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Terminology, Gender Diversity, and the Primacy of Gender (2000)

Terminology, Gender Diversity, and the Primacy of Gender (2000)

©2000 by Sandra S. Cole, Dallas Denny, A. Evan Eyler, & Sandra Samons

Source: Cole, Sandra S., Denny, Dallas, Eyler, A. Evan, & Samons, Sandra. (2000). Terminology, gender diversity, and the primacy of gender. In Leonore T. Szuchman & Frank Muscarella, Psychological perspectives on human sexuality, pp. 149-195. New York: John Wiley & Sons. This version reprinted courtesy of John Wiley & Sons.







By Sandra S. Cole, M.H.S., Ph.D., Dallas Denny, M.A.,

A. Evan Eyler, M.D., M.P.H., Sandra Samons, M.S.W.




This chapter discusses gender diversity and transgender issues. It is written for the practicing therapist, who is likely to encounter transsexual, transgendered, and cross-dressing persons as well as others with “non-traditional” (or non-Western) gender identities in the course of his or her professional career.

The chapter begins with a brief discussion of the concept of gender and a review of some of the theories which have been proposed regarding the etiology of transsexualism. This is followed by a brief transgender history and a description of the contemporary transgender community. Although this is not primarily a medical text, a short overview of transgender physical health issues has been included, with the remainder of the chapter devoted to the mental healthcare of transgendered persons, their partners and their families.

Throughout this chapter, the term “transgender” will be used in the broadest sense, including persons who identify as transsexual, transgendered, who cross-dress, or whose self-perception is as a member of a gender other than women or men, unless otherwise noted.


Until the mid 1990s, it was believed that transgendered individuals could be categorized as either transvestites or transsexuals. Male-to-female transsexuals were considered to be of two types: primary and secondary (Person and Ovesey 1974a, 1974b). “Primary” transsexuals were thought to be more “naturally” feminine (cf Stoller, 1968a), to present for treatment at an earlier age, and to make better post-transition adjustments than “secondary” transsexuals, whose transsexualism gradually developed out of either heterosexual or homosexual crossdressing. Female-to-male transsexuals were considered to be of only one type, masculine women who were sexually attracted to other women. Female crossdressers were believed not to exist. Some clinicians emphatically denied the existence of female crossdressers and female-to-male transsexuals who were sexually attracted to men, even when confronted by those whose existence they denied.

In the early 1990s, the dichotomous system of transgender labeling began to break down. Subsequent labels, which have grown primarily from self-description by transgendered persons, have included two-spirit (from Native American traditions), transgenderist, drag king, drag queen, genderblend, and androgyne, among many others. Even if the etiology of transsexuality could be definitely determined, it is difficult to envision a biologic or social etiologic explanation which would adequately capture the diversity of gender behavior and self-perception which is evident within the transgender community.

As cultural norms have changed, gender expression has become more variable, both within the transgendered community and in the population at large. This diversity sometimes manifests in minor ways within traditional normative gender role expression, and sometimes in more overt ways. Sometimes gender variability is a significant part of an individual’s life and may be expressed openly to various degrees. For some, it means living all or nearly all the time in the gender role with which the person identifies most strongly. For a few, it results in a complete transition of gender role, accompanied by hormonal and anatomic transformation.


Is Gender A Primal Force?

Intersexed persons are born with various forms of ambiguous genitalia. Almost all are socially assigned as male or female during the first few months or years of life, and many receive surgery to make the genitals more congruent with the social assignment. It is not yet known what percentage of intersexed individuals are satisfied with their social and surgical sex assignment. However, the last few years have seen the emergence of a group of persons who as adults are outraged about surgical intervention which was performed before they could have had a voice in the gender assignment process. Despite the prevailing societal view that gender is central to self-concept, and that one must identify clearly as male or female in order to be emotionally healthy, some intersex persons identity as neither, and some feel that their individuality was damaged, rather than enhanced, by surgery.

One of the authors (SS) recently had occasion to meet someone who was born intersexed and was not surgically assigned, but was allowed to grow up without a specific gender. Since she does not give it much importance, she accepts people using whatever pronoun they prefer to use. Most people use “she.” She stated that she doesn’t consider herself to have a gender and is satisfied with life as a person. She is intelligent and clearly understands and accepts that she is different from other people. She could still have surgery to make her genitals conform more closely to male or female genitals, but simply sees no need. She is in a satisfying relationship of several years duration. Even in the face of ubiquitous societal pressure toward gender conformity, it appears that it is entirely possible to live well without a gender.




Contextual Issues in Scientific Investigation

A great deal of effort has been devoted to attempts to explain transgender identity and behavior, with the net result that its cause remains unknown. Aside from purely scientific motivations, there are strong political reasons for wanting to explain both transgender behavior and homosexuality. Curiously, both those who condemn these behaviors (and the individuals who exhibit them) and those who defend them seem equally anxious to obtain answers. One possible reason is the following: if homosexuality, transsexualism, or transvestism can be conclusively shown to be biological in nature, it can be argued that the individual cannot “help” the behavior. One could be said to be born transsexual or homosexual, and therefore could not be blamed or faulted. If, on the other hand, it could be shown that there is not a biological etiology, it could be claimed that the individual “chooses” to be homosexual or transgendered, and is thus accountable, and could be held to blame with impunity.

Such concern regarding possible etiology sidesteps a number of important issues. First, human behavior is exceedingly complex, the result of multiple causal mechanisms, the nature of which are often impossible to determine at our present state of knowledge. Second, scientists have historically found it almost impossible to remain objective in such a politically charged atmosphere (see Gould, 1981). Third, most people do not consider homosexuality a mental illness (indeed, the American Psychiatric Association removed homosexuality from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 1980), and it is a matter of current debate as to whether crossdressing and transsexualism should remain in the next revision of the DSM. If homosexuality and transgender behavior are not illnesses, it becomes less important to determine their causes.

Furthermore, there is also the issue of personal freedom. Why should it matter why someone wishes to crossdress, change their sex, or engage in same-sex sexual behavior? It is one’s right to do so. Etiologic investigation (or speculation) has tended to obscure this central truth, so that the focus on human freedom of expression is lost.

Political concerns aside, what causes crossdressing and transsexualism? The short answer is, no one knows. The space limitations of this chapter do not permit an exhaustive review of the salient etiological theories, but several lines of research, in which initial results seemed to support either environmental or biological causes, are presented below. In some cases, preliminary conclusions did not survive further scrutiny; in the others, definitive evidence is currently lacking.


