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Through The Looking Glass
A Look at the Literature Available on Counseling
Transgendered Individuals
There has been an increased focus on diversity and multiculturalism within
the counseling field. However, the transgendered population has not been given
much attention in research and in counselor training. Discussions of issues
relating to the transgendered are rare and information available in articles is
scarce. This means that a significant section of the population is being poorly
served by the counseling community. Ettner (1999) suggests that those
experiencing some sort of gender dysphoria can be conservatively estimated as
3-5% of the population. Others suggest the percentage to be greater. My personal
doctor, a rural general practitioner, estimated that over 10% of his patients
could be considered transgendered in some form. Historically, and to some extent
currently, the assessment, treatment and research tends to pathologize the
transgendered. For the most part, mental health practitioners’ views about
transsexuals, cross-dressers, and others with transgender status have "not been
informed by objective empirical research" (Fox, 1996). Therefore, counselors are
ill-prepared to meet the needs of such clients (Raj 2002). My personal
experience, and what I have heard from members within the transgendered
community, is that often it is the client who educates the therapist, at the
client’s expense.
It is useful to begin this discussion with an examination of the terms. Very
simply put, sex is between the legs and gender is between the ears.
Transgendered is an umbrella term referring to those who experience discord
between sex and gender. This can be seen as a continuum with an almost infinite
variation in the expression of the gender variance. However, three general
groupings can be discussed. The crossdresser (CD) is dual gendered male
and female. This is exhibited by dressing in clothing of the opposite sex. The
transgenderist (TG) is also dual gendered but more likely to cross-live
as the opposite sex, perhaps full time. The transsexual (TS) identifies
as the gender opposite of birth sex. Gender dysphoria can affect both males (M
to F) and females (F to M).
Identification
Within the transgender community is an almost infinitely
diverse group, who define themselves in many ways. Establishing a gender
identity often results in conflict. Many resist being "pigeon holed" and others
want the comfort of a label, not having had a sense of self. It is important to
remember that gender identity is only one of a host of fluid categories that
make up self-awareness (Moorhead, 1999).
"Self-identification and the discussion of gender issues is clouded by the
fact that language and (Western) cultural assumptions commonly applied to erotic
or partnered relationships do not allow for couples for whom the psychological
dynamics are incongruent with the ‘genital’ sexes. Therefore, individuals must
search for understandable ways of communicating about themselves and their
relationships" (Eyler & Wright, 1997). Coming out is a life long process not a
specific event. There may well be rights of passage in that process. These can
include finding an identity, self acceptance, and sharing with others your "real
self" (Rogers, 1961).
One cause of misunderstanding stems from identifying the intentions of the
transgendered person. "Only a certain percentage of individuals who disclose
gender dysphoric feelings express a desire or intention to live full time in the
preferred gender"(Ettner, 1999). Many are part time and do not wish to go
further. Clinicians can help clients to determine where they fit in the gender
continuum. It is essential to understand the difference between sex and gender.
Many professionals have little understanding of those who identify as
crossdressers, and assume that crossdressing is always fetishistic in nature.
Those, however, are the minority. In general, CD’s are motivated to wear and
appear in the clothing of the opposite sex to create the image of who they
perceive them selves to be. They also report a tension that builds between
periods of dressing (Ettner, 1999).
Gender identification and sexual orientation among genetic females can become
quite complicated. They are often not aware that they are transgendered or
gender blended. Research has primarily focused on those that present themselves
for treatment. Many genetic girls (GG) can live comfortably in a male or
androgynous state with little or no cultural discontinuity.
Concepts
There is an increasing realization that the concepts of self and gender are
of major importance in the field of gender dysphoria (Hartman, et al., 1997),
and in the treatment of gender variant individuals. One of the serious problems
in counseling transgendered individuals is helping them deal
with their sense of self: the lack
or confusion about who they really are.
One of the theories in sociology is called the looking-glass self.
You tend to become what those whom you value most (i.e. parents, spouse, boss),
value. This is the definite imagination of how oneself is perceived by another (Cooly,
1901).
