Transgender Emergence

Therapeutic Guidelines for Working with Gender-Variant People and Their Families

Arlene Istar Lev

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136384950
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Explore an ecological strength-based framework for the treatment of gender-variant clients This comprehensive book provides you with a clinical and theoretical overview of the issues facing transgendered/transsexual people and their families. Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families views assessment and treatment through a nonpathologizing lens that honors human diversity and acknowledges the role of oppression in the developmental process of gender identity formation. Specific sections of Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families address the needs of gender-variant people as well as transgender children and youth. The issues facing gender-variant populations who have not been the focus of clinical care, such as intersexed people, female-to-male transgendered people, and those who identify as bigendered, are also addressed. The book examines:

• the six stages of transgender emergence
• coming out transgendered as a normative process of gender identity development
• thinking "outside the box" in the deconstruction of sex and gender
• the difference between sexual orientation and gender identity, as well as the convergence, overlap, and integration of these parts of the self
• the power of personal narrative in gender identity development
• etiology and typographies of transgenderism
• treatment models that emerge from various clinical perspectives
• alternative treatment modalities based on gender variance as a normative lifecycle developmental process

Complete with fascinating case studies, a critique of diagnostic processes, treatment recommendations, and a helpful glossary of relevant terms, this book is an essential reference for anyone who works with gender-variant people. Handy tables and figures make the information easier to access and understand.Visit the author's Web site at http://www.choicesconsulting.com

PART I:
THEORETICAL UNDERSTANDINGS OF TRANSGENDERISM

Chapter 1

The Transsexual Phenomenon Meets the Transexual Menace

The clinician's phone rings and the woman on the other end is distraught because she just found a suitcase filled with women's clothing and pictures of her husband dressed in the clothes. She is weeping into the telephone, alternating between expressions of compassion, confusion, sadness, and rage.

A lesbian couple who have been lovers for a decade seek counseling because one of the partners has disclosed that she has always felt like a man, and that she feels ready to begin to live as one. Her partner is devastated, caught between loving her partner and not wanting to be lovers with “a man.”

A message on the telephone machine says, “I am calling you as a last resort. I know I am a woman,” the deep male voice insists. “I don't know whether to be who I am or just kill myself. Please help me.”

A mother seeks therapy because she discovers that her fourteen-year-old son has ordered female hormones on the Internet. The family comes into therapy for one session but cancels each following appointment, saying, “Everything is fine now.” A year later, her son e-mails the therapist, “What can I do about my facial hair growing in? I have to do something.”

Gender-variant people and their families seek professional help for a variety of reasons. They are often in emotional pain and confused, and are seeking understanding and information. At the time of initial contact, people are often “at the end of their rope,” expressing suicidality and despair. Sometimes they seek services after a disclosure—or exposure—of the gender issues that have caused chaos in their family life. They enter therapy angry, resentful, and feeling hopeless. Clients often seek out specialists in gender issues after years of conventional psychotherapy, wanting to move ahead in their gender transformation and feeling stymied and trapped by the medical establishment. Questions immediately arise:

• What are the clinical responsibilities for a therapist faced with a client dealing with issues surrounding his or her gender?
• What are the therapeutic guidelines that should be used to assess a client?
• What tools and treatment strategies should a professional helper use to assist the client coping with gender dysphoria?
• What are the guiding theoretical modalities for a social worker, psychologist, or counselor committed to compassionate and empowering therapy?

Looking at the clinical vignettes listed previously, what advice would a therapist have for a woman who has discovered that her husband is a cross-dresser? What is the clinical stance for a therapist counseling a couple in which one female partner identifies as a man and the other identifies as a lesbian? What are the guidelines we use to assess whether the despairing male, who “knows” he is a woman, is really a transsexual or simply a delusional person? Finally, what are the ethical implications of working with a gender-variant child who is seeking services and support without his parent's knowledge?