Etiologic Theories

The likelihood of identifying a specific etiology of transsexualism appeared more promising prior to the recognition of behavioral diversity within the transgender community. By the 1970s, clinicians had identified several diagnostic categories to which transgendered persons could be assigned (cf Person 1974a, 1974b). At first, these categories seemed to be exhaustive. However, by the mid-1990s, transgendered persons were evidencing a great deal of diversity in their self-identities and gender expressions (Bolin, 1994) which had not been present (or at least had not been recognized) only a decade earlier (Bolin, 1988). As more members of the transgender community have come to question a system in which there are two and only two possible genders, the historic categories of crossdresser and transsexual have become but two of a number of possible self-identities.

Freud was the first to elucidate a theory of gender as learned behavior. A number of psychiatrists have drawn upon his developmental theory in attempts to show environmental causes for transsexualism and crossdressing. The late Robert Stoller believed that male-to-female transsexualism was caused by the child’s failure to adequately separate from a bisexual “empty” mother who kept the child too close to her body during the first two to three years of life (Stoller, 1967). Stoller believed that MTF transsexuals were “among the most feminine of males” (Stoller 1968a), and discounted as transvestites those males who identified as transsexual but did not look or sound like females. However, the family dynamics of many transsexuals did not support Stoller’s theory, and a longitudinal study by Richard Green (1987) showed that extremely feminine boys like those studied by Stoller were more likely to grow up to be homosexual than transsexual. Perhaps most telling was Stoller’s revelation that the subject of an early case study had turned out to be “extremely feminine” as an adult only because she had been surreptitiously taking female hormones since puberty (Stoller, 1968b).

More recently, the “John/Joan” case has received a great deal of public attention. In the 1950’s, John Money and his colleagues John and Joan Hampson concluded that gender identity was primarily learned rather than innate, was well-formed by about age three, and was thereafter quite resistant to change (Money, Hampson, & Hampson, 1957). Later Money (1975) reported on the case of a six-month-old boy whose penis had been accidentally ablated during circumcision. The parents were counseled by Money to raise the child as a girl, and the intact twin brother as a boy.

Follow-up reports (Money, 1984) indicated that “Joan”, as the patient was called in the literature, was well-adjusted as a girl. However, Diamond & Sigmundson (1997) discovered that at adolescence Joan, who had been long unhappy as a female, began to live as “John,” a male. John subsequently had surgery to construct a penis and married as a man (Colapinto, 1998).

This case resulted in a great deal of media attention, as it suggested that biology plays more of a role in the formation of gender identity than does environment. However, a second, similar case was recently followed-up (Bradley, et al., 1998). In this case, a male infant similarly reassigned as female after penile ablation chose to remain female-gendered in adulthood.

It is possible that one day there will be a sufficient number of such cases identified to allow conclusions to be drawn about the relative roles of biology and environment in gender identity formation; however, this is not possible at the present time.

Perhaps the most thorough review of the etiology of transsexualism was done by Jon Hoenig (Hoenig, 1985), who devoted several pages to a theory of causality which initially caused a great deal of enthusiasm. Hoenig notes that in 1979, the German gynecologist Wolf Eicher discovered that one of his male-to-female patients showed an absence of the histocompatibility (H-Y) antigen, which is typically present in males and absent in females. Eicher and his colleagues published several papers in which they presented their findings that male-to-female transsexuals tended to lack H-Y antigen and female-to-male transsexuals tended to have the antigen (Hoenig, 1985, p. 54). A number of attempts were made to replicate Eicher et al.’s results, mostly without success (Hoenig, 1985, p. 60). Consequently, the H-Y antigen theory has fallen into disfavor. However, at one time, the prospect of an unambiguous genetic marker for transsexuality caused a great deal of excitement in the scientific community.

A similar burst of enthusiasm occurred after an announcement by Levay (1991) that there is a difference of the hypothalamic structure of heterosexual and homosexual men, and after Swaab et al published their findings that the xxx of the hypothalamus of male-to-female transsexuals tended to be smaller than the same area in females, whose xxx were in turn smaller than those of nontranssexual males. Other teams are currently attempting to replicate Levay’s and Swaab’s work; however, at present, their work is unreplicated, and should be considered to be suggestive, rather than definitive.



It is possible that, given sufficient time and further research, causal mechanisms for many human behaviors, perhaps even transsexualism, will be elucidated. Currently, however, it is clear that gender is in many ways an individually-based and self-perceived characteristic, the origins of which are not well understood. Gender (and transgender) may evolve in a variety of ways, and should not be restricted by societal prejudice.1




In recent years, a transgender history has begun to emerge. Compiled from ancient texts, turn-of-the-century works of cultural anthropologists, biographies and autobiographies, Medieval legal documents, and even reconstructions from the scanty evidence of Paleolithic burials and campsites, it has gradually become clear that rather than being the aberrations that Western science has held them to be, same-sex relationships and cross-gender behavior have been present in all societies from the earliest times and both the behaviors and those who exhibit them have been positively acknowledged by many cultures. It has become equally clear that throughout history, sexually and gender variant people have filled well-defined social roles in a wide range of cultures, often as shamans, healers, entertainers, and storytellers (Feinberg, 1996, Chapter 3). Usually, these roles were filled by those who chose them, but sometimes individuals were deliberately selected (R. Green, 1998, p. 9). Dragoin (1995) has speculated that the presence of members with a “two-spirit” nature may have provided a selective evolutionary advantage for tribal groups throughout human history. There is some evidence to support this point. Most notably, Whitam (1997) found that homosexual and transvestic males in many cultures tend to become entertainers of one type or another. Green and Money (1966), who studied extremely feminine boys in the United States, reported that they exhibited a variety of theatrical traits, including dressing up in womens’ clothing and “putting on shows” for their friends and families.

Because they did not emerge as distinct and separate social identities until the twentieth century, accounts of what we today call homosexuality and transvestism have usually been conflated, so that they are not really distinguishable. Much of this history is scattered, and much has been systematically repressed and is lost to us. Still, a surprising amount of information has become available in recent years. This section reviews only a small amount of the accumulated evidence. Those interested in further reading should consult sources such as Ackroyd (1979); Bullough & Bullough (1993); Dekker & Van de Pol (1989); Feinberg (1994); R. Green (1998); Herdt (1994), Ramet (1996), Taylor (1996), and Williams (1986).



