By Kristen Porter, MS, MAc, LAc and Beth Sommers, PhD, MPH, LAc
"Please bear in mind, however, that the concept of yin and yang is relative and that it defines no clear-cut antithesis understood to be absolutely active and positive or absolutely passive and negative.
Yin can exist within yang, and yang within yin. The active and passive principles are not merely an arbitrary division of energy, but they are the actual interplay between the elements. All, let it be remembered, is relative."1
- Mme. Dr. M. Hashimoto
In May and August of 2003, we published a two-part series titled "The Dance of Yin and Yang: Transgendered Health," which provided basic terminology and resources for working with the transgendered community. This article will take a closer look at acupuncture's potential role in the life of both the transgendered patient and the transgendered practitioner. Transgender is an umbrella term to describe people who cannot or choose not to conform to societal gender norms associated with their physical sex.2 Transgender people live their lives to varying degrees as their chosen gender and may self-identify as female, male, transwomen or transmen, nonoperative transsexuals, preoperative transsexuals, or transsexuals who have completed surgical sex reassignment, among others. A person's sexual identity is not relevant to this issue.
We completed a chart review to help us understand more about who transgendered clients are and why they seek services.3 Of those patients who identified themselves as transgender at intake, 22 patient records were reviewed. Of this group, 27 percent identified as FTM (female to male), 27 percent identified as MTF (male to female), and 45 percent did not specify. Ages ranged from 21-50 years old, with a mean age of 36. Ethnic breakdown included 65 percent Caucasian, 18 percent Latino, 4 percent African American and 4 percent Native American. Twenty-seven percent of the group listed drug use, past or current, as a concern. Nine percent were currently using street drugs, and 18 percent were in recovery from street drug use.
When asked about infectious disease, 41 percent had tested positive for HIV, 14 percent for hepatitis B and 9 percent for hepatitis C. However, it is unclear what percentage of the overall group had received testing.
The main presenting issue for the group was pain, with 45 percent citing it as their main complaint. Specific areas of pain included back pain, muscle pain and headaches. Stress, anxiety and fatigue were listed as the main complaints in 27 percent of patients. Depression was cited as the primary complaint in 14 percent of patients; however, 23 percent of the overall group had previous suicide attempts, which is significantly higher than the general population. In the general population, among adults ages 18 or older who experienced a major depressive episode in the past year, 10.4 percent had attempted suicide.4
Other complaints included infertility in one FTM patient who was using in-vitro fertilization (IVF) to achieve pregnancy; several digestive symptoms such as nausea, constipation and irritable bowel syndrome (IBS); and anti-androgen-related low blood pressure.
In our research, we had the pleasure to interview a transgendered acupuncturist practicing in Florida. Ki Ennes is 45 years old, originally from Chicago, with a 20-year history as a massage therapist. Ki wanted to take holistic health to the next level, and therefore pursued Five-Element acupuncture training. He has a private acupuncture and herbal practice, and also teaches at an acupuncture school in Miami.
Ki was born into a female body and identifies as male or a "trans guy." He is 14 months into his transition, which has included "top" surgery ( bilateral mastectomy and shaping of a masculine chest ) and hormone-replacement therapy. For a FTM transition, this includes taking testosterone, which deepens the voice, grows facial and body hair, and puts the body into menopause.
Ki says his transition is going amazingly, with tremendous support from family and friends, although he is quick to include that his experience is not typical. Ki began his private acupuncture practice two years ago. His southern Florida patient demographic is not heavily progressive. In fact, Ki states many of his patients are Republican and politically conservative. He also treats a handful of Jehovah's Witnesses.
Currently, 90 percent of his patients are aware of his transition. As a matter of integrity, Ki feels strongly that each patient should be told individually. At the end of a treatment, once outside the treatment room, Ki explains his transition. He credits all of his patients who have been told as supportive and receptive. None of them has ceased treatment; many are curious and return with questions for him.
Why have you decided at this point to "come out" as transgendered to each patient?
I've been on testosterone for five months now. Soon things are going to start to change considerably. Because of the nature of our medicine, and especially the focus of Five Element on personal transformation, in order to be true to the philosophy, I need to be forthcoming and honest and say, "This is who I am." As acupuncturists, we are models for our patients, so I have to walk the walk.
Do you think this has affected your practice or your patient relationships?
Yes, I think it has. As a practitioner, I dive into the deep and hard stuff with my patients much faster now. I've felt more ready and able to do that and quickly dispense with the more superficial stuff.
Do you have any identified transgendered patients?
No. However, I plan to specifically market and reach out to the community. When I had my top surgery, I treated myself with herbs, with great results. My surgeon was so impressed that he now encourages other transitioning patients to consider acupuncture post-surgery.
What role do you see acupuncture and herbs playing for the transgendered patient?
There are so many. On one hand, transitioning is very liberating, but it is an intensely stressful process as well. To admit to yourself you are transgendered, yet still be in the body you were born in and be seen by everyone as the gender with which you do not identify, is very difficult. So stress is a big one. Herbs can help with the physical transition for postsurgical symptoms, and acupuncture can help reconnect the qi from the meridians that are cut during surgery. For an FTM, testosterone induces menopause, so both can help with the hot flashes and other symptoms.
Above all, just having the experience of working with a practitioner who is nonjudgmental and accepting can make such a difference. Most of the medical community by and large is not sympathetic, and some are downright hostile. So trans folks often forgo medical treatment altogether.
How do you interpret yin and yang in the light of gender duality?
I don't interpret it any differently. Every being is a combination of both.
Based upon your transitioning experience, how do you now relate the concepts of gender and constitution (for example, the correlation made between yin and the feminine as weaker)?
My body now is transitioning from female to male with testosterone as the agent of change. I now have a new appreciation for yin and yang ; the strength and weaknesses of both are so rich. As the Dao De Jing teaches, ultimate strength is yielding like water, which is yin.
For practitioners wanting to treat this population, what advice would you give?
It's really important that practitioners respect the gender with which we identify. Therefore, use the patient's chosen pronoun consistently. For example, when questioning, you would not say "Back when you were a female" because as transgendered, I was never a female - I was only in a female body. Coming out as transgendered is not a realization, it's an admission. Be mindful of the subtleties.
Be very upfront with the patient about where they are at in their transition - don't beat around the bush. For example, in an FTM patient, ask specifically "Have you had top surgery, or are you binding?" (Binding is the use of constrictive material to bind the breasts to decrease visibility.) For a patient who is binding, upper body (or shu points) might not be an option, and you can help the patient avoid embarrassment and worry by addressing this at the onset.
Transgenders have been an underserved population by the medical community in general, and the acupuncture community specifically. As acupuncturists, we are so well-equipped by the virtue of our medicine to really address this population's needs in body, mind and spirit, so we should avail ourselves.
Mme. Dr. M. Hashimoto, Ed. Japanese Acupuncture. Dr. P.M. Chancellor. New York: Liveright Press, 1966.
"Gender Education and Advocacy. Gender Variance: A Primer," 2001. www.gender.org.