A therapist working with the wife of a cross-dresser as described in the first vignette could find a small amount of research on heterosexual cross-dressers and their wives to assist him or her in doing marriage counseling. The research shows that, through a process of educating the wife about cross-dressing and addressing the issues of betrayal and trust, it is possible for the marriage to remain viable. Guidelines also exist to assess the kind of gender dysphoria exhibited by the male in the third vignette and to assist the therapist in delineating gender dysphoria from “other” mental illnesses, outlining the distinctions between cross-dressing, transsexualism, and homosexuality, and examining the eligibility and readiness for medical sexual reassignment. However, if either of these males wants to modify his body through the use of hormones but not “go all the way” with surgical reassignment, the clinical guidelines become muddier and the research base to understand these experiences is not yet available. Gay and lesbian couples managing issues of identity when facing gender transition have few resources available to assist them in their journey. The ethical dilemmas facing therapists working with transgendered youth are complex, and although guidelines to assist clinicians have been recently revised, they are an area of current professional debate.

It is obvious that more research, information, and clinical discussion are needed to address the issues of these previously marginalized populations. It is perhaps less obvious that a reexamination of existing treatment modalities is also in order for some types of gender variance that have already established clinical trajectories. The following vignettes will illustrate some examples of therapeutic treatments that need to be revisited in light of the currently expanding knowledge.

Luz and Felix Garcia were surprised when, after an uncomplicated delivery, their newborn child was quickly removed from the delivery room. After a few tense hours, the physician explained to them that their daughter had some medical complications concerning her genitals that could be addressed surgically. They were assured there would be no further complications and surgical alteration of their child's genitalia was completed within a few days. They received emotional support and postoperative counseling regarding their daughter's medical condition, but they were not informed that their daughter had been born with an intersexed condition and that there were alternatives to surgery.

Alex (nee Alexandria), 13 years old, was referred by the school district, who described her as “very disturbed.” The paperwork they sent described her as avoidant, depressed, slovenly dressed, and isolated. She came to the first session accompanied by her parents. Her dress hung awkwardly on her small frame, and her hair was uncombed. Her father spoke to her in a condescending tone, ordering her to talk about “her problem.” Alex spoke in a distant voice, avoiding eye contact. Her chart said she was prescribed three pyschotropic medications, and it was obvious she was having difficulty remaining focused. As Alex tried to explain that she felt like she was a boy, her parents cut her off, telling her she was an “idiot.” They explained they had brought her to a number of therapists, including one program two hours away. Alex had spent a year in a residential facility for “disturbed children,” and she had also been psychiatrically hospitalized three times for suicide attempts. No one had been able to “fix” her, her mother said sadly. Alex looked up with hollow eyes, wondering what her next treatment would be.

Louis seemed an unlikely person to be talking about cross-dressing. He was a large man, with burly hands worn and stained from Louis's fifteen years as a car mechanic. There was very little that could be called feminine about his mannerisms, yet as he talked about his cross-dressing, he grew tender and vulnerable. He confided to me how he'd been hiding his clothes in a box in the attic, and had been secretly dressing when his wife and children were not home. He admitted he did not look all that good in women's clothing, saying, “I know I could never leave the house. Everyone would know that I was a man in a dress.” He was terrified that his wife would find out and he would lose his family and children. Louis had seen two other therapists in the past ten years. The first had tried behavior modification techniques, but Louis said, “I failed at all of them.” The second clinician recommmended psychoanalysis, and asked Louis whether he could come in to therapy at least twice a week, an expense beyond Louis's budget. With tears in his eyes, Louis said that this was his last hope. He'd heard that there may be a drug he could take that would make his feelings go away.

Spike looked like a young boy, although she was nearly a thirty-year-old female. She wore jeans, work boots, and a very loose shirt. Her hair was very short and mostly covered by a baseball cap. She explained that a friend referred her, although she was not sure she wanted to be in therapy. “I've tried that before,” she said, smirking. Spike shared that she had spent two years in counseling nearly a decade earlier with a therapist who thought she dressed like a boy because her father was an alcoholic who had beat her mother and sexually molested Spike and her sisters. “My sister doesn't dress like a boy, even though my father got her too,” she said. “I don't want to talk about my father,” Spike said.” The only reason I'm here is my friend said you could help me get some kind of medication that would turn me into a boy. I mostly live as a boy anyway, but it would be nice if I could really become one.”

The preceding vignettes illustrate the modern “state of the art” of many physicians, psychiatrists, and psychotherapists, and the theoretical models underpinning these clinical strategies are still the therapeutic modalities of choice for many clinicians. Although some trained specialists who work with people dealing with gender identity issues will say that the examples are too critical of helping professionals, many gender specialists are skilled in treating these kinds of cases with compassion and experience. However, the reality is that few helping professionals are actually trained in gender identity concerns and these treatment strategies are more often the norm than the exception.

