What is the Role of the Helping Professional? (1997)
©1997, 2013 by Dallas Denny
Source: Denny, Dallas. (1997, August). What is the role of the helping professional? Transgender Treatment Bulletin, 1(1), pp. 1-2, 8.
Transgender Treatment Bulletin, V. 1, No. 1, December, 1997
What is the Role of the Helping Professional?
By Dallas Denny
There is a dilemma inherent in persons who request medical treatments to change their bodies, yet resent the professionals who deliver those treatments. Certainly, some transgendered and transsexual people have such resentments. But it is no less perplexing that those very same medical treatments have historically been very difficult for transgendered and transsexual people to obtain. One reason for this is because the medical treatments necessary for sex reassignment are contingent. upon approval from mental health professionals (Walker, et al., 1985).
The protocols which arose in the 1960s and 1970s to treat transexual people were based on pathology-based models which presumed that persons wishing to alter their bodies had a mental illness called gender dysphoria (now gender identity disorder) which was resistant to psychotherapy and other “cures,” but for which sex reassignment could afford some relief (Fisk, 1973). Sex reassignment had as its goal the transformation of dysfunctional males into functional heterosexual women, and dysfunctional females into functional heterosexual males (Kessler & McKenna, 1978). It was assumed that clients desired to approximate as closely as possible the sexual organs, appearance, and mannerisms of the other sex, even if that meant submitting themselves to intrusive, expensive, and even disfiguring medical procedures. Gender programs expected their clients to blend into mainstream society after treatment, and considered those who would not or could not failures (cf Blanchard & Steiner, 1990). Often, clients were expected to dress and behave as sexual Barbie and Ken stereotypes and show “heterosexual” sexual interest; those who did not desire genital surgery and those who were unable to conform to the expectations of these clinics were often turned away without treatment (Denny, 1992).
Such a model seems naive today, but it has only been in the past few years that it has begun to be seriously questioned. Today, many clinicians realize it is possible to live productively as a member of the other gender without genital surgery, and that embarking on a process of body change with hormones does not necessarily mean the goal is surgery or even full-time crossliving. Unfortunately, this realization is not universal. There are individual caregivers and even some gender programs that still require their clients to conform to their demands about choice of name, hairstyle, mode of dress, occupation, and even sexual orientation (Petersen & Dickey, 1994). A recent (1995) issue of the newsletter of the Harry Benjamin International Gender Dysphoria Association noted that the organization is still undecided about whether it should concern itself only with “transsexuals;” i.e., those who desire genital surgery, or with all persons who desire to masculinize or feminize their bodies. The fact that this is even open to debate is a call for more and better education of caregivers.
Kessler & McKenna (1978) noted that requirements imposed on transsexual clients by mental health and medical professionals were often arbitrary and capricious; for example representative of one gender clinic told them they weren’t “taking Puerto Ricans any more; the Puerto Ricans all looked like homosexuals.” Bolin’s (1988) field study clearly showed that the power dynamics of a relationship in which a therapist serves as a “gatekeeper” for access to medical procedures is out of balance and causes resentment in the client. This imbalance has been a source of frustration to both therapists and to their transgendered and transsexual clients.
Certainly the clinician, confronted with a series of clients who have been struggling for years with gender identity concerns, is likely to see confused, anxious, and somewhat dysfunctional individuals. It is not surprising that clinical impressions of transsexual people and the literature which has arisen from studying them has centered around the transgender phenomenon as pathological. However, it is also possible to view the same clientele as individuals who have been struggling for years with very powerful feelings of gender dysphoria without access to sources of support which would be available for almost any other human condition, but which were unavailable to the clients simply because of the nature of their struggle. Parents, siblings, partners or spouses, children, the extended family, teachers, clergy, and friends often either do not know about the gender issue, or have been told and have exhibited negative or even catastrophic reactions. Being without support in such a situation is very much like being swept down a raging river. In such a circumstance, one is in danger of drowning unless one can grab a tree branch. With that single source of support, it is possible to pull oneself out of the river. Perhaps what is remarkable is that so many transsexual and transgendered persons have coped so well with their condition in the face of adversity.
Clients who go to therapists for support are not particularly likely to do so when everything is going well. This is as true for someone with transgender or transsexual issues as it is for a a single parent with a behaviorally disturbed child. A few weeks of exposure to a support group, a knowledgeable and supportive therapist, or even a friendly electrologist or primary care physician can result in a much calmer and less dysfunctional client. As such support becomes increasingly available, the frantic, confused clients who once presented for intake are being replaced by more knowledgeable, more determined clients. Some, of course, have mental health concerns in addition to gender dysphoria—but most don’t.
As a society, we have a dysphoria about gender. Our notions of manhood and womanhood have been rigid and stereotyped, leaving those who varied from the norm out in the cold. Masculine women, feminine men, gay men, lesbians, crossdressers, fetishists, transsexual people, intersexed people, and other gender-transgressive persons have historically received messages that they are sick, deviant, unworthy, and sinful. Unfortunately, our medical and psychological sciences have mirrored this discomfort with difference and concentrated on turning “deviant” people into “normal” ones. The assumptions made when conducting research on transsexualism, the assumptions made by clinicians when confronted with transgendered or transsexual clients, and the assumptions of the clients themselves led to the formation of a pathology-based treatment system which has labored along, after a fashion, for more than 40 years. But those assumptions have changed—and the methods of delivering treatment must change, as well.
I have argued [AEGIS News, 1(5), 1995] that a sea change is occurring in the way we think about gender. I believe it is time to rethink our assumptions about treatment, reinterpret the empirical data, and reexamine the power balance between client and caregiver.
This does not mean that we should throw the baby out with the bathwater. I absolutely do not advocate that medical procedures should be available on demand. Hormones and surgery are powerful technologies, and society has restricted access to them for good reason. Many people who ask for them have unrealistic expectations about what they will and will not do; others may seek them out because of desperation or frustration; and some, because of mental illness, are unable to give informed consent.
Our challenge is to rethink the issue of access to hormonal and surgical treatment, balancing the right of the individual to control his or her own body with the ethical obligation of the caregiver to do no harm. It’s a difficult equation with many variables, some of which may never be properly defined. And it’s an issue which we will revisit in future issues of this newsletter.