Introduction

This article was initially submitted as a co-authored autobiographical account by a 53-year-old skilled machinist and a commentary by his psychiatrist with whom he reconnected after a complete hiatus of 31 years. By the time the reviews of the submission were available 6 months later, his desire to share his story of transition and return to his natal sex had morphed into a greater awareness of the risks to him. He then decided that he wanted to remain anonymous. He was tired of thinking about the trans aspects of his life and had moved on to a new writing project. This article, rewritten with his permission, conforms to his recent request: “Do not refer to me at any point with female pronouns.” My account is a much more typical case history that lacks the intimate details of the processes of the patient’s subjective experiences that led to returning to living as a man. Seeing the patient through my limited professional vision is clearly not equal to his account, an earlier version of which can be accessed at (https://gendertrender.wordpress.com/2016/09/07/living-life-as-a-woman-was-like-a-career-now-im-retiring/).

Case Report

My View from 1983

Mike, a 5′5″ masculine-appearing 21-year-old senior engineering/physics student, presented to our Gender Clinic wishing to live his life as a woman. His vocational interests, academic performance, and social involvements had deteriorated over the previous 6 months in a deepening but personally familiar pattern of depression. At the end of his junior year, feeling unbearably lonely, he experienced suicidal ideation. He explained that maleness carried too much social and familial responsibility and required aggressiveness that his orderly controlled self did not possess. He longed to be able to spontaneously express his feelings, which he felt was impossible for him as a man. He began periodically cross-dressing, with arousal, in his mother’s underwear at age 12 with great happiness. Later, when he was home alone, he began putting on full outfits using her apparel. Sometimes he imagined that he was a socially dynamic, kind, happy girl, unlike the awkward, shy, unemotional person that he experienced himself to be. Sometimes, he was merely excited by the vision of himself as woman, the image of which emerged as the ambition for his future by age 16. He had begun to severely restrict his diet and took up running in order to keep his body small for his planned womanly life after college graduation. He felt disconnected from his often angry, domineering, punitive father. He had decided early in his childhood that he did not want to grow up to be like him. He initially denied to me feeling close to his mother whom he described as intrusive, although by contrast he felt closer to her compassionate nurturant style. His parents, two younger brothers and sister, and two male best friends knew neither of his gender aspirations nor of his depression. He avoided dating because of his ambition to be a woman and to marry a man, but he claimed to be consistently attracted to girls whose beauty he envied. He was certain that he was not gay, although he had had two separate one-time genital experiences with adolescent males.

I perceived Mike to be a highly intelligent but stubborn, self-isolating, obsessive person with fetishistic transvestism and a worsening depression. He described himself as somewhere between a transvestite and a transsexual. He refused antidepressant medication. I met with his parents after he told them about his plans to transition. They were intensely pained by the revelation and felt that transition was a sin. His mother had been “born-again” a year earlier. His mother urged him to do the same because “only Jesus Christ could help him.” His youngest brother became born-again after Mike’s revelation. Mike felt an increased distance from his mother once she became “crazy religious.” He tried to work with me on his depression but found my probing questions about his feelings about his parents and earlier life processes irrelevant; he was confident that he could make his fantasy into reality. He left the university, moved in with two friends, and took a factory job. Soon he began living alone. After a year of seeing him occasionally, I referred him to an endocrinologist. Denise gradually emerged. Denise planned to have sex reassignment surgery as soon as the money was available.

My View Beginning January 2016

Denise said that he thought of me often during the ensuing years and wished that he were able at the time to listen to my advice. “It would have saved me from a great deal of wasted time—30 some years!” His decision to return to living as Mike emerged as he gradually acknowledged to himself that he long felt inauthentic as a woman and had limited his self-awareness. Although everyone outside his family regarded Denise as a woman, he was exhausted by the constant worried vigilance required to act feminine. He was lonely, longed for love, and to end the relative isolation from his parents, sibs, and best friends who by now were married with children. Mike stopped estradiol and spironolactone. Denise’s gender specialist assured him that he was not mad at him and that he had other trans patients who had detransitioned. Denise declined his offer of testosterone in favor of allowing his testicular function to return on its own. The immediate issue was that he had been working for several months at the best job he had ever had in three decades. He did not want to lose it or be asked to leave the inexpensive farmhouse he leased as a woman. We agreed on a strategy that he courageously followed that led to his acceptance by 200 co-workers without incident. His elderly landlords were eager to have their no-trouble tenant stay. His family and friends were overjoyed to have Mike reappear in their lives. Holidays and birthday parties were celebrations. He legally changed his name back to Michael, went on a few walks with a hiking club, and thought about getting himself ready to date. The latter process has thus far proven daunting. Nonetheless, wearing a goatee, becoming more comfortable in his masculinizing body, he claims to be far more relaxed and happy. He is busy working and writing.