Our knowledge of human prehistory is limited; we know only what we can deduce from the fossil record. Unlike bones and stone tools, which tend to be preserved, the social behavior of our ancestors must be inferred from physical artifacts which can somehow give us clues about such behavior. Understandably, making sense of complex social roles is a difficult task with such scanty evidence, and a variety of interpretations can be drawn using the same artifacts. Still, a transgender pattern has begun to emerge.

In his fascinating book The Prehistory of Sex, Timothy Taylor (1996) points out paleontological evidence which shows that early humans almost certainly engaged in a range of sexual behaviors as extensive as that displayed today. Citing evidence from ancient burials, cave paintings, pottery decorations, and carvings which display hermaphroditic figures, Taylor points out that from prehistoric times some members of every society would likely have had androgynous physical traits, and a certain number—perhaps one individual per 1000-2000– would have been born with physical intersex conditions (pp. 63-65). Reaction to individuals with such characteristics could have ranged from indifference to acceptance to rejection to celebration. In many non-Western societies, Taylor notes, children are accepted as they are (p. 64). This is not universal however– in some societies, intersex and gender-variant individuals may be treated badly, or put to death (cf Edgerton, 1964).

Individuals who crossdressed would have faced the same range of reactions, perhaps being ridiculed in some societies and in others being culturally constructed as members of the other sex, or as members of a third sex (pp. 210-212). Taylor describes carvings of androgynous figures which are full-breasted but potently phallic (pp. 130-131, 215-219) and burials containing sex-typed grave goods which differ from what would be expected from the physical characteristics of the skeleton (p. 67, pp. 212-214, Chapter 8). Taylor notes that ambiguous physical measurements of some skeletons make them impossible to classify as either male or female (pp. 65-68), and suggests that the potent pharmacopeia of the time may have been used to deliberately produce estrogenic and androgenic effects– Paleolithic sex changes (pp. 212-214). Taylor’s evidence comes from widely separated sites, suggesting that gender-variant behavior was widespread, and not limited to a few small areas.


Cross-Cultural Accounts

Before they came under the influence of Western missionaries, many modern hunter-gatherer groups had institutionalized social roles for gender-variant persons. These roles were part of the accumulated cultural wisdom of the tribes, having been passed down, like their language and other customs, from their ancestors. Institutionalized alternate gender (transgender) roles have been described in societies in all the continents except Antarctica. Anthropologists have documented such roles in cultures ranging from Polynesia (Besnier, 1994) to Siberia (Czaplicka, 1914, cited in R. Green, 1998, p. 10) to Eastern Europe (Dickemann, 1995) to Native North America (Kurti, 1996; Roscoe, 1988; Williams, 1986). Will Roscoe’s Living the Spirit (1988, pp. 217-222) contains a six-page listing of North American Native tribes which had well-defined alternate gender roles.

Typically, individuals in alternate gender roles lived openly and without shame, wearing the clothing of and functioning socially as members of the “other” sex (see the various chapters in Herdt, 1994 for descriptions of such roles). Transgender roles were common in Western cultures before the rise of Christianity, when they began to be systematically eradicated (Bullough & Bullough, 1993, pp. 39-40, 45; Roscoe, 1994).

Although female social roles for those born male have been the more commonly documented across cultures than male social roles for those born female (cf Roscoe, 1988, pp. 217-222), this may be at least partially due to a bias in reporting. Some societies had both types of roles. For more information on cross-transgender roles in a variety of cultures, see Feinberg (1996), R. Green (1998), Herdt (1994), Ramet (1996), and Wheelright (1979).


Early Written Accounts

Many societies, ranging from Greek and Roman to East Indian to Native American, have creation and other myths in which hermaphroditic or cross-gendered figures play prominent roles (see Bulliet, 1928, for an early review). Having been passed down orally, these tales were set down in writing when this new technology developed. Early manuscripts in Greek, Latin (R. Green, 1998), Sanskrit (Money, 1992) and Sumeric (Ochshorn, 1996) describe transgender behavior, and even the Gospel of St. Thomas talks positively about androgyny:

When you make the two into one, when you make the inner like the outer and the outer like the inner, and when you make the male and the female into a single one so that the male will not be male and the female will not be female, then you will enter the kingdom of heaven.

—Thomas, 22 in the New Hammadi Library, p. 121

By all accounts, a number of the Roman emperors and several of the Egyptian pharaohs (both male and female) were transgendered (R. Green, 1998; Harrison, 1966; Margretts, 1951; Taylor, 1996). For instance, it is reported that the Roman Emperor Heliogabalus offered half his Empire to any physician who could change his genitals from male to female (R. Green, 1998, citing Benjamin & Masters, 1964, p. 5).

Transgender behavior was also common among the general populace or ancient cultures:

 Philo, the Jewish philosopher of Alexandria [Greece], wrote, “Expending every possible care on their outward adornment, they are not ashamed even to employ every device to change artificially their nature as men into women… Some of them… craving a complete transformation into women, they have amputated their generative members”

—Masters, unpublished, cited by R. Green, 1998, pp. 4-5

The Roman poet Manilus wrote: “These (persons) will ever be giving thought to their bedizement and becoming appearance; to curl the hair and lay it in waving ripples… to polish the shaggy limbs… Yeah! and to hate the very sight of (themselves as) a man, and long for arms without growth of hair. Woman’s robes they wear… (their) steps broken to an effeminate gait….”

—Masters, unpublished, cited in R. Green, 1998, p. 5

Transgender roles were widespread in pre-Christian Europe and Eurasia as well (O’Hartigan, 1993; Roscoe, 1994). Early Christianity incorporated ritualized crossdressing (Torjesen, 1996), which survives in symbolic form in ecclesiastical robes even today, but transgender behavior and roles were systematically and often violently suppressed by Christian and Jewish cultures over a period of nearly 2000 years (Bullough & Bullough, 1993, pp. 39-40, 45).