This is not a new notion. In his first Epistle to the Corinthians, the
Apostle Paul says:
For now we see through a glass, darkly; but then face to face: now I know in
part; but then shall I know even as also I am known.1 Cor. 13:12 KJV
The Greek word for darkly is ainigma root for enigma. One of the words
in Old Testament Hebrew which can not be translated fully into English is Nepesh,
soul, and one of the concepts is how you see yourself as well as how others see
you.
Growing up as a transgendered child, it is learned very quickly that what you
are is not acceptable (Ettner, 1999). Our society and culture has
conditions of worth (Rogers, 1961) reinforced by parents, peers, and the media.
We are given rewards when we accomplish, love when we behave, punishment when we
transgress. Rogers (1961) calls this "conditional positive regard," i.e.
getting positive regard "on condition." Since we need positive regard, the
affect is huge. It is not based on our organismic value but on society and
culture. These forces can be subtle and pervasive.
Conditional positive self-regard is the result of this conditioning. We like
ourselves only if we have met the conditions and standards expected of us by
others, rather than if we are realizing our own potential. Since the "standards"
are created with out regard to the needs of the individual, it is impossible to
meet them and therefore have a positive sense of self. This happens early in
childhood before the child understands cognitively that gender problems are
social problems. The child learns very early that the real self must be hidden
and a wall or mask is built. The public persona of a transgendered individual is
an artificial construct that is built to fit in, to be like every one else
(Ettner, 1999; Rogers, 1961).
There is now an incongruity between the real self and the psudoself
or as Rogers (1961) states it, the "ideal self" and the not real self. The
gap between the I am and the should be is incongruity. "The
greater the gap, the more the misery" (Rogers, 1961).
There is a need for intimacy that begins in preadolescence between roughly
ages 8 ˝ and 10 years. During this period any negative influences of family life
may be attenuated or corrected. Because one draws so close to another, and
because one is newly capable of seeing oneself through another’s eyes, the
preadolescent phase of personality development is particularly important in
correcting ideas about oneself or others. The progress of this phase of
personality is of extreme importance. It is during this time that close
friendships need to be formed. The intensity of the relationship needs to be
powerful enough for each to get to know virtually everything about the other.
Such familiarity remedies a good deal of the "often illusory, usually morbid,
feeling of being different, which is such a striking part of insecurity in later
life" (Sullivan, 1953).
For the young gender variant individual this level of intimacy is not
possible as the real self can not be disclosed. It is during this time that the
experience of aloneness begins or increases (Ettner, 1999). The force field
around the self is strengthened. {"More power to the shields Scotty!" " I’m
givin’ her all she’s got, sir." (any number of Star Trek episodes).}
Adolescence is a time of tremendous cognitive, biological, and social change.
Formation and exploration of the self occurs. Homophobia silences LGBT youth.
Attitudes and norms of introjected societies can lead to silence, self hate, and
suicide. Drugs and alcohol are used to numb and cope. LGBT students are 1.6
times more likely to experience substance abuse (Little, 2001). Some
transgendered teens will become involved with the Gay community out of
ignorance, not realizing that what they are is transgendered not homosexual
(Brown, et al., 1996).
AIDS Vancouver distributed a pamphlet stating: "It takes a lot of energy to
deny your feelings, and it can be costly. You may have tried using drugs and
alcohol to numb yourself against these thoughts. There are alternatives to
denying these valuable feelings."(from the Campaign to End Homophobia). (Little,
2001).
Asked what would have been helpful to them in school, transgendered adults
indicated several things that they felt might have been useful. These included
role models (some one who is out), an advocate or representative to speak for
them, awareness curriculum to educate other students, counselors open to
questions, and to put a stop to all the jokes (Little, 2001).
Christian Issues
For those that are Christian and transgendered, there is often a
double whammy. Not only are there the societal norms that are being transgressed
but Biblical decrees that seem to censure transgender activity. (cf: http://www.gendertree.com/Bible%20Verses.htm
) These have influenced Christians to condemn those that are gender variant. The
perception that what you are is sinful is exceedingly powerful. Compound
that with those that have entered the ministry in part to escape their
transgender nature you have a recipe for suicide.