View from the Blog Post Written in Fall 2016

For 3 years, I was an only child before a brother came along, followed by a second brother when I was six and finally a sister when I was eleven. From the first brother’s arrival, I felt a sharp diversion of my mother’s attention away from me and toward him, though I remember her letting me help change or feed him. The second brother seemed to further diminish her affections for me. That blissful time, when it had been just my mom and me at home, was gone. I missed being alone with her, missed “helping” her bake cookies or doing housework together, missed sitting with her while we read a book.

I was much closer to my mother than my father. I felt strongly that I understood her sadness, especially as the wife of a man like my dad. I loved her while perceiving him as cold, domineering, someone extremely capable in practical matters but having little time for, or interest in, the emotional undercurrents of life. I was sure as a child that I was nothing like him. I knew I was a boy and boys become men, but if my sentence was to end up like him, I wanted no part of it. I wanted to be like my mother, someone open to her emotions, generous and loving to those around her—in every way beautiful to me. In short, I wanted to grow up to be her….

I never considered myself gay but I think it is quite possible that I might have turned out so, had I not felt mentally blocked from exploring same-sex attraction. During my cross-dressing I often thought about sex with a man—an intense, wonderful fantasy—but never indulged these daydreams while in my public role as a male. Oddly enough, my cross-dressing habit eventually became less taboo to me than the idea of sneaking off somewhere to have sex with other boys. Possibly, this prohibition was instilled by my hyper-masculine, homophobic father, or it could be that I was just old-fashioned, finding it too strange for men to be with men, or women with women.

My View During 2016

While Denise had his first partner sexual experience during adulthood at age 39 with a man he met through a personal ad, their occasional non-intercourse sexual activity dissipated because there was no emotional bond other than mutual curiosity. During these encounters, he engaged in autogynephilic imagery to augment his arousal. Another decade passed before Denise become friends at a church with an older woman. They initially shared literary interests but over time revealed their life histories. Gradually, they became sexual partners. Denise’s pleasure was a revelation but it created waves of regret for what he had given up to maintain his female social self.

Denise’s idea of femininity and orientation underwent a number of changes over the years. Originally, the ambition and the identity were to be like the attractive girls he envied when he witnessed the attention and affection they received from boyfriends. Clothing symbolized natural femininity during his adolescence. In the early years of his emerging identity, he fantasied that he “welcomed home a husband with a martini and a kiss.” After assembling a feminine wardrobe during his 20s, Denise found that there were few places to wear the lovely clothing. His parents forbade him returning home in female attire. Factory work clothes were jeans and a tee shirt or a female uniform top and steel-toed shoes—not high heels. Denise only wore the nice clothing to shop. This pleasure gradually faded until the clothes were just clothes. Denise began thinking of himself as a tomboy. In his early 40s, he thought of himself as a lesbian. His attraction to women never wavered even though he tried to talk himself into attraction to men. Denise rejected every advance by male co-workers because of “having a boyfriend” and eventually concluded that co-workers regarded him as a lesbian. Having accumulated enough money for surgery, Denise began to fear its complications. In particular, Denise worried about the loss of genital pleasure and recurrently wondered whether the ability to wear tight jeans was worth the chance of losing genital sensitivity.

Slowly, I realized that I didn’t want the risk of surgery…didn’t want a hospital stay, didn’t want to take a leave of absence from work and worry about explaining it. I decided I didn’t want any of it. So I went from seeing myself as pre-op to no-op.

Mike’s inner life was barely disguised in his two unpublished novels.

My protagonist was short, shy, still a virgin in his twenties. He loves women but doesn’t know how to approach them. He has a difficult relationship with his father. When he was a teenager his mother was killed in a bus crash while on a trip with a church group.

While the author recognized how easy it was to write a male character with a happy ending, he doubted that such an ending would be Denise’s fate: “I had baggage and was stubbornly attached to my trans state even though my identity was clearly wavering.” Mike was embarrassed to admit that nothing about the transgender elements of his life brought satisfaction.