By the Middle Ages, fear of punishment, banishment, or even execution had driven transgender expression in the West underground, where it has largely remained. However, despite the danger of societal sanction, many individuals across the centuries have lived either openly or secretly in the clothing of and have sometimes passed as members of the other sex. Reports of men living as women and women living as men are common throughout the Middle Ages and into the modern era (Bullough & Bullough, 1993, Chapter 3; Dekker & van de Pol, 1989), including both commoners (Dekker & van de Pol 1989) and royalty (Abbe de Choisy, 1966; Gilbert, 1926; Kates, 1995). Dekker & van de Pol (1989) found records of hundreds of females who lived as men in the Medieval Netherlands; no doubt there were many more whose records did not survive, or whose records reflect unambiguous identities as men. There are also numerous accounts of “passing women” in other European countries and the early United States (cf Wheelright, 1979). Historical accounts of women living as men are more common than accounts of men living as women. Perhaps women were more likely to take on cross-gender roles because they offered an escape from the strict social proscriptions placed on women (Bullough & Bullough, 1993, p. 51); perhaps it was easier for women to “pass” as men than it was for men to “pass” as women; perhaps punishment was less severe for passing women than for passing men; perhaps women were more likely to be discovered and revealed because their active sexual and social lives made them more public and thus more vulnerable to discovery, or perhaps there were simply more passing women than passing men. Passing women often took wives, and many volunteered for military service (Wheelright, 1979, Chapter 1). There are accounts of more than 150 female soldiers passing for male in the U.S. Civil War, and probably several times that number actually served.(Lowry, 1994; Meyer, 1994).

A number of female and male saints transgressed gender roles, both in their behavior and in their manner of dress (Bullough & Bullough, 1993, Chapter 3; Torjesen, 1996). Most in fact became saints because of their crossdressing. The best-known saint is perhaps Joan d’Arc of Orleans, who was put to death for, among other things, refusing to wear womens’ clothing (Bullough & Bullough, 1993, pp. 57-60). There is even a persistent rumor that Pope John VIII, Anglicus was a woman who passed as a man until she gave birth to a baby during a Papal procession (Bullough & Bullough, 1993, pp. 55-57).


Twentieth Century Accounts

Beginning about 1850, physicians began to take an interest in individuals who varied from the gender norms of the day (Bullough & Bullough, Chapter 9). The case studies of both Krafft-Ebing (1894) and Hirschfeld (1910, 1991) depict individuals who clearly conform to current-day definitions of crossdressers and transsexuals. Correspondence unearthed by Peter Farrer in a variety of Victorian newspapers (Farrer, 1987) show that a significant number of English men were interested in crossdressing. Male crossdressing had been common in bawdy houses since at least the seventeenth century (Trumbach, 1989), and boy actors played female roles on the Elizabethan stage, and sometimes offstage (Howard, 1993).

The popularity of crossdressing continued with the establishment of gay night clubs early in this century (Paulson, 1996), and thrives in the present day (cf Aviance, 1996). Female and male impersonation was common in American vaudeville and British pantomimes (Slide, 1986) and in moving pictures almost from their inception (Bell-Metereau, 1993; Dickens, 1984). Some performers, like Julian Eltinge, were careful to maintain a public facade of respectable heterosexuality (Moore, 1994, Chapter 8). Others were deliberately outrageous, but in general, crossdressing in public invited interference from the police, and much crossdressing took place behind closed doors (Paulson, 1996). Public crossdressing began to emerge only in the 1950s and 1960s, as female impersonators began to grow bolder (County, 1995), and when small groups of male crossdressers started to meet in secret in California and the Northeastern United States (Bullough & Bullough, 1993, Chapter 12).




The last several decades of the twentieth century have seen the rise of a transgender community, a broad-based alliance of transsexuals, transgenderists, crossdressers, other “non-traditionally gendered” persons and helping professionals who have formed support groups, information clearinghouses, and other organizations which serve the manifold needs of transgendered and transsexual persons. This community developed from a model of heterosexual crossdressing created by Dr. Virginia Prince and a medical/psychological model of transsexualism developed by Dr. Harry Benjamin.


The Heterosexual Crossdressing Model

Virginia Prince was the founder of the Hose and Heels Club, which was perhaps the first club in the U.S. for heterosexual crossdressers. Prince also founded the Foundation for Personality Expression, a national organization for heterosexual crossdressers, and was co-founder of Tri-Ess, The Society for the Second Self, which replaced FPE and which still exists. She was also editor of 100 issues of Transvestia, the first nationally circulated magazine for crossdressers (Bullough & Bullough, 1993, Chapter 12).

In the pages of Transvestia, Prince developed a model of male heterosexual crossdressing, downplaying the importance of self-eroticism and homosexuality in crossdressing and emphasizing the evolution of a nonsexual “girl within,” a social woman with male anatomy. At the time, (the 1950s and 1960s), crossdressers were automatically assumed to be homosexual. Prince demonstrated that this was not so by surveying her readers and publishing the results not only in Transvestia, but in professional journals (Prince, 1957; Bentler & Prince, 1969a, 1969b). For more than 40 years, Prince has vigorously promoted her concept of the crossdresser as a heterosexual male. From a contemporary perspective, it is clear that although there are many thousands of heterosexual crossdressers, many gay and bisexual persons also cross-dress.


The “Medical/Psychological” Model of Transsexualism

The 1950s also brought news of Christine Jorgensen, and the notion that change of sex was possible (Bullough & Bullough, 1993, 1998; Denny, 1998a; Hamburger, et al., 1953). Jorgensen was not the first transsexual, as male genitals had been surgically altered since ancient times (O’Hartigan, 1993), and sex reassignment using modern surgical techniques had been attempted as early as the 1930s (Abraham, 1931; Hoyer, 1933). However, the news of Jorgensen’s sex change galvanized the press, introducing to the general public and to scientists alike the notion that sex was not immutable, but subject to change (Denny, 1998a).

Following the news of Jorgensen’s sex reassignment, hundreds of men and women came forth, requesting sex reassignment (Hamburger, 1953). Harry Benjamin, a New York endocrinologist, began treating many of these individuals, and in 1966 published a text, The Transsexual Phenomenon, in which he defined the syndrome of transsexualism. Benjamin, an empathic soul who seemed to genuinely enjoy his transsexual patients, described them as profoundly miserable in their gender of original assignment, so much so that they were often unable to function and were at considerable risk of taking their own lives. Benjamin noted that medical science was unable to rid them of their compelling desire to change their sex or to give them peace of mind in their original bodies. Surely, he argued, the humane thing in select cases would be to give transsexuals relief from their suffering by altering their bodies with hormones and surgery and allowing them to live as members of the other sex. Benjamin pointed out the success of his own patients who had had sex reassignment. (It should be noted that, given the severe and prevailing social sanctions against transsexuals and other gender or sexually non-conforming persons which were present in the 1950s and 1960s, it is likely that only the most desperately dysphoric individuals would have sought transition services from the medical establishment of the time. Transsexual clients seen during the 1990s are no more likely to be suicidal or severely impaired than are other persons who present for mental health services.)

