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Counseling Needs of Transgendered Persons (1993)

Counseling Needs of Transgendered Persons (1993)

©1993, 2013 by Dallas Denny and Carol Miller

Source: Miller, Carol, & Denny, Dallas. (1993, 14 March). The counseling needs of transgendered persons. Pre-convention workshop, American Counseling Association 1993 National Convention.





The Counseling Needs of Transgendered Persons

Dallas Denny, M.A., Licensed Psychological Examiner (TN)

Carol Miller, M.Ed., Licensed Professional Counselor (GA & MS)

 American Educational Gender Information Service (AEGIS), Inc. (1)

(1) The American Educational Gender Information Service is a nonprofit organization which provides referrals and information about gender identity disorders to service providers, to transgendered persons, and to the general public.

In the course of their careers, mental health professionals are likely to encounter a number of clients with gender identity disorders. Although some therapists understandably choose not to deal with issues of gender and sexuality, it is nevertheless important all caregivers be sensitive to the needs of transgendered persons, so they can be given appropriate referrals. It is important to realize many of the issues which confront such persons are only peripherally related to their gender conflict, and many of their counseling needs are essentially the same as those of other clients, and so they can be helped by almost any therapist. The client with gender dysphoria should be considered as a whole person, with needs in areas which often do not require a sex or gender specialist, and offered services, if the therapist specializes in the areas of need. Ideally, the actual gender conflict is best handled by someone with special training and experience with gender issues. Unfortunately, therapists with such training and experience are relatively rare, and it may be necessary for the client to be seen by someone who is relatively unexperienced, at least until someone who specializes in gender dysphoria can be located. The transgendered client should never be dismissed without careful referral.

In the areas of sexuality and gender, therapists need to explore their feelings, being careful not to let personal bias or religious beliefs creep into their professional presentation. Transgendered persons often have endured a lifetime of scorn and ridicule, even from those who would ordinarily be supportive. Seeking professional help is a big step. Transgendered persons are often insecure, with feelings of guilt and a lack of understanding of their condition. Much like gay men and lesbians, they must “come out of the closet,” admitting first to themselves and then to society that they are conflicted about their gender. A negative experience with a mental health professional, experienced at this time of venturing forth, can send them scurrying back into the closet to spend a lifetime of quiet misery.

Unfortunately, many transgendered persons report just this type of experience when seeking help. Repeated attempts to obtain advice or treatment from family doctors, psychiatrists, psychologists, counselors, and other professionals can result in rejection, misunderstanding, lack of referrals, and sometimes, hostility. Feelings of anger or distrust towards those in the helping professions by transgendered persons are, unfortunately, all-too-often empirically based.

The appearance and demeanor of transgendered clients can be highly variable. They may be male or female, young or old, rich or poor. The transgendered client may be a postoperative transsexual person dealing with problems of adjustment in his or her new role; or perhaps he is a heterosexual male crossdresser, married with adult children, who is beginning to have a strong desire for sex reassignment; or perhaps an adolescent female with a masculine demeanor and a sexual preference for women; or perhaps a heavily made-up prostitute. The therapist may find himself or herself facing an extremely angry young woman or a seductive crossdressed male. Each will obviously need help with gender issues, but each will have counseling needs associated with his or her circumstances and social role. The life situation and problems of a married heterosexual crossdresser with a career in high finance are quite different, for instance, from those of an unmarried transsexual person who works as a gardener and whose sexual orientation is toward men.

Transgendered persons do not live in vacuums. They have parents, children, brothers, and sisters. They have friends and employers and workmates. They are part of the larger community, in which they must somehow function. Their gender dysphoria impacts those about them, and they in turn are impacted by those about them. This is exacerbated when the individual takes the drastic and controversial step of changing sex.

Consequently, a common counseling need of the transgendered person is relationship counseling. Families, friends, employers, and others are often ignorant of the characteristics and needs of the transgendered person, and may have any of a variety of misconceptions which are due to a lack of knowledge and education about gender issues. A common misapprehension, for instance, is that the transgendered person is inevitably gay. The wife of a crossdresser may wrongly feel her husband is likely to decide upon sex reassignment (this rarely happens). Counseling can provide education to significant others, and help the involved parties to deal with frictions caused by crossdressing or the desire for sex reassignment.