I was clinging to the accomplishment of “becoming a woman” but wasn’t yet ready to admit that my real accomplishment had merely been a successful impersonation of one…this victory which carried with it such sexual and social collateral damage; it was becoming less and less worthy of celebration. All along I had never been a woman, and honestly couldn’t say anymore that I’d ever felt like one…Still, I couldn’t give up what I now realized, but could not admit, was a need to pretend.

In 2012, the family, save for his youngest brother who still articulated that he missed his older brother, began using the name Denise. This development followed several years of permitting their son to wear female clothing in their presence. The entire family, however, referred to Mike when Denise was not present. Denise thought that this slow grudging partial acceptance was as good as could be expected. When Denise heard the news of the killing of multiple children at Sandy Hook Elementary School, he had an intense catharsis of sobbing that lasted 3 days during which he realized that the mass killing was a real tragedy, which made his own disappointments in life–which were largely of his own making—pale in comparison.

I knew I was still the same introverted, narcissistic, self-centered fool I had been when I decided, back in 1984, that I had to be “free,” no matter the toll taken on my family or my relationship with them.

The catharsis led agnostic lonely Denise to go to church on Easter 2013 where the friendliness of a twice-widowed woman led to a new relationship. She was a year older than Denise’s mother. Denise moved in with her eventually and began fantasizing about being her husband. He occasionally wore the deceased husband’s shirts, used his tools to repair the house, and shaved with his electric razor. Their happy life together lasted almost 2 years. It ended abruptly when the woman required hospitalization with a febrile illness. Her children, one of whom had known about Denise’s trans state, told him that they suspected that he was a con artist preying on the elderly. They summarily evicted him and forbade further contact. Although they have not seen each other since, they talk by phone and write. Mike recently said, “We are dear friends. I love her and am grateful for her.” Despite her initial acceptance of Denise as a woman, over time both came to understand their relationship as a male–female heterosexual one. Denise felt masculine during these encounters. Mike’s sexual experiences with her did not require any fantasies. For a long time, when sex was over, Mike maintained his female identity. Eventually, however, his female identity increasingly felt uncertain.

I swore to everyone in my early twenties that living as a woman, to the extent I could, was my destiny, that fulfilling this destiny was my only path to contentment. I argued my case with great conviction and skill. But I was still wrong. My dream of being a woman—that beautiful, crystalline, impossible dream—eventually dissolved, leaving nothing behind except…myself. My hope is for a future in which people’s desperate and damaging attempts to change gender have faded into history, rendered needless by the full and honest appreciation of humanity in all its forms.

Discussion

There are ethical tensions involving confidentiality when professionals write in detail about a patient or a series of patients (Levine & Stagno, 2001). Additional dilemmas may arise when a patient and a psychotherapist write a joint paper as we initially did. The patient may become a public figure who receives praise, condemnation, or both, immediately or in the future. The professional may be viewed as exploiting a patient for his or her own professional advancement. Their original therapeutic goals may get lost in the processes of publication. Mike and I discussed the advantages and disadvantages of writing the original article with two parts (his and mine) recognizing it may distract us from the work of easing his way back to a male life. We agreed to undertake these risks because we share the view of the importance of sharing his life experience with others. His capacity to do it well added to the likelihood that it would create a memorable contribution for professionals, policy makers, and individuals who are considering gender transition. We also shared an ambition to advance the level of discourse about this important but rarely professionally discussed topic. Mike, who has experienced moments of fear during the writing and editing processes, still desires that his life experience be respectfully considered, but anonymously.

The value of this case report is its capacity to raise the question of the long-term fate of early life decisions to change gender presentations. In my view, this dramatic shift in behavior is always preceded by an internal process of imagining a better life for oneself in the opposite gender. This adolescent act of imagination becomes a conviction that the new identity is not only the most important aspect of life but that the individual possesses the power to overcome the anticipated and unforeseen obstacles. The Internet is part of the process these days. It seems reasonable that a professional would be interested in a person’s psychological dilemmas that preceded the repudiation of the assigned gender. In recent years, there has been a stunning increase in such decisions among young people. There is now considerable social, political, and medical support for these decisions. It is striking that there is a paucity of information about the fate of those individuals who transition without the benefit of genital or breast surgery. These natal males and females may be characterized as individuals who knowingly or unconsciously keep their options open. Without systematic follow-up data on how they lead their lives, however, professionals are left with opinions based on theory, anecdotal clinical contacts, and the blog postings of those who have detransitioned, none of which provides a basis for prevalence.