Three years later, in 1969, Drs. Richard Green and John Money published an edited textbook which established a medical protocol for sex reassignment, based on their own experience at the new gender identity clinic at JohnsHopkinsUniversity (Green & Money, 1969). Now there was not only a model for transsexualism, but a sex reassignment protocol from one of the most prestigious medical schools in the United States. Other universities started gender programs; within 10 years, there were more than 40 university-based gender clinics scattered across the U.S. The universities disassociated themselves from their programs in 1979 and 1980, following the release of a report by Jon Meyer and Donna Reter which showed “no objective improvement” following sex reassignment (Meyer & Reter, 1979). Meyer & Reter’s report came under immediate attack (cf Fleming, Steinman, & Bocknek, 1980) and eventually was found to be lacking in scientific validity (Denny 1992; Ogas, 1994). The clinics nonetheless closed, except for two, which continued as private for-profit centers, and the program at the University of Minnesota, which came under the control of the Program for Human Sexuality after its original departmental sponsor disassociated itself (Walter Bockting, personal communication).

The closing of the university programs led to the eventual development of a market-driven sex-change industry (Denny, 1992) which made sex reassignment more widely available than ever before, frustrating those who had worked for the closing of the gender programs (McHugh, 1992). Today, professional services are available to practically anyone in the United States who desires to change his or her sex and has the financial means to do so.


Being a “Good” Transsexual

Despite the groundbreaking work of Dr. Benjamin and his associates, the Benjamin model ultimately resulted in a narrow definition of transsexualism. Those who varied from the prescribed characteristics were at risk of not getting treatment– in fact, of being declared nontranssexual by medical professionals and by their peers (cf Newman & Stoller, 1974). To qualify for treatment, it was important that applicants report that their gender dysphoria manifested at an early age, preferable by age 3 or 4; that they had a history of playing with dolls as a child, if born male, or trucks and guns, if born female; that their sexual attraction was exclusively to the same biological sex; that they had a history of failure at endeavors undertaken while in the original gender role; and that they were able to pass successfully as a member of the desired sex (Denny, 1992).

The literature reported that transsexuals were manipulative and had high levels of psychopathology, had narrow and stereotyped notions of masculinity and femininity and conformed to those stereotypes in their personal presentations; that they had a desire to disappear into the larger society after surgery, passing as nontranssexual; and that they viewed themselves as having been born into the wrong body because of some sort of birth defect or horrible joke of nature (Bolin, 1988). Most transsexuals do not in fact have such characteristics; the literature which suggests that they do reflects the bias and sexism of the psychologists and physicians who wrote it, often in keeping with the dominant culture of the time (Denny, 1998b).


Challenges to The Benjamin Model

Benjamin’s model supposed that there were but two sexes, and that the only alternative to remaining unhappily in the original gender role was to work hard to conform to the only available alternative. That is, one “changed sex,” going from male to female, or from female to male. The model did not question the society which created such restrictive gender roles or examine the possibility of living somewhere outside those binary roles. Those who were not interested in going from one polar extreme to the other were defined as nontranssexual and presumed to be crossdressers, even when they were profoundly gender dysphoric. Transsexualism itself was considered a liminal state, a transitory phase, to be negotiated as rapidly as possible on one’s way to becoming a “normal” man or “normal” woman.

The Benjamin model of transsexualism was held as the only valid model of transsexualism until the early 1990s, despite challenges from opponents to the concept of transsexualism per se (refs) and from the clientele whom it was intended to serve.


The Transgender Model

The 1990s saw the rise of a model which provided an alternative to both Benjamin’s medical /psychological transsexual model and Prince’s model of heterosexual crossdressing. Early in the decade a transgender sensibility began to emerge, in which the notion of changing sex or remaining rigidly in one’s original sex was replaced by the idea of multiple or even infinite sexes. Prince herself had advanced this notion in the 1970s, but it was overlooked until resurrected by Holly Boswell, Kate Bornstein, and others in the early 1990s (Boswell, 1991; Bornstein, 1994; Rothblatt, 1994). Perhaps even more profound (from the North American perspective) was the decoupling of sex, which is largely defined by anatomic phenotype, and gender (which is a psychological phenomenon, and which had previously been viewed as a function of anatomic sex). This process also furthered the dissolution of socially “correct” gender roles, both for transgenders and for other members of society. Those subscribing to the emerging transgender model tended to see themselves as both man and woman, or neither, or as something else entirely. Under this model, the in-between state somewhere between manhood and womanhood, unacknowledged under either Benjamin’s and Prince’s models became a goal for which to strive, or at least a comfortable place at which to rest. As the decade draws to a close, the transgender model is pervasive throughout the transgender community and is beginning to have a significant impact in academia (cf Wilson, 1998).


Issues of Sexuality

Like everyone else, transgendered and transsexual persons experience sexual attraction to other human beings. Some are attracted to males, some to females, some to both, some to neither, and some to other transgenders or members of other sexual or gender minorities. This mirrors the range of sexual attractions in the larger society. Labeling such attractions as heterosexual or homosexual becomes a bit confusing (and perhaps irrelevant) in the case of transsexuals. Therefore, it is more informative to reference the gender or genders to which the transgendered individual is attracted. The authors of the most recent revision of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV) recognized this and avoided the use of the terms homosexual and heterosexual in the section on Gender Identity Disorders.


Identity and Community

Before the mid-nineteenth century, the social identities of homosexual and heterosexual as we know them did not exist. Of course, men and women engaged in a wide variety of sexual behaviors; however, it was only when scientists began to take an interest in sexual behavior that the terms homosexuality and heterosexuality came into common usage.

Before the turn of the century, homosexual behavior and transgender behavior were commonly believed to be manifestations of the same underlying condition. Male homosexuality was believed to be due to a strong feminine element (cf Ulrichs, 1994), and female homosexuals were considered “mannish” (Devor, 1995). Indeed, a look at Radclyffe Hall’s 1928 novel The Well of Loneliness, which has long been considered to have a lesbian protagonist, features a cross-dressing female protagonist who calls herself (himself?) Stephen, and who almost certainly fits the diagnostic criteria for female-to-male transsexualism.