Therapy models
Many times when a male-to-female transgendered individual enters counseling
to address his gender identity issues, a personal history reveals a pattern of
choices that may have been consciously or unconsciously made to in an effort to
deny his transgendered nature. There may have been the feeling that it would
disappear with time. Commonly, there are a number of ways this is attempted.
Often careers that are very macho are entered. These include police,
construction and military. One therapist reported over half of her TS clients
had had a military career (Brown, et al., 1996). Many adopted a hypermasculine
persona, for example active in motorcycle racing and hot cars. Choices in
marriage partners and involvement in religious denominations that are not
tolerant gender or sexual variance, (including as pastors) are also prevalent.
Such choices help define an existence with support for the efforts to keep the
transgender nature safely locked in the closet (Samons, 2001).
Recommendations
The Royal College of Psychiatrists (1998) made several recommendations for
dealing with transgendered individuals. These include:
A full assessment, including emotional, behavioral, environmental, and
family.
Therapy, assist development, gender identity. Reduce stress caused by
gender identity.
Acknowledgment and acceptance of the gender incongruity and that removing
secrecy can bring relief.
Decisions concerning what expressions of gender (clothing, name) are
complex and not easily answered recommended is consultation with other
professionals and that it be done as early as possible.
The therapeutic model espoused by most of those experienced in gender therapy
is client-centered, existential, Rogarian, and rather eclectic. Person centered
is the keystone of any effective means of therapeutic change (Duncan, et al.,
1992; Ettner, 1999; Hubble, et al., 1999). A holistic health care approach which
genuinely strives to address the individual's physical, emotional-mental,
sexual, 'social' and 'spiritual' health is recommended (Raj, 2002). Becoming
your true self is the stage when that little child trapped inside an artificial
persona in order to fit in, breaks free, starts to grow up, and has their own
life.
Trans-Culture and the influence on sense of self
When looking at a culture, it is often beneficial to look from the outside as
an anthropologist and to compare other cultures. It neutralizes Maslow’s hammer
to some extent (when you have a hammer, everything looks like a nail). Or
expressed another way, we do not see our culture, we see through it. The current
heterosexist society has the presumption of binary sex and gender (and that they
match). Those living outside these paradigms often find themselves isolated and
fragmented.
Trans-cultural paradigms are influenced by, and in some cases erroneous and
certainly ethnocentric, views of gender (Towle, 2002). Popular books such as
Transgender Warrior influence views of transgenderism on the part of
therapists, supporters, and transgendered individuals themselves.
Developing Self
A universal for those that are transgendered is a sense of isolation. Many
first become aware of what and who they are as a result of the
internet; it will be the first step in coming out. It is a mirror and tool. Much
of what people do on the internet is a search for self, exploration and
presentation, e-mail, home page (Turkel, 1995).
The Internet feels safe because it provides anonymity and freedom from the
judgments of others. Internet surfers embark on an unfettered, self trip. Web
searching provides a history of their interests, hobbies and fixations. Creating
a home page is a way of presenting an ideal self to the world. They are
disinhibited; the on-line world lacks the constraints they live under every day
(Suler, 2003).
Much hinges on the personal approach. If people use the Internet to
compartmentalize selves—if online and offline selves are forever separate and
split—problems can ensue. An example would be a transgendered individual who has
no expression of the transgendered self other than on line. Conflict is
probable. "People ‘stick’ in online alter-egos and can't reconcile them with
offline life. People can work through their situation and it can bring a sense
of not alone" (Suler, 2003).
Sometimes the need is to hide a bit or stay put a while before moving
forward. "But as long as they're using the net in the spirit of self-reflection,
they're making the most of life on the screen" (Turkle, 1995).
"The Web is a safe place to try out different roles, voices and identities.
