Demystifying the Transgendered: Renowned Brookline Physician
by Ellen S. Glazer

From Brookline Magazine, April 2005, pages 22-27

The stereotypes of the past that tormented transgendered individuals have given way to sensitive care and support from a Brookline physician who has helped open new pathways for their often painful journey.

"I admit that before I began this work, I had an image of exotic drag queens and TV exhibitionists.  When I began seeing plumbers, truck drivers, doctors, accountants, teachers and carpenters, I realized that these are just people who, in the realm of gender identity, were born with brains that didn't fit their bodies.  And, almost all of them knew it as far back as they could remember," Dr. Norman Spack told Brookline Magazine.

Dr. Norman Spack is Clinical Director of the Endocrine Division at Children's Hospital.  Courageous.  Strong.  Resilient are the words he uses when he speaks of his patients: transgendered children, adolescents, and adults.  Spack respects and admires those who, as he explains it, have landed in physical bodies that differ from their gender identity.  Spack says, "Seeing transgendered individuals has opened my mind to the complexity of the human brain in the realm of gender."

How did a pediatrician and adolescent medicine specialist become one of the leading medical resources for the transgendered community?  "From 1978-1998 I practiced Adolescent-Young Adult Medicine in Chestnut Hill with Dr. Estherann Grace.  Because I also had trained in endocrinology, someone called and asked if I would provide hormonal treatment for a transgendered person in transition from female to male," he said.

Dr. Spack paused a moment to say something about language.  "The terms we use to refer to these people and what they are going through are significant.  For one thing, I don't see this as a psychiatric disorder and, I am among those who prefer not to use the term "Gender Dysphoria."  Dysphoria means `anxious and depressed,' but I see their anxiety and depression as reactive to their situation.  I have also come to understand that being transgendered is not about sexual orientation.  One of my patients brought this across to me when he said, `It's not who you go to bed with -- it's who you go to bed as."  Spack goes on to explainsome of the other significant terms.  "Some people use the term `transgendered' for those who are `pre-operative and transsexual' for those who have had surgery.  I use the word "transgendered" for anyone who has no internal or external genital malformations but sees him/herself in a gender identity different from their biologic (genetic) sex.  Among my reasons for this choice of terms is the fact that not every transgendered person chooses to have surgery.

New Challenge

When he received his first referral, Spack knew little about working with transgendered people.  "I had virtually no experience in the area, but I felt that this patient could teach me.  That is what happened and something else happened as well.  Some older endocrinologists in our area were retiring, and the psychotherapists in the field, who are the first health care professionals to counsel and evaluate transgendered people, were in desperate need of a physician who would initiate and support their patients hormonally.  It turned out that I could be that physician.

The hormonal support that Dr. Spack offers transgendered patients represents the second phase in their "transition."  The first stage is for them to meet with a therapist.  "There are some very skilled therapists in the Greater Boston area who have extensive experience with this population.  My patients must confront a range of issues," he said.  "These vary, of course, depending upon age, family situation and support from the community and workplace.  A transgendered high school student who doesn't know whether to use the `Boys' room or the `Girls' room faces very different issues from a 50-year-old married father who has been suppressing feelings about gender identity for 30-plus years.

After months of counseling, transgendered people can begin hormonal treatment.  In this second phase of treatment, Dr. Spack emphasizes, counseling continues because "although the hormonal treatment can go smoothly for some people, it can prove very challenging for many others.  Whether the transition is Male to Female (MTF) or Female to Male (FTM), it involves high doses of hormones.  I follow patients closely to be sure that their dose is optimal -- that it brings about the desired changes but does not overwhelm the patients physically or emotionally."

Not all of Spack's patients go on to the third stage of treatment, which is known as SRS or Sex Reconstructive Surgery.  Spack explained the various reasons why someone would or would not choose to have surgery.  "Cost is a factor and, until recently no U.S. insurance company were covering it.  That may be changing, as there has been recent news that one major company may cover the expense.  Another determinant is whether the transition is FTM or MTF.  The Male to Female surgery can be remarkably effective, cosmetically and functionally.  Since the Female to Male surgery is so complicated, expensive and risky, most FTMs limit their transition to breast reduction and hormonal treatment.  Soon after androgen treatment, their menses stop and within a year they can blend in so readily that few people recognize them in public as transgendered."

Social Issues

For some transgendered people, decisions about treatment are impacted by social considerations.  Spack said, "This process in no bed of roses. Often people postpone decisions for many years because they realize that going ahead with transition means redefining some of their most important relationships -- with family, friends and colleagues at work."

Spack, who has witnessed major sea changes in social attitudes towards transgendered people, has been touched by some of the stories his patients have told him.  "I had one MTF who transitioned while in a high-level position in a fairly large office.  My patient was reluctant to tell the boss that going to the bathroom required a five-minute drive to a gas station.  The boss asked what could be done to help his "new female" employee, since a number of other female employees were uncomfortable sharing the ladies room with her.  The boss had a unisex bathroom installed at considerable expense."

Another moving story involves a name.  Spack spoke poignantly about what parents go through when they "mourn the loss of a son or daughter in the process of adjusting to gaining an offspring of the opposite gender."  He recalled one mother who said that when she was pregnant, she and her husband had selected names for a boy and for a girl.  Twenty-five years later, when one of their two sons told them that he was transitioning to female, the mother said she always wanted a girl and asked if her new daughter would accept the female name she had chosen two decades earlier.

For Dr. Spack, many rewards come from working with transgendered people.  One has been the support he has received from colleagues.  The staff at Children's Hospital has embraced his work and treated his young patients with sensitivity and respect.  Another reward has come from collaborating with physicians internationally, "especially in Belgium, The Netherlands and the United Kingdom, where they have well-developed treatment protocols for this population.  Locally, I work closely with internists and, sometimes, with gynecologists to be sure that people get the treatment they need.  For example when a FTM needs a PAP test -- it invariably provokes a call from the pathology lab wondering why someone with a male name had a PAP!"

"There must be more public attention to transgenderism," Spack observed, "because parents of gender variant prepubertal children are forming chat-groups on the internet.  I get several calls each week from families seeking advice."

In talking with Norm Spack, it is clear that he sees himself on a journey with his transgendered patients.  Just as they are facing the multiple and complex challenges that come with transitioning from one gender to another, so is Spack trying to learn from their experience in order to pave a smoother path for those who will follow.

Copyright © Brookline Magazine, 2005

See also:

"Transgenderism", by Norman Spack, M.D., Lahey Clinic Medical Ethics Journal, Fall 2005.
http://www.lahey.org/NewsPubs/Publications/Ethics/JournalFall2005/Journal_Fall2005_Feature.asp

Contact information:

Norman P. Spack, M.D.
Specialty: Endocrinologist/Pediatric
Endocrine Division, Children's Hospital
300 Longwood Ave., Boston, MA 02115
Contact: Michele Hopkins
(617) 355-7476
norman.spack@tch.harvard.edu