Shall we assume that those who detransition, like my patient, were not “true” transsexuals, to use a term from the early 1980s, and were merely initially misdiagnosed? Or that their autogynephilic characteristics predisposed them to unhappiness in their lives? Or that persistent heterosexual attraction (based on natal sex) set them up for an unstable identity? Mike identified as a preoperative transsexual woman for decades. Who can argue with an apparently stable personal identity? This patient recalls that during adolescence autogynephilic elements coexisted along with nonsexual pleasures while imagining himself in his future gender role (Lawrence, 2011). His adolescent fetishistic responses to clothing attenuated and began to disappear as Denise emerged. Mike then invested more heavily in the exciting idea of being loved by a man. Despite this powerful fantasy, the attraction to women persisted. In 1983, although acknowledging the pleasure of masturbation, Mike described discomfort with his penis because it signified to him his repudiated maleness.

Mike to Denise to Mike illustrates that it is possible to be convinced that one is a transsexual, a real woman, and gradually become less certain as social (external) and psychological (internal) impediments and life opportunities are experienced. My patient’s initial presentation is clinically familiar (Zucker et al., 2012); it is the outcome that is noteworthy. Is this a common or a rare outcome? The answer is not known. Given that the organizer of the eighth edition of WPATH Standards of Care is planning a new section on detransitioning (E. Coleman, personal communication, April 21, 2017), other clinicians must be witnessing this as well.

While Mike has been able to bear his existential dilemmas without professional assistance, substance abuse, or irresponsible or illegal behaviors, one can only wonder what happens to trans individuals of lesser emotional strength who over time experience a similar set of social and psychological dilemmas. It is useful to wonder whether the growing sense of inauthenticity contributes to some of the psychiatric problems described among postoperative transsexuals (Dhejne et al., 2011; Simonsen, Giraldi, Kristensen, & Hald, 2016). In 2016, Mike told me what he wrote in his blog posting: “I left maleness because I did not feel authentically a man, only to feel inauthentic as a woman.”

Throughout my career, I have striven to understand transgender phenomena as an individual developmental process (Levine, 1984, 2016; Levine & Schumaker, 1983). For some trans individuals, my interest initially provokes resistance—that is, the patient begins to experience an array of sadness, frustration, distrust, and hostility. To lessen this resistance and to establish a working alliance, I now explain to my new patients that I consider them first to be human. I assert that having gender pain, genital dysphoria, identity confusion, or an ambition to belong to the other gender does not exempt them from the psychological challenges that all of us face. This explanation is often understood and perceived as caring. I recognize with the patient that gender change is a momentous decision that needs to be well thought out because of its numerous unanticipated consequences for family relationships, employment and sexual and nonsexual interpersonal relationships, for physical health, and fertility. I do not pretend that my ideas are easy to consider among these adolescents. While some are relieved to hear this articulated, others perceive this only as a refusal to quickly offer hormonal or surgical support. In 2016, Mike understood this in a manner he could not at age 21. He, too, now wonders how I might have convinced him that maturation inevitably occurs, the desire for loving connection is not satisfied just by having sex, and that certainty about most endeavors is unjustified.

Today, whether professionals think of gender dysphoria as a symptom of: a mental illness (Mayer & McHugh, 2016); a brain predisposition with inevitable identity consequences (Guillamon, Junque, & Gomez-Gil, 2016); a permanent state once established (Berlin, 2016); a solution to a rare intrapsychic problem; a courageous struggle toward a happier, healthier destiny (Byne et al., 2012); or an uncommon response to a common intrapsychic problem (Levine, 2016), its origins officially remain uncertain. New ideas are to be welcomed.

As gender dysphoria occurs throughout the life cycle, its varied presentations raise two overarching questions:

1. “What are the pathways that lead to these intense aspirations to belong to the other gender?” When the search for a causal factor shared by those with the condition and without which there is no gender dysphoria succeeds, the factor will be properly labeled an etiological one. The study of most psychiatric diagnoses has led professionals to believe that a single etiology is an illusion. Too many influences bear on psychiatric symptoms to believe diagnostic entities are created by a single etiologic factor. This is why the common summary statement for the etiology of this and most psychiatric diagnoses is gene–environment interaction (Berlin, 2016).