It's sort of like training wheels for the self you want to bring out in real
life" (Suler, 2003). The rise of a sense of community is part of what helps
transgendered folks not feel so alone. That community is often found first
through the internet.
So…what is it all about? It is about being your self, or, as a Japanese
transgendered person put it, "Living like my self" (newhalfnet IJT, 2002). The
result of a survey at the "Create Our Own Destiny" conference stated "To be
fully and wholly themselves and to belong with dignity" (Moorhead, 1999).
Conclusion
When considering the counseling of those who identify as transgendered, one
aspect stands out: the general lack of information. This is a relatively new
area of research and accepted practices are evolving. Traditionally,
transgenderism has been considered to be pathological behavior. The object of
treatment was generally elimination of symptoms rather than management and
understanding. There was little distinction made between transsexuals and
cross-dressers. It was often assumed that a transgendered individual either
wished the behavior to disappear or they wished to physically transition. The
Harry Benjamin Standards of Care (2001) was the guideline for counseling. Now in
its sixth edition, the SOC was developed as a road map for transsexuals who
desired reconstructive surgery. It does not address the needs of those who do
not intend to transition or who have no interest in transitioning.
Recently, the emphasis has shifted in counseling the transgendered
population. Rather than eradication of feelings, the focus is toward awareness
and coping with being transgendered. It is acknowledged that "the concepts of
self and gender are of major importance" (Hartman, et al, 1997), but there is
little information available on therapeutic treatment techniques. The research
being conducted appears to be primarily on possible physical causes. Hopefully,
further research will provide directions for counseling.
Through the internet, the transgendered community is actively helping in
creating and enhancing the sense of self. In some ways, this has out-paced the
counseling community. As therapists, there is much that needs to be done.
 | Blanchard, R., & Steiner, B.W. (Eds.). (1990). Clinical management
of gender identity disorders in children and adults. Washington, D.C.:
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| Brown M.I., & Rounsley, C. A. (1996). True selves: Understanding
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| Ettner, R. (1996). Confessions of a gender defender: A psychologist’s
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| Ettner, R. (1999). Gender loving care: A guide to counseling
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Project Muse. Retrieved July 20, 2003, from http://muse.jhu.edu
APPENDIX
Glossary of Terms
Cross-dresser: An individual who dresses in
clothing that is culturally associated with members of the "other" sex. Most
cross-dressers are heterosexual and conduct their cross-dressing on a
part-time basis. Cross-dressers cross-dress for a variety of reasons,
including pleasure, a relief from stress, and a desire to express "opposite"
sex feelings to the larger society.
Drag King: A term usually reserved for
individuals who identify themselves as lesbians and who cross-dress for
entertainment purposes in lesbian and gay bars.
Drag Queen: A term usually reserved for individuals who
identify themselves as gay men and who cross-dress for entertainment purposes
in lesbian and gay bars.
Gender: A complicated set of sociocultural practices
whereby human bodies are transformed into men" and "women." Gender refers to
that which a society deems "masculine" or "feminine." Gender identity refers
to an individual’s self-identification as a man, woman, transgendered, or
other identity category.
Gender bender: An individual who brazenly and
flamboyantly flaunts society’s gender conventions by mixing elements of
"masculinity" and "femininity." The gender bender is often an enigma to the
uninitiated viewer, who struggles to comprehend sartorial codes that challenge
gender bipolarity. Boy George, a popular culture icon, was often referred to
as a "gender bender" by the press.
Genderdysphoria: A term used by the psychiatric
establishment to refer to a radical incongruence between an individual’s birth
sex and their gender identity An individual who is "gender dysphoric" feels an
irrevocable disconnect between their physical bodies and their mental sense of
gender. Many in the transgender community find this term offensive or
insulting because it often pathologizes the transgendered individuals due to
its association with the DSM—IV.
Genderidentity: see Gender.