Utilizing surgical tools, behavior modification techniques, psychoanalytic ideologies, and standardized diagnostic nosologies, clients are “labeled,” “repaired,” “fixed,” “analyzed,” and “qualified” within the established framework of institutionalized guidelines. Through extensive psychotherapeutic and analytically based modalities clients are encouraged to explore the unconscious reasons underlying their gender deviance. Behavioralists try to modify improper gender expression by children and youth with the goal of alleviating the anticipated future problems caused by unconventional gender expression. Surgical models attempt to align newborn babies into preestablished normative sex categories, hoping to eliminate later sex or gender confusion, and yet adults who struggle with sex or gender dysphoria, but resist surgical treatments, are refused medical assistance to redefine their gender expression.

The working assumption of the medical model of mental illness is that there is something underlying the “dysfunction” or “disorder” that can be “repaired,” “fixed,” or “cured.” Even contemporary treatment modalities to assist adult transsexuals in sexual reassignment are often based on an expression of resignation and hopelessness that no other options exist. Surgical and hormonal treatments, available for those able to access and afford them, are seen as last resorts after psychotherapeutic models have failed. The modern treatment of transsexuals is based on a medical model that describes variant gender identity as “disordered” and surgical reassignment is framed as the “cure.”

It is undeniable that transsexuals and other transgendered and gender-variant people often experience emotional turmoil and are in need of access to both medical and psychological treatments. However, it is questionable whether models that infer disorder and dysfunction are useful for the self-actualization and empowerment of humans whose basic dilemma involves having a sex or gender identity that does not simply match their physical bodies.

COMPASSIONATE AND CONTROVERSIAL TREATMENT OF TRANSSEXUALS

Transgendered people who choose transsexual treatment, who allow themselves to be medicalized, depend on a system of approval that grants them access to treatment.

Jamison Green
Reclaiming Gender, 1999

Endocrinologist Harry Benjamin (1885-1986) was a pioneer in the compassionate treatment of gender-variant people and was the first modern physician to present the idea that transsexuals could not adjust to their birth sex regardless of the psychotherapeutic intervention aimed at curing them. He encouraged the development of a medical system that would support transsexuals in gender transitioning. Benjamin viewed himself as a maverick and a reformer (Meyerowitz, 2002). Speaking about male-to-female transsexuals, he said,

Psychotherapy with the aim of curing transsexualism, so that the patient will accept himself as a man . . . is a useless undertaking. . . . Since it is evident, therefore, that the mind of the transsexual cannot be adjusted to the body, it is logical and justifiable to attempt the opposite, to adjust the body to the mind. If such a thought is rejected, we would be faced with therapeutic nihilism. (Benjamin, 1966, p. 116)

This radical idea, that transsexuals could not be “cured,” i.e., they could never become comfortable within the gender parameters of their bodies, was the seminal idea from which the modern medical and therapeutic treatment of transsexual people has developed. The idea that intersexed children should not be surgically altered as a “cure” for their sexual ambiguity, or that gender-variant children should not be behaviorally modified as a “cure” for their deviance (defiance?) is just beginning to find advocates now at the beginning of the twenty-first century.

Although, as will be seen, gender variance has always existed historically and cross-culturally, the rise of medical technology and the development of synthetic hormones and surgical procedures to assist males and females in dramatic and effective “sex-changes” brought with it amazing possibilities that shifted the ability of people to physically alter their bodies to conform to their internal experiences. Advances in modern medicine have undeniably been life-saving for many transsexuals. It has been suggested that the emergence of a specific contemporary transsexual identity can be dated to the 1940s when hormones and surgeries first became obtainable, and Hausman has questioned whether the term transsexual should even be used “before the advent of surgical and hormonal sex reassignment” (Hausman, 1995, p. 116).