Transvestism was differentiated from homosexuality by Hirschfeld (1910), but Hirschfeld’s work had little impact in the United States because it was not translated into English until the 1990s (Vern Bullough, personal communication). Transsexualism was differentiated from transvestism by Benjamin (1966); before that, Christine Jorgensen and others who had sex reassignment were frequently called transvestites in the medical literature (cf Hamburger, 1953).

The Stonewall Rebellion of 1969 saw the birth of the modern gay liberation movement (Duberman, 1993). In the immediate post-Stonewall period, a new homosexual culture emerged, in which stereotypes of feminine gay males and mannish lesbians were replaced by new social constructions of male and female homosexuality in which masculine dress and demeanor were embraced by most gay men, and most lesbians rejected butch identities. Almost immediately, the drag queens and kings who had instigated the fighting were marginalized by the movement because they were visually different from these emerging notions of straight-looking, straight-acting gay men and woman-identified lesbians, (Brewster, 1970). Over the ensuring decades, bisexuals and then transgendered persons lobbied for and were (sometimes grudgingly) re-admitted to the movement.

In 1985, when the International Foundation for Gender Education (IFGE) was formed in Boston, transsexuals throughout the U.S. and Canada began to come into regular contact with other transsexuals. As soon as they established the necessary level of comfort, many began to admit to one another that they did not conform to Harry Benjamin definitions of transsexuals or transvestites. As an open organization, IFGE welcomed both transsexuals and crossdressers, so for the first time, transsexuals and crossdressers came into regular communication. Within five years, this interaction resulted in the development of a worldwide transgender community and the development of the transgender model.

The transgender model minimized the differences between gay and straight crossdressers and transsexuals and helped the transgender community confront and begin working through its not inconsiderable homophobia. The transgender model was brought to the attention of the gay, lesbian, and bisexual community by an awakening transgender political movement, by the publication of transgender literature, such as Leslie Feinberg’s novel Stone Butch Blues, in which the protagonist rejected transsexualism in favor of an essential (FTM) transgender identity. Feinberg has also been an inspiration to many female-to-male transgendered people, who have long been in the shadow of male-to-females, and who are now coming forth in large numbers (J. Green, 1998). Other emerging groups on the social and political landscape include FTM cross-dressers, persons born intersexed, and persons who identify as genderblended or as members of another “non-traditional” gender identity.

The politicization of transgender identities has also been a common theme in the nineties. Transgendered individuals have protested when their peers have been murdered, lobbied for civil rights previously denied them, and engaged in vigorous letter-writing campaigns and political demonstrations when they have been slandered by those in power. Civil rights protection for transgendered people has been achieved in the State of Minnesota and more than a dozen cities throughout the U.S. Transgendered voices have also begun to appear in the professional literature, from which they had previously been excluded (Denny, 1997), and transsexuals have begun to run for and be elected to public office, and to be out as prominent members of a variety of professions (cf Wilson, 1998).

Transsexuals have begun to criticize the medical literature, which has often treated them as individuals with a mental illness. At issue is the Gender Identity Disorders section of the DSM-IV. The call for reform of the diagnostic category Gender Identity Disorder of Childhood has been of particular concern, since it is sometimes used to institutionalize gender-variant homosexual boys and girls, and other gender role non-conforming children and adolescents (see Burke, 1996; Scholinski, 1997). Also at issue are the Harry Benjamin Standards of Care, which place restrictions on access to body-altering medical treatment without empirical evidence that such restrictions are necessary or even advisable (Levine, et al., 1998).

The rise of postmodern gender theory (cf Butler, 1990; Foucault, 1979) has provided a new language for the discussion of transgender issues (Wilchins, 1997). The careful reader will notice that throughout this section there has been no mention of gender identity disorder (except when naming the diagnostic categories in the DSM), or other language which would predispose the reader to view transgendered persons as mentally ill or otherwise deficient. When resorting to the medical /psychological model, it is difficult to discuss transgendered people or their issues without the using terms which imply or overtly state pathology and lack of judgment and reinforce the expertise of the medical or mental health professional. In view of the groundbreaking work which Harry Benjamin performed on behalf of his transsexual clients, it is ironic that the current HBIGDA. Standards of Care (Levine, et al., 1998) contain language which diminishes and demeans transsexuals. It is likewise unfortunate that the new Standards of Care continue and even strengthen restrictions on access to treatment without citing empirical evidence for doing so, especially as the modern transgender model is being embraced by many professionals. (Talks on the transgender model by Holly Devor (1997) and Walter Williams (1997) set the tone for the 15th Harry Benjamin International Gender Dysphoria Association Symposium in Vancouver, British Columbia, in 1997.) Conversely, it must be noted that as recently as 1997, medical and psychological professionals have been held liable by persons who received sex reassignment surgery and later regretted that decision. Given this precedent, it is unlikely that self-protective professional standards will be eliminated in the near future. Full freedom of gender expression (and free access to medical services which foster it) will come as the transgender community succeeds in gaining recognition from society as fully autonomous, personally responsible adults.

The transgender model, which offers an infinite number of gender identities and lifestyles, is much less restrictive than previous models, which emphasized and even required conformity. As the Twentieth Century closes, one is struck by how much gender roles and sartorial styles have changed in only one hundred years. From an era in which women wore nearly twenty pounds of clothing, were not allowed to vote, and were routinely arrested if they appeared on the streets wearing trousers(Atlanta Constitution, 1911a, 1911b), we have come to a time in which the gender norms of 1900 are transgressed daily by practically every American citizen, including those who are opposed to those who are pushing the frontiers of acceptance today. Perhaps we will eventually arrive at a time in which people’s clothing (and genitals) will cease to be a focus of public debate.




A comprehensive discussion of the medical needs of transgendered persons is beyond the scope of this chapter. Nonetheless, it behooves the mental health practitioner who provides services to gender variant persons to acquire at least a basic knowledge regarding the effects of contragender hormone supplementation and the health maintenance needs of this population. A brief description of these facets of transgender healthcare has therefore been included below.


The “Second Puberty”

A hormonal substance is commonly defined as one which travels from a specific tissue, in which it has usually been manufactured, through the bloodstream to receptive cells in another location, upon which it exerts its characteristic effects (Speroff et al, 1994). Hormones, including estrogens, progesterones, and androgens are the biochemical substances which cause much of the pubertal change experienced by young women and young men. Every healthy, living human has at least small amounts of each of these hormones in his or her body throughout life. However, the character of pubertal change experienced depends upon the amounts of each of these substances which are present and biologically active at the target tissue sites.

Although natural pubertal development is completed by the later teen years, persons desiring the physical characteristics usually associated with the other gender can obtain some of them through the use of supplemental hormones at any stage of life. In essence, the transsexual or transgendered person who takes estrogens, progesterones, or androgens, at sufficient doses and for a sufficient duration, will experience a second puberty.


Pubertal Change and Irreversibility

The physical effects which the “second puberty” is able to achieve can be summarized with the caveat: “Hormones can stimulate change, but can not undo what has already occurred.” Once these biologically active compounds have acted upon their target organs to produce specific physical effects, these become irreversible even after the hormones are withdrawn. Therefore, transsexuals and transgenders of any pre-existing hormonal configuration will require a combination of hormonal (and perhaps) surgical therapies, depending on the previous development and the desired outcome.

Female-to-male (FTM) persons who utilize androgen supplementation (usually injectable testosterone cipionate or a related compound) will experience effects such as deepening of the voice (through thickening of the vocal cords); increase in facial and body hair in a typical male pattern; and growth of the clitoris. Although reports of clitoral growth sufficient to permit intercourse exist, in most cases, surgical procedures will be required in order to approach the size and morphology of a normal penis. Since the hair follicles of the scalp are also sensitive to the effects of testosterone, male pattern baldness may occur.

Development from the “first puberty” will not regress even after the hormonal pattern becomes that of a genetic male. Most FTM persons will require breast surgery with nipple relocation, in order to create a male-appearing chest, and although menstruation will cease with sufficient testosterone supplementation, hysterectomy with removal of the ovaries is usually performed for cancer prevention. The changes of the “second puberty” are also permanent. If the FTM individual decides to return to life as a female, beard and body hair growth will not disappear as testosterone is withdrawn; electrolysis will be necessary. Clitoral growth and vocal changes will also remain unchanged.

The male-to-female (MTF) person who undertakes hormonal transition faces the same caveat. Although she will develop breasts and experience a cessation of scalp hair loss (if male pattern baldness has already begun) estrogen supplementation will not raise the voice or greatly change the pattern of body hair growth. Most MTF individuals pursue speech therapy, and in some cases vocal cord surgery, in order to achieve a more feminine sounding voice. Extensive electrolysis is often necessary to remove the beard and male pattern chest, neck, back, and abdominal hair. Most MTF persons also take anti-androgen agents, such as spironolactone, finasteride, or cyproterone acetate. However, although these medications can soften the skin so that electrolysis can be performed more easily, and can potentiate breast development and testicular shrinkage, they can not undo the development of the “first puberty” which has already occurred. Similarly, if estrogen is discontinued at a later time, the female breast morphology will persist unless surgery is performed.


Hormonal Safety During Transition

Although the “second puberty” can occur at any stage of life, adults who undertake hormonal transition face one disadvantage which adolescents do not: the loss of physiologic resilience which occurs with advancing age. Even during the months and years when sex hormone production is highest, adolescents do not normally develop complications such as elevated cholesterol and coronary artery disease (which can accompany testosterone use, especially at high levels) and deep vein thrombosis (which can result from elevation in serum estrogen levels). Unfortunately, middle-aged and older adults do experience these illnesses, especially if they smoke. The two most important contributions which the mental health practitioner can make to the physical well-being of transgendered clients who use hormones are to be encourage them to seek care with a physician who is familiar with contragender hormonal therapy (and who will monitor the serum estrogen and testosterone levels on a routine basis to avoid inadvertent overuse) and to provide information about locally-available smoking cessation groups and other resources.


Health Maintenance for Transgendered Persons

Transgendered and transsexual persons who are in the process of hormonal transition have the same needs for routine health maintenance as their age-matched, non-trans peers. These include such services as cervical cancer screening and mammography for women, prostate examinations for men, and colon cancer screening and coronary artery disease prevention for both (U. S. Preventive Services Task Force, 1996). Many transgendered clients receive these services from the same physicians who prescribe and monitor their hormonal therapies; others, especially those who by choice or of necessity are following a more “a la carte” approach to transition services, do not (and may be unaware of the need for these procedures). Other impediments to receiving appropriate health maintenance services include anatomic incongruity and a lack of preventive focus.

Anatomic incongruity refers to the apparent mismatch between an individual’s appearance while clothed and while undressed, especially while undergoing medical procedures. Transgendered persons (even if they are post-transition) often demonstrate anatomic incongruity, which can be problematic if the examining clinician is unprepared for these findings. For example, a woman who is undergoing a rectal examination may be wrongly found to have a rectal mass, which is in fact her prostate. (She is a post-operative MTF transsexual; the prostate gland is not removed with sex reassignment surgery.) Or the clinician may note that a masculine-appearing gentleman has no hair on his back, chest, underarms, limbs and pubic region, and wonder whether this indicates a disease state, a psychological disorder, or an unusual personal hygiene custom. This individual is simply a MTF cross-dresser, although he may not wish to discuss his gender identity with the treating clinician, unless previous rapport has been established.

Lack of preventive focus often results from the expenditure of time and financial resources which is characteristic of the transition process. An individual who is involved in regular therapy sessions, medical visits for hormonal monitoring and other associated care, plus family counseling or a support group, may have little enthusiasm for additional medical services such as mammography or colon cancer screening. In addition, for persons desiring sex reassignment surgery, attention to long-term health maintenance issues may be subsumed in the quest for this greatly anticipated short-term goal.


A Response From the Mental Health Professions

Therapists and other mental health practitioners who wish to assist their clients in maintaining physical health during and after the transition process can intervene in two ways. The first is to assist the client in achieving a long-term, preventive focus. The second is to communicate with regional medical providers, and to develop referral lists of physicians who are knowledgeable regarding gender variance (or who are at least welcoming of sexual and gender diversity within their clientele).

When discussing the need for preventive medical care with a client who has been using a more “a la carte” or “hormones only” approach to healthcare services, it is often useful to point out that, although it is possible to have the experience of being both biologically male and female during the course of one’s lifetime, each person still only experiences life in one body. If it is not properly cared for, life in the new gender will be compromised or shortened, i.e.,Your new self will come from your old body. Even if the client does not care for his or her body because it is the wrong sex, the tissues from which it is formed represent the only source of materials for the “right sex” body, and in fact for life itself.