Often, the significant others of transgendered persons are themselves in need of counseling. The wife of a crossdresser, for instance, may believe she is in some manner responsible for her husband’s behavior, and mistakenly believing that if she was a better wife, he would not crossdress. She may wonder if she has hidden homosexual tendencies because she has chosen such a man. If her husband has decided upon sex reassignment, these issues may be compounded by the very real need for planning for separation and divorce, division of property and assets, and custody of minor children.

Those men and women who have chosen sex reassignment are confronted with a variety of challenges. They are embarking on a process which is fraught with physical, financial, social, and psychological hazards. In the course of their transition, the very fabric of their lives will be changing. They will be faced with great financial expenses, coupled with possible loss of or reduction of employment, rejection by their loved ones, and by the tremendous difficulty of changing their bodies and social role to those of the other sex. Counseling can be of great benefit throughout this difficult period.

Transsexual persons have a profound disturbance of their core gender identity—the sense of the self as a woman or man. Crossdressers often start dressing because of strong sexual motives. Their sense of self is unquestionably male, but with time, they can come to have a disturbance of their gender identity. Sometimes a male crossdresser becomes increasingly dysphoric. Eventually he may be diagnosed as transsexual, but more often, crossdressers have unrealistic and stereotypic notions of what being a woman is all about. The therapist can help these individuals make wise life choices, helping them to understand they have options which fall short of transsexualism. There are a variety of lifestyles which can bring relief, but which do not require surgery or even hormonal therapy. There is no reason, for example, that one who lives as a member of the opposite sex must have genital surgery, and persons should not be pushed to have this surgery or held back because they do not want it.

Many transgendered persons have a history of self-punishment. This may take the form of substance abuse, needless risk-taking, eating disorders, or thoughts of or attempts at suicide or self-mutilation. Transgendered persons often report feelings of depression. This may be to a great deal situational, but depression may persist long after the individual has begun to live in the desired gender role. Completed suicide and suicide attempts are believed to be considerably greater than has been reported for the general population.

Persons with gender identity disorders often come into conflict with society. Since the end of World War II, the United States military has taken an exceedingly dim view of any form of transgendered behavior. Even a rumor that a member of the armed services has been seen crossdressed may result in a security investigation and an eventual court martial and dishonorable discharge. Sometimes, transgendered persons come to the attention of law enforcement agencies. This may be due to inappropriate behavior when crossdressed, or to lack of understanding or misapprehension of motives by law enforcement officials, who may suspect the individual is crossdressed for purposes of prostitution or as a criminal disguise. A letter from a therapist, carried at all times, can serve as verification of transgendered status, and help to avoid problems with the law. Transgendered persons often have a great deal of guilt, and frequently engage in denial. They may seek out hypermasculine or hyperfeminine activities, begin sex-typed careers, and marry and have children in hopes that doing so will somehow resolve their gender problems. They may periodically “purge,” throwing away their cross-gender clothing. They may structure their lives so it is impossible to crossdress (for instance, by joining the military and living in a barracks). For some, periods of denial may alternate with periods of relative acceptance; for others, there may be a clear trend towards self-acceptance and open expression of their gender dysphoria. Consequently, counseling needs can range from the doubts and self-recrimination associated with “coming out” to self-actualization in the new gender role.

Transgendered persons may have questions about their sexuality. Those who were heterosexual before changing their sex may find their sexual preference has not changed, and must confront issues of lesbianism or gayness. Those who are heterosexual after transition must learn to deal with man-woman relationships, but from the opposite side of the fence. Those who were gay in their previous incarnations must learn to live in the straight world. Many transgendered persons are sexual and social isolates and must learn to deal with their insecurities and fears, if they are to ever to function normally; changing sex will not automatically solve these problems.

Children with gender identity conflicts frequently suffer from persecution. This is more often a problem for boys. Despite intelligence that is usually above the norm, poor school performance is common in transgendered boys. Masculine behavior in girls, especially before adolescence, is better tolerated in our society. It is important to note most children with disturbances of gender identity do not grow up to be transsexual or crossdressers. Extreme childhood femininity in boys is much more likely to be a precursor of homosexuality. Childhood masculinity in females, on the other hand, often disappears at the time of adolescence, and the individual becomes unremarkably heterosexual.