Modern medical sex reassignment treatments were first explored early in the twentieth century. Eugen Steinach first brought public attention to “sex-change” possibilities through his work with animals in 1910 (Meyerowitz, 2002). In 1945, Magnus Hirschfeld described two surgical cases of the 1920s—one a male-to-female transsexual and the other a female-to-male—and, in 1966, Harry Benjamin described the use of hormones in the 1920s to induce breast growth (Pfäefflin and Junge, 1998; Whittle, 1995). As early as 1930, Lili Elbe (born Einar Wegener), a Danish painter, underwent surgical reassignment in Germany (Ebershoff, 2001). In 1965, Pauly (as quoted by King, 1996) cited twenty-eight cases of transsexualism before the 1950s. It was, however, the power of the popular press that brought news of Christine Jorgensen's 1952 “sex change” into the living rooms of middle America and made “transsexualism” part of the contemporary discourse (Bullough and Bullough, 1993; Denny, 1998; Meyerowitz, 1998, 2002). Gender-variant males (and to a lesser extent females) heard for the first time of people actually changing their sex and began to approach the medical establishment for assistance. Reassignment surgeries became the focal points of interest for both medical experts and individuals struggling with gender dysphoria. It is, however, more likely that the advent and availability of synthetic hormones has had the most dramatic impact on the ability of transsexuals to pass undetected in their chosen gender (Bullough and Bullough, 1998). After all, the physical effects of hormones are publicly visible and the surgical alteration of genitals is a private matter.

Although some clinicians are deeply empathetic and regard the use of hormonal and surgical treatments as a necessity for the mental health of transsexual clients, other clinicians and researchers view transsexualism as a pathological disorder that masks mental illnesses. They question whether “transsexualism may be considered iatrogenic, in that advances in surgical technique now permit the realization of fantasies of sexual metamorphosis” (Pauly and Edgerton, 1986, p. 318).

Researchers, academics, policy analysts, feminists, and even transgender activists have expressed a variety of negative opinions on medical and surgical treatments. Billings and Urban (1982) said, “The legitimation, rationalisation and commodification of sex-change operations have produced an identity category—transsexual—for a diverse group of sexual deviants and victims of severe gender role distress” (p. 266). Socarides (1969) said, “Transsexualism represents a wish, not a diagnosis. It is a wish present in transvestites, homosexuals, and schizophrenics with severe sexual conflicts. The issue comes down to whether individuals in these categories of mental illness should be treated surgically for what is basically a severe emotional or mental disorder” (p. 1424). One feminist scholar, critical of transsexual reassignment for “constructing” transsexual identity, said, “Without [surgery's] sovereign intervention, transsexualism would not be a reality. Historically, individuals may have wished to change sex, but until medical science developed the specialties, which in turn created the demand for surgery, sex conversion did not exist” (Raymond, 1979, p. xv). Even trans-gender activists have voiced criticism about the role of surgical procedures in the modern treatment of transsexuals. MacKenzie (1994) wrote, “The medical promise that sex-reassignment surgery will provide physical characteristics of the ‘opposite’ sex promotes unrealistic expectations about the physical capabilities of sex-reassignment” (p. 13).

It is perhaps accurate that some transsexuals have unrealistic expectations of the surgical outcomes, regarding appearance as well as its life-changing potentiality. The changes produced by surgery do not, however, “create” transsexuals, as much as it manifests physically a psychic and psychological experience. The anthropological and historical record clearly shows that despite the concerns that transsexualism is iatrogenic and a creation of the modern medical system, rudimentary forms of gender body modification have always existed “throughout history and across cultures” (Cromwell, 1999, p. 98). Stone (1991) said, “Although the term transsexual is of recent origin, the phenomenon is not” (p. 282) and Devor (1997b) said, “The evidence seems clear that there have always been females who felt the need to live their lives as men” (p. 35). Bullough and Bullough (1993), Califia (1997), and Meyerowitz (1998) also give evidence that what is now called transsexualism existed long before the discovery of synthetic sex hormones or the development of advanced genital surgical reconstruction. In reviewing history it is of course hard to know which gender-variant person would have desired hormonal or surgical reassignment had it been available, but as Halberstam (1998a) reminds us, that is perhaps “just as difficult to know today” (p. 97).

During the past forty years, the clinical literature on the therapeutic care of transgendered and transsexual populations has, to a large extent, centered on a discussion of hormonal and surgical bodily transformations. Some areas of scrutiny have included assessing the distinctions between transsexuals and transvestites to determine...