different ones in these various sexual circumstances. Many of his reasons will appear logical to you both, yet you can help him learn (if he wishes) to incorporate what would be a `hot’ fantasy for him into his coital experiences with his spouse. That will end up providing a JND in the quality of the experience for him, which may be an adequate accomplishment at this point in time. Good luck and keep us informed.

                                                                                                    Michael A. Perelman (perelman@earthlink.net)

3

Dear Gabrielle: this sounds like a typical case of autogynephilia or dual-role transvestism (ICD-10: F64.1; DSM-IV has no clear equivalent to it; it´s a mixture of Transvestic Fetishism- 302.3 - and Gender Identity Disorder-302.85). By no means is this transsexualism, so make sure your patient doesn’t  suffer hormonal treatment, or still worse, SRS! If he is unable to accept couple therapy, which would be the gold standard to enable him and his wife to cope with his transvestic urges, and to integrate them into their marriage, it will be hard to help him: He can´t have the cake and eat it, too. Maybe he will benefit from a treatment of his transvestic urges, for instance with an SSRI.

                                                                                      Hartmut A.G. Bosinski (skihagbosi@sexmed.uni-kiel.de)

4

To me it would seem like a good idea to work with his wife - who as it appears, lacks necessary skills in living with a gender variant individual.

                                                                               Esben Esther Pirelli Benestad (esben.esther@sexologi.com)

5

Gabrielle: In this case the relational aspects are most important. David’s wife doesn’t accept his longing to be female (Mary), and he fears her. Probably he is not only anxious but also angry with his wife. Vaginal intercourse with his wife is too intimate for him, too close in connection with her, and too confronting with his unrealizable wishes (to have a vagina himself). I agree with others that couple therapy would be the best option. But his wife will certainly not participate. It will be too embarrassing for her to talk about accepting his feminine wishes. Therefore, you can only counsel him and explore his inner life in a psychotherapeutic setting. Could he love his wife despite her rejection of important aspects of his identity? It will be hard for him, but he wants to stay married with her. Maybe he can learn to talk more openly to her about his pain because of being rejected as Mary. Of course he also has to listen to her pain of being rejected as the only woman in his life. And if he does not succeed in having orgasm during vaginal intercourse, he may try to accept and enjoy orgasm in other ways, even if not intravaginally.

                                                                                                          P.M.Wagenaar (p.m.wagenaar@kliksafe.nl)

6

Gabrielle: Intricate case and a complex one. Many issues can be raised:

-Clearly he is conflicted about his gender. I am not sure that he is a true transsexual. He is having intercourse and enjoying it.

-We cannot force his wife to accept his situation. He should have told her.

-I would work with his ANGER towards her. His inability to ejaculate is his way of expressing anger towards her for not allowing him to come out as Mary. I am not sure (with due respect to Mike) that working with his cognition would help.

-He seems wanting to keep his family, and maybe he can cross-dress when the wife is away or go away where he can do it. Hope this helps.

                                                                                                             Pierre Assalian (pierreassalian@3web.net)

7

Dear Dr. Bosinski:  I am unaware of any data to support your statement that individuals, such as this patient, would suffer any adverse consequences from hormonal therapy or SRS.  Can you provide any citations to support your statement? Obviously, the patient would need to undergo a formal full evaluation before either hormonal therapy or SRS could be considered, but my reading of the literature shows few regrets in these patients. 

                                                                                                                   Charles Moser (docx2@ix.netcom.com)

8

Dear Gabrielle:  I consider the recommendations offered by Dr. Perelman to be excellent. In addition, I would inquire about how he dealt with this situation in the first 15 years of his second marriage, since he has lost his intravaginal ejaculatory capacity only in the last five years of his 20 years of marriage to his second wife. Maybe he just stopped managing the situation successfully in the last five years. Good luck.

                                                                                                                      José R. Pando (pando7870@aol.com)

9

This is a couple’s challenge - and I do not think it optional to be treated as an individual issue.
At the same time, the two main characters certainly need individual attention. 
Many human beings (all?) long to be loved the way we are, with our flaws, qualities and 
capacities. In a couple where one partner seemingly must give away something precious 
(like the right arm), the other partner is also at a loss. It is sad, but frequent, that people 
with unusual talents, like those of trans- for instance, do not tell all their flaws, qualities and 
capacities when they enter a relationship. This certainly carries consequences for them, 
but the major guilt rests elsewhere. Some societies label the expressions of unusual 
proclivities as crime, sin or pathology, thus shaming the person and promoting silence. 
I would consider it malpractice to not take the complexities of shame, shared shame and 
all the couples’ relationships (including their networks) into account when addressing 
the ejaculatory issue.

                                                                                      Esben Esther P. Benestad (esben.esther@sexologi.com)

10

Thank you all very much for your expertise and suggestions. I’m very grateful.

                                                                         Gabrielle Morrissey (drgabrielle@bananasandmelons.com.au)

11

Fascinating discussion of the psychological and intra-marital issues.  But there is also the strong possibility that the inability to achieve orgasm during intercourse is biological.  After all, this man is now in his 50s, and like all men of this age there is a good chance his testosterone is low. This can raise the threshold for orgasm.  Would check total and free T, and offer T therapy if low.

                                                                                                  Abraham Morgentaler (amorgent@yahoo.com)

12

Dear Dr. Morgentaler: I agree with and support your ideas. Though a complete marital and sexual experiences review before and after marriage could be supportive. Thank you.

                                                                                                                        Arif Adimoelja  (ariclin@indo.net.id)