Issues of differential diagnosis are critical. It is important to differentiate effeminate homosexuality, transvestism and a generalized dissatisfaction with one’s assigned gender from gender dysphoria and to rule out schizophrenia and other mental illnesses as causes of the desire to change sex. Although some clients will be psychologically healthy apart from their gender dysphoria, others will have other problems which must be dealt with—chemical dependency, personality or character disturbances, paraphilias, histories of sexual or physical abuse, involvement with the criminal system, or a positive HIV status. Some may have totally unrealistic or even fantastic notions of what being a man or woman will be like. The trick is to treat the individual as a whole person, and to treat the gender dysphoria along with co-existing problems.

The therapist must be able to differentiate gender identity concerns from issues of sexuality, and to exclude other explanations for the individual’s feelings, including psychosis, organic conditions, and feelings of inadequacy—all things which can lead to a transsexual-like presentation. Transvestites, for instance, often fantasize about being women, but their desire to change their sex or even to crossdress may evaporate when their libido decreases, which is certain to happen on a regimen of estrogens. Exploration of the actual gender issues should ideally be done by a therapist with special training in gender identity disorders and human sexuality. Unfortunately, specialty training programs in human sexuality are rare, and training programs in gender are virtually nonexistent. Most professionals who routinely deal with transgendered persons began to do so because of the very real need for services in a setting in which specialists are hard to find.

Referral to a gender specialist may be impractical, especially in rural areas. Even in urban areas, those who provide services to transgendered persons may not be readily apparent from their advertisements or telephone listings. It may be in the best interest of the client to be seen, despite the therapist’s feelings of inadequacy. However, the client should not be required to pay for the therapist’s education. When the counseling experience is an exploration for the therapist as much as for the client, some kind of financial consideration—perhaps a reduction of rates until the therapist feels comfortable with the situation—is indicated. The therapist may want to contact specialists in gender dysphoria, and should also consider contacting local transgender support groups and sit in on meetings, so she or he can learn more about the characteristics and life problems of the members. The therapist should consider taking classes in human sexuality, as word of mouth may sent other transsexual clients in his or her direction. Certainly the therapist should have at least rudimentary knowledge—understanding, for instance, that gender dysphoria arises unbidden and has not proven to be amenable to cure, but therapy can help the individual to understand his or her condition and make important life decisions on a rational, rather than an emotional, basis.

Diagnostic criteria for gender dysphoria first appeared in 1980 in the DSM III, and were revised for the DSM III-R. They will be revised again for the DSM-IV. Therapists should make themselves familiar with these criteria, and with the scientific literature, when possible.

The Harry Benjamin International Gender Dysphoria Association, Inc., is composed of professional providers of services to transgendered persons. Their Standards of Care are available for a small fee from AEGIS.

The Standards of Care are a set of minimal guidelines, designed to safeguard both service providers and transgendered persons. They provide a recommended course of action for those who are changing their gender, with genital reassignment surgery being allowed only at the end of a period of successful living in the gender of choice. The Standards minimize risks by making it possible for the individual to revert to the original gender at any time before the final surgery.

The Standards of Care require the transgendered individual to produce a letter from a clinical behavioral scientist (psychiatrist, psychologist, or counselor) for the authorization of hormonal and surgical sex reassignment procedures. Such letters should not be withheld if the individual is truly gender dysphoric and is capable of giving informed consent, but the therapist should take precautions to determine the veracity of the individual’s statements, and especially that the gender dysphoria has continued unabated for at least two years; this can be accomplished by interviewing friends, family, and employers (using discretion, for the individual’s transgendered status may be unknown to some parties). The occasional client may resort to coercion in order to receive a letter; the therapist should stand firm, giving the letter only when comfortable doing so.

Because there are large numbers of transgendered persons, because being transgendered is one of the most painful conditions in the human experience, because the Standards of Care mandate continuing involvement of mental health professionals, and because they can be exceedingly mature and self-actualizing in the face of adversity, counseling transgendered persons can be both financially and emotionally rewarding for the therapist. Currently, there are many more persons with gender dysphoria than there are experienced caregivers.

In summary, many of the counseling needs of transgendered persons are similar to those of other persons who experience periods of stress and change. Many therapists, even those who do not specialize in sex and gender, can be of help to these transgendered clients in dealing with peripheral issues. Whenever possible, the client should be referred to a therapist who has special training and experience in dealing with gender dysphoria. It is important, however, that the client, who may be experiencing extreme doubt and guilt, not be turned away without a carefully considered referral; neither should a “cure” be attempted. The therapist must take care not to let personal biases interfere with the transgendered client’s right to treatment.