Gender outlaw: A term popularized by trans activists
such as Kate Bornstein and Leslie Feinberg, a gender outlaw refers to an
individual who transgresses or violates the "law" of gender (i.e.., one who
challenges the rigidly enforced gender roles) in a transphobic, heterosexist,
and patriarchal society
Gender queer: A term that refers to individuals who
"queer" the notions of gender in a given society. Gender queer may also refer
to people who identify as both transgendered and queer (i.e.,
individuals who challenge both gender and sexuality regimes and see gender
identity and sexual orientation as overlapping and interconnected).
Gender trash: A term that calls attention to the way
that differently gendered individuals are often treated like "trash" in a
transphobic culture.
Gender variant: A term that refers to individuals who
stray from socially accepted gender roles in a given culture. This word may be
used in tandem with other group labels, such as gender-variant gay men and
lesbians.
Intersex: Formally termed hermaphrodites,
individuals termed intersex are born with some combination of ambiguous
genitalia. The Intersex movement seeks to halt pediatric surgery and hormone
treatments that attempt to normalize infants into the dominant "male" and
"female" roles.
Queer: Queer is a term that has been reclaimed by
members of the gay, lesbian, bisexual and transgender communities to refer to
people who transgress culturally imposed norms of heterosexuality and gender
traditionalism. Although still often an abusive epithet when used by
heterosexuals, many queer-identified people have taken back the word to use it
as a symbol of pride and affirmation of difference and diversity.
Queer theorist: An individual, usually an academic, who
uses feminism, psychoanalysis, poststructuralism and other theoretical schools
to critically analyze the position of gay, lesbian, bisexual, and
transgendered individuals in cultural texts.
Sex: Separate from gender, this term refers to the cluster
of biological, chromosomal, and anatomical features associated with maleness
and femaleness in the human body. Sexual dimorphism is often thought to be a
concrete reality whereas in reality the existence of the intersex points to a
multiplicity of sexes in the human population.
Sexuality: An imprecise word that is often used in
tandem with other social categories, as in race, gender; and sexuality.
Sexuality is a broad term that refers to a cluster of behaviors, practices,
and identities in the social world.
Sexual orientation: This term refers to the gender(s)
that a person is emotionally, physically, romantically, and erotically
attracted to. Examples of sexual orientation include homosexual, bisexual,
heterosexual, and asexual. Transgendered and gender-variant people may
identify with any sexual orientation, and their sexual orientation may or may
not change during or after gender transition.
Trans: An umbrella term that refers to cross-dressers,
transgenderists, transsexuals and others who permanently or periodically dis-identify
with the sex they were assigned at birth. Trans is preferable to "transgender"
to some in the community because it does not minimize the experiential
specificities of transsexuals.
Transgender: A range of behaviors, expressions, and
identifications that challenge the pervasive bipolar gender system in a given
culture. This, like trans, is an umbrella term that includes a vast array of
differing identity categories such as transsexual, drag queen, drag king,
cross-dresser, transgenderist, bi-gendered, and a myriad of other identities.
Transgendered lesbian :An individual, regardless of
biological sex, who identifies as both transgendered and lesbian. This could
include male-to-female transgenders who are sexually attracted to women, or to
biological females who identify as lesbians and who often "pass" as men or who
identify to some degree with masculinity or with "butch."
Transgenderist: Coined by Virginia Prince, this
category refers to an individual who dis-identifies with their assigned birth
sex and lives full time in congruence with their gender identity. This may
include a regime of hormone therapy, but usually transgenderists do not seek
or want sex reassignment surgery.
Transphobia: The irrational fear and hatred of all
those individuals who transgress, violate, or blur the dominant gender
categories in a given society. Transphobic attitudes lead to massive
discrimination and oppression against the trans, drag, and intersex
communities.
Transsexual: An individual who strongly dis-identifies
with their birth sex and wishes to use hormones and sex reassignment surgery
(or gender confirmation surgery) as a way to align their physical body with
their internal gender identity.
Transvestite: An older term, synonymous with the more
politically correct term cross-dresser, that refers to individuals who have an
internal drive to wear clothing associated with a gender other than the one
that they were assigned at birth. The term transvestite has fallen out
of favor due to its psychiatric, clinical, and fetishistic connotations.
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