I am aware that some clinicians who are devoted to the supportive management of patients find the question of pathway to gender dysphoria irrelevant. The diagnosis is the first issue—does the patient meet the requisite criteria? The World Professional Association for Transsexual, Transgender, and Gender Nonconforming Health’s Standards of Care provide little guidance for transgendered individuals who do not meet diagnostic criteria (Coleman et al., 2011). The second issue is what the patient wants at this time and in the future. Support means proceed with transition and hormones and consider surgery in the future. In contrast, those who value knowing how this identity formed and how it has been maintained have to seek to understand these patients’ lives, one person at a time. In offering a rich, thoughtful exposition of the genesis of his feminine years and the dissolution of his trans identity in his blog posting, Mike has provided a wide audience an opportunity to consider one such pathway.

2. “What are the long term consequences of social, biological and surgical transition? This used to be debated as uncertain, but in recent years many believe that science has established the wisdom of transition and hormonal and surgical treatments (Weyers et al., 2009). The data for this policy-engendering conclusion derive from many one-, two-, and five-year follow-up studies of those who had sex reassignment surgery. Despite the monumental accomplishment of these studies (Lawrence, 2003; Pfäfflin & Junge, 1998), one is left to wonder what the high lost-to-follow-up rates mean. As represented in the published English literature, those who have not had genital or breast surgery seem either to be of no interest or have lost contact with researchers. Pfäfflin, in an afterword to a German autobiography, reviewed outcomes that have been depicted in film, biographies, and autobiographies (Pfäfflin, 2012). In the U.S., trans females who have not had genital surgery are largely ignored by social, government, or insurance policy makers (Baker, 2017). Following up on any previously encountered groups of transgendered individuals is a considerable challenge that has yet to be solved.

Today, Mike is a contemplative articulate man who has illustrated the intrapsychic forces that led to his costly repudiation of maleness. His wish to become a woman seemed driven by forces he did not want to discuss in 1983. My formulation of these psychodynamics caused a subdued fight and a flight. Today, when seeing such intelligent adolescents, I couch my remarks in more philosophical tones. I reflect upon idealization versus reality, the dangers of certainty, the prejudice inherent in thinking that all men are destined to be like their fathers, the unpredictable evolution of every life over time, and the inherent limitation that individuals have when they cannot know and express their inner lives to themselves and to others. In retrospect, rather than simply regarding Mike’s envy of women as a diagnostic indicator of the problem, today I might be better able to explore this in terms of inhibition of expressing his sexual desires. I might have educated him about sublimation and his current failure to integrate warmth, compassion, and empathy into his soft-spoken kind masculine gender presentation. And I might have discussed his hidden angers. Nonetheless, today I marvel at Mike’s description of his life and urge readers to use this article as an introduction to his blog posting. His narrative contains details that I either never knew or heard but could not appreciate.

Although the consequences of adult maturational shifts over decades among the transgendered are not described in the literature, there are a number of studies that have indicated that all is not forever happy among this varied cohort (Reisner et al., 2016). In two registry studies in Scandinavian countries, where death rates of all operated-upon transsexuals over 30-year periods were available, higher death rates from all causes, cardiovascular disease, cancer, and suicide, have been noted (Dhejne et al., 2011; Simonsen, Giraldi, Kristensen, & Hald, 2016). In Sweden, compared with controls of both sexes, the suicide rate was 19.1 times greater, the attempted suicide rate was 7.6 times greater, and the all mortality rate was 2.9 times greater. In Denmark, 10% of 98 patients who were operated upon had died before age 60. Two were suicides–a number far in excess of controls. In the US Veteran Administration Health system, the mortality of trans identified patients (not just operated-upon individuals) is comparable to the early death rates of those with schizophrenia and bipolar disease (Blosnich, Brown, Wojcio, Jones, & Bossarte, 2014). In a meta-analysis of 33 studies, 71% of trans patients were found to have significant psychopathology apart from their gender problem (Murad et al., 2010). And, there is a recent report of individuals seeking surgery to reverse their sex reassignment surgery (Djordjevic, Bizic, Duisin, Bouman, & Buncamper, 2016). These studies suggest caution about the long-term medical and psychiatric consequences of living a cross-gendered life. They do not mean, however, that all long-term medical and psychiatric outcomes are poor. It does suggest to me that passionate professional advocates for transition need to keep an open mind and resist thinking about their recommendations as a means to cure the problem diagnosed as gender dysphoria.

I am left with several basic questions: What happens to those who do not have surgery? How do trans identities evolve over time? Can the process of regret be captured by a questionnaire at a point in time? What are the ideal parameters to measure outcomes in this population? Are policies that promulgate that gender dysphoria is fixed—untreatable and unchangeable by any psychological means—overlooking the influence of time?