Sandy came to us as a healthy, highly intelligent, pre-operative trans-girl in her early 20s who had a family problem obstructing her desire for feminization.

She'd had a female identity since early childhood but didn't start cross-dressing until age 14. She was strongly attracted to men & had no desire to be a top. Sandy had been prone to episodes of anxiety & stress-related blood pressure elevation relating to the conflicting pressures of on the one hand the gender dysphoria that was associated with her compulsive need to feminize, & on the other hand the conforming, anti-sexual & anti-gender pressures of her family's fundamentalist religious background. 

I treated Sandy with a moderate dose of estradiol well below the maximum dose that I tend to give, along with low-dose progesterone.  These feminizing hormones were delivered non-orally and in a steady-state format ensuring a smooth, steady, gentle delivery ( in contrast, intramuscular injections of estradiol tend to be highly erratic & unpredictable, and the brain is sensitive to sex hormone fluctuations, hence for example the existence of PMS).  And as is customary in our office, I advised her to obtain psychological counseling, not concerning the subject of transsexuality, which after all is not a psychogenic phenomenon, but to address the conflicts that often attend the transgender process. 

Between a rock & a hard place

Sandy returned to our office some four months later stating that she loved the physical changes she had been experiencing.  Even at this early stage her face had begun to feminize, her hair was more luxuriant, her personality softer & she seemed more at home in her new skin. She told me that life had become better for her.  She had become calmer, more relaxed & less subject to episodes of anxiety & blood pressure elevation.  Now her social interactions with others were also much improved.  There was just one problem and it was a big one.  Unfortunately she had now become subjected to tremendous pressures from her highly religious family.  They ostracized her & pressured her to discontinue the feminizing process, or they would remove her from their lives & God would punish her, they said. 

Going backwards

Sandy was still quite young & hadn't yet become intellectually independent.  She knuckled under to her family and insisted on pursuing a reversal of the feminizing process, without discussing the concept with a psychologist.  I urged her to hold off on her decision & instead to mull it over with her mental health worker. I also explained the significant depression & suicide risks that often accompany avoidance or reversal of the hormonal treatment of gender dysphoria, especially when these decisions are made in response to pressures coming from external forces such as family, instead of stemming from the convictions of the patient herself.  Sandy admitted that without the pressures of family, she would not make the reversal, but now felt compelled to do so.  

About turn

I reluctantly and with great misgivings put a stop to the feminization process, since the choice ultimately had to be Sandy's, and treated her instead with anti-estrogens & a modest injection of testosterone.  Two months later she returned with a sad story.  After the beginning or the reversal, her stresses had increased dramatically.  She experienced a burgeoning depression with loud anxiety & suicidal ideations that were severe enough to cause her to be hospitalized for 3 days in a psych unit.  What could we do to steer her carefully between the rocks of gender dysphoria and family conflict, while preventing her from foundering? 

Compromise

I started Sandy back on a low dose of estradiol chosen to get the genie of her gender dysphoria back in the bottle while at the same time being mild-enough that she could enter a stealth mode of feminization, visible only in private.  And I pressed for her to see her psychotherapist on a regular basis.  Did I start her on anti-depressant therapy?  No, and so far neither has her psychiatric team, since on her current regimen, mood problems still have not recurred, and neither have her suicidal urges, but we continue to watch her progress carefully. 

The moral of the story

Sandy's story illustrates the problems that arise when family members, operating out of a position of abject ignorance, put the trans-woman into an untenable, no win situation, literally between a rock & a hard place.  One wonders whether they would still place these kinds of pressures on the people they claim to love if they were aware of the very real risk of suicide that this kind of behavior puts people under.  Needless to say, Sandy is still conflicted thanks to the pressures placed on her by her religion, and we have simply temporized by treating her with low estradiol doses aimed at keeping the pot from boiling over, in the hope that her conflicts may become resolved as she gets older & more emotionally independent.  This is her choice & her prerogative but it also demonstrates the need for a subtle, nuanced, truly skilled, professional form of hormone therapy delivered by a real expert instead of the crude, slapdash, one-size fits all approach of cookbook hormone therapy.