A further caveat for persons in transition, or in states of permanent anatomic incongruity, is that it is necessary to take care of a body part for as long as it is part of your body. MTF transgenders and transsexuals need prostate examinations throughout the adult lifetime. MTF persons who have developed female-morphology breasts should have mammograms, even if they have not yet come out in all arenas of life. And even fully masculinized FTM persons require cervical cancer screening if they have female internal anatomy. (One of the authors (AEE) has suggested the public health slogan, “Real men get Pap tests” for use in the FTM community.) Unfortunately, inattention to a body part does not keep it healthy or free of cancer.

If the client is aware of the need for preventive and routine medical services and has no financial limitation to obtaining them, it may be necessary to explore the prior experiences which have occurred in healthcare settings, especially episodes of abuse. If the client has a history of shaming, threatening or inappropriate medical experiences, referral to a physician or other clinician who is known to the therapist and knowledgeable about transgender (or willing to learn) can be lifesaving.

Clinicians who are particularly useful to transgendered clients include family physicians or gynecologists who are able to put pre-operative and non-operative FTM clients at ease during pelvic examinations, mammography technicians who are comfortable with masculine-appearing MTF patients, and urologists and gastroenterologists who are knowledgeable regarding gender variance and anatomic incongruity. It is often useful for therapists who provide services to transgender clients to develop a referral network of welcoming medical and mental health providers. Although there is currently no board certification available in transgender medicine, most physicians (and therapists) who devote a substantial proportion of their time to transgender practice are members of the Harry Benjamin International Gender Dysphoria Association, and can be located through that organization.

The remainder of this chapter addresses clinical issues in the mental healthcare of transgendered persons and their families.




Transgendered persons represent an emerging minority population in North America and the world. Although mental health professionals currently in training will almost certainly to be asked to provide services for clients with “non-traditional” gender identities in their future practices, few graduate programs currently include transgender mental health care in their curricula. This section provides a brief introduction to mental health practice with transgendered clients, including an overview of common clinical presentations; evaluation; diagnostic issues; therapy during the gender transition process; terminating therapy; multidisciplinary practice; and an introduction to the professional organizations and standards of care associated with transgender medical and mental health service provision.




The Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA) Standards of Care

HBIGDA is best known for its standards of care, which are recognized throughout the world. However, they are also the source of a significant amount of controversy within both the transgender and professional communities. Among other things, the standards require mental health care and written endorsement from mental health providers as a condition for access to hormonal therapy and surgical sex reassignment, on the grounds that these procedures are permanent and profoundly life changing. The standards also require a period called the real-life experience, in which the individual is required to crosslive 24-hours a day, functioning as a member of the new gender, before genital surgery is undertaken.

The Harry Benjamin standards place the mental health professional in the role of gatekeeper. Understandably, this can cause resentment in transsexual clients who desire hormones and surgery and must convince a therapist to authorize access. Unfortunately, the standards of care do not have an empirical basis; that is, although there is a strong feeling among clinicians that adhering to the standards results in better outcomes than providing treatment on demand, there are currently no data which either confirm or disprove that opinion.

In late 1998, HBIGDA introduced standards which were considerably different from previous versions. Furthermore, the revised standards were not brought before the general membership of HBIGDA for a vote. It remains to be seen whether the worldwide professional community will follow these standards in the same way they embraced earlier revisions.



The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, currently in its 4th edition, provides a comprehensive listing of diagnostic criteria for hundreds of mental disorders. Insurance companies typically will not provide reimbursement for counseling or other mental health treatments unless the claim includes a DSM diagnostic code. Clients who do not meet the diagnostic criteria for a mental disorder do not receive funding for counseling or therapy.

Gender Identity Disorder (GID) and Transsexualism first appeared in the DSM-III in 1980, just as homosexuality was removed. In DSM-IV, the diagnosis Transsexualism was replaced by the more generic Gender Identity Disorder. Both transsexuals and transgenderists may be diagnosable with GID (see Table I), provided that they are experiencing substantial intrapsychic conflict, or if an important aspect of their social functioning is significantly impaired.

The DSM-IV also contains the category Transvestic Fetishism, which is limited to heterosexual or bisexual males who obtain erotic gratification from crossdressing. Many male-to-female transsexuals do report a history of transvestic fetishism. However, they should not be given this diagnosis; nor should transvestic fetishists (or other persons) who occasionally fantasize about being a woman be given a diagnosis of GID.

Opinion is divided about whether GID should be removed from the forthcoming DSM-IVR. Many transgendered and transsexual people, as well as many professionals, believe that a non-normative expression of gender, per se, is in no way pathological. Further, since many insurance companies exclude coverage of all medical and psychological treatment associated with GID, this diagnosis may not confer a financial advantage, and may serve only to stigmatize the individual. Others argue that inclusion of GID in the DSM holds out a promise of insurance reimbursement, without which many transsexual and transgendered people cannot hope to pay the considerable medical expenses related to transition to a new gender role. (However, because of the stress associated with gender variant living in an often hostile social environment, many otherwise healthy people will also qualify for another diagnosis which is recognized by the DSM-IV, such as dysthymia, anxiety, or an adjustment reaction.)


Differential Diagnosis

Gender Identity Disorder should be reserved as a diagnosis only for those who are extremely conflicted about their gender identity. Only the most pervasive feelings and behavior are suitable for diagnosis of GID, and only when they cause significant distress or impairment in social functioning (See Table 1).

Table 1: DSM_IV Diagnostic Criteria for GID

Table 1

DSM-IV Diagnostic Criteria for Gender Identity Disorder


A. A strong and persistent cross‑gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is the other sex

(2) in boys, preference for cross‑dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

(3) strong and persistent preferences for cross‑sex roles in make‑believe play or persistent fantasies of being the other sex

(4) intense desire to participate in the stereotypical games and pastimes of the other sex

(5) strong preference for playmates of the other sex

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.


B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis. or aversion toward rough‑and tumble play and rejection of male stereotypical toys, games, and activities; in girls. rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.


C. The disturbance is not concurrent with a physical intersex condition.


D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Code based on current age:

302.6   Gender Identity Disorder in Children

302.85 Gender Identity Disorder in Adolescents or Adults


Specify if (for sexually mature individuals):

Sexually Attracted to Males

Sexually Attracted to Females

Sexually Attracted to Both

Sexually Attracted to Neither


 302.6 Gender Identity Disorder Not Otherwise Specified

This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include

1. Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria

2. Transient, stress‑related cross‑dressing behavior

3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex


Source: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (1994