Counseling Transsexual Populations
(Summer, 1998)Although not all therapists are necessarily going to deal with individuals who have issues of gender identity, it's also not so rare as to be completely unexpected in a client/therapist relationship. There are also many issues which are relatively unique to dealing with people who are questioning or unsure with respect to their gender identity, as well as those who are certain for a fact that they are transsexual. For purposes of simplifications, I've divided this article into the following topics:
- Many people confuse sexual orientation with gender identity.
- Many people who self-diagnose themselves as transsexual know that they're required to go through therapy in order to get treatments which they feel necessary in order to obtain medical treatment.
- Given many social attitudes, it's common for people dealing with questions about their own gender identity to feel marginalized, fearful, distrustful (of both themselves and others) and occasionally, depending upon local attitudes and support structures, in danger for their lives.
- It's common for transsexuals to experience major emotional changes as they go through the physiological process of the sex change.
- Not all individuals who think of themselves as transsexual will retain that self-identification throughout their lives.
- Not all individuals who feel their biological sex is at odds with their self-identification of gender are going to opt for surgery as a solution.
- No one agrees completely on what is "masculine" and "feminine."
- As with many rare conditions, the client knows a great deal more about the condition than the therapist.
"Sex," in the context I am using it, refers to one's physiology, speaking specifically to biological information (i.e., chromosomes, genitalia, secondary sex characteristics). "Gender" is more of a social and internal state, reflecting how someone perceives themselves to be.
"Gender Identity Disorder" (also referred to as "transsexualism") is feeling as though your body's sex and your own internal gender identity are at odds with one another. This can be (but is not always) corrected by surgery and hormone therapy.
"Non-Op Transsexuals" are transsexuals who don't choose to opt for surgery, for a variety of reasons.
"Transition Mode" is the state of being in transition from one gender role to another on a social level.
So, onto the individual points:
Many people confuse sexual orientation with gender identity.There's a lot of confusion with respect to people's gender identity, and it's common for clients who are attempting to deal with questions about gender identity to spend some time considering that they might instead be lesbian or gay. The converse is also true: It's very common for people dealing with questions regarding their sexual orientation to spend some time thinking that they might be transsexual. This gets more complicated when you take into account that not all transsexuals will retain their sexual orientation post-operatively.
From an ethical standpoint, it's important not to direct the client with respect to these matters. I.e., it's possible that a therapist who has dealt frequently with transsexual patients might take a certain amount of pride in helping people through the process. This could be harmful if the client is confused enough that they've mistake one condition for another. To lead a patient down a path which includes hormone therapy and electrolysis is costly, painful and can have some permanent side effects for someone who does not continue the process.
Many people who self-diagnose themselves as transsexual know that they're required to go through therapy in order to get treatments which they feel necessary in order to obtain medical treatment.A great many transsexuals go to therapy for one specific reason: to get "the letter." The letter is a diagnosis from the therapist that says, in effect, "This person is transsexual. Treat the individual as is necessary." This is often necessary for obtaining surgery and hormone treatments. Therefore, some transsexuals go into therapy with no specific problem or need other than to have a therapist insure that they (a) know what they're doing, (b) are competent to know who they are and self-diagnose their own transsexualism and (c) provide them a letter which they can give to public officials for the purpose of changing one's name, legal identity, etc.
The problem with this is that it leads people into therapy who don't necessarily need any therapy. This can lead to resentment, hostility and frustration on the part of the client. If the client is mentally sound and able to make decisions competently, it seems a great hardship to expect someone to pay for therapy sessions which they neither need nor want only to make sure that they know what they're doing.
However, I'd have ethical problems with signing off on some one's mental competency without actually having a few meetings with them. Some surgeons require a minimum of six months contact between the surgical candidate and a therapist in order to perform the surgery. Though I understand the need for being absolutely certain that someone knows what they're doing before performing sex reassignment surgery, I find it frustrating to think that I'd be required to spend six months with a therapist to get approval for any form of surgery.
Given many social attitudes, it's common for people dealing with questions about their own gender identity to feel marginalized, fearful, distrustful (of both themselves and others) and occasionally, depending upon local attitudes and support structures, in danger for their lives.It's very hard for some people in transition mode to find work, and often transsexuals lose family support. Society at large can be fearful of people who's gender isn't clear from the outset. Thus it can be difficult for many transsexuals to deal with making new friends, social situations can be scary and uncomfortable.
This is compounded by the fact that during transition, for some it's difficult to know what their sexual orientation is or will be, and that many people are reluctant to involve themselves with someone of mixed physiology, from a sexual perspective. This becomes further complicated by the fact that there are classes of sexual predators who specifically target people they perceive as transgendered. These predators achieve this by trying to make use of the fact that people going through transition sometimes have limited social support and financial resources.
And, in fact, the problem becomes even more severe when we take into account that some therapists themselves have specific fetishes towards pre-operative transsexuals. Imagine the situation which one is faced with, if one is a male-to-female transsexual who knows exactly what she wants. She lives in a rural area and needs to find a therapist who is willing to deal with issues of gender identity and finds out that there is one within a 100-mile radius. She gets the courage to go to this therapist, and upon telling him her story, he informs her that he's interested in her, and is willing to recommend hormone therapy in exchange for sexual favors.
As absurd as this sounds, it happens, and more often than one might think. It almost never gets reported officially, because that would be extremely humiliating for the client, and some clients are even willing to take the therapist up on the offer. This creates a conspiracy of silence between an unethical therapist and a specific client population who feels silenced and unable to speak for themselves.
Needless to say, I'm repulsed by this, as any ethical counselor should be. But I report on it because it's important to remember as therapists that some transsexuals who come to us have already dealt with an experience such as this, and not to dismiss or ignore feelings of mistrust on the part of the client.
It's common for transsexuals to experience major emotional changes as they go through the physiological process of the sex change.Hormones can have quite a strong impact on people's psychology. While it's not at all clear just what this effect is, and there are no universal answers about this, there obviously is an effect. While treating someone who is going through hormone therapy, it shouldn't be assumed that major emotional upheavals are representative of a pathology or some other problem in some one's lives.
However, nor should major emotional experiences be dismissed by way of the hormones. I.e., if someone on hormone therapy comes in and appears to excessively upset about a relationship issue, the fact that they're on hormones should not be used as an excuse to just pass over the emotional state of the client. It should be addressed and explored, but with the caveat that it might be a result of the hormone therapy. This doesn't, however, make it irrelevant. It merely adds a new element to the equation.
Not all individuals who think of themselves as transsexual will retain that self-identification throughout their lives.It's common for people who are exploring gender identity (as well as sexual orientation) to go through periods of confusion and fear, and sometimes they may in the process explore transsexualism when it is not, in fact, where their true path lies. There is nothing wrong with this. However, what becomes frustrating for the therapist is that after putting effort into the act of accepting the client's own self-definitions, and learning to respect their own world as they perceive it, the therapist might have to then again adjust perspectives.
This, however, should not be seen as all that dramatic. All clients continue to reevaluate and reperceive the world which exists around them, and the therapist needs to make a point of respecting these varying world views as they come into play, without judging someone for being willing to know themselves well enough to reject what they used to believe.
Not all individuals who feel their biological sex is at odds with their self-identification of gender are going to opt for surgery as a solution.There is such a thing as the "non-op transsexual." What this means is that some transsexuals go so far as the hormone therapy and electrolysis and discover that, surprise surprise, they are actually happy with themselves without requiring sex reassignment surgery. This is especially common for female-to-male transsexuals, for whom the surgery is often ineffective and prohibitively expensive.
What's important for the therapist is to take the time to evaluate this situation and respect it. If someone chooses not to go through with the operation it is not necessarily due to lack of commitment or inability to follow through, though it's understandable that those who don't understand the condition might perceive it as such. There will also be additional issues in social situations which exist for non-op transsexuals. I.e., if a female-to-male transsexual who, to all external cues is male, but still has female genitalia, becomes interested in a heterosexual woman, how does he deal with this? At what stage would it be appropriate to disclose his condition to her? Should he even approach the relationship? The therapist should not be bothered with trying to classify such relationships in terms of sexual orientation, because our classical definitions of sexual orientation can easily go right out the window in such circumstances. Trying to box the client into labels and categories which do not really fit are of no help to anybody.
No one agrees completely on what is "masculine" and "feminine.""Masculine" and "feminine" are terms which vary considerably from person to person in their scope. They furthermore can apply to people, regardless of sex or gender. I.e., a woman can be "masculine" while seeming no less a woman. It would be very easy for a therapist to make assumptions about what a transsexual wants or needs because of stereotypes about gender. This can sometimes be enforced by the client as well. Some clients are so eager to embrace their new gender role that they fall into extremes, either becoming ultra-feminine or hyper-masculine, to the point where they sometimes can come across as an insulting stereotype. The therapist should be careful about taking offense at such stereotypes-- they do not often last through the entire process, but instead are part of a reaction to a newfound freedom.
Furthermore, even if the particular expression of gender identity does offend the therapist, that's not the therapist's responsibility. I.e., if a genetic female showed up in the therapist's office for some other issue, and she happened to be extremely feminine by the therapist's standards, the therapist would be unlikely to treat this as something which needed to be cured. It should be no different when treating someone who is transsexual.
Furthermore, some people before beginning their transition tend to fall into stereotypes which are more consistent with their biological sex. I.e., a male-to-female transsexual might join the army, be into muscle-building, grow a thick beard, engage into rough-and-tumble sports, etc., as a means by which to escape the condition of being transsexual, or at least hide from it for awhile.
As with many rare conditions, the client knows a great deal more about the condition than the therapist.Transsexualism is a long and complicated process. It varies considerably in how it manifests itself from individual to individual. No two people will perceive their own gender identity in the exact same fashion. While there are certain patterns which are fairly consistent from one client to another, the therapist should not expect that everything will be consistent across the board.
The best possible thing the therapist could do is to listen, and when confused, ask questions. It's dangerous to make assumptions about specific individuals in such cases. Furthermore, if a therapist choose to give unsolicited advice about such issues as how to better "pass," what the laws are about change of name, etc., it could come across as condescending or patronizing.
Final comments
Our job, as therapists, is to address what needs to be addressed, not what our moral qualms or our uninformed prejudices suggest might need to be addressed.
I'm not suggesting that the topic of transsexualism is off limits to the therapist, or that it's impossible that the client need to deal with issues of their transsexualism. I'm merely cautioning the therapist to be careful to insure that if they do start exploring the client's transsexualism that they do so because the client wants to do so, not because the therapist feels that it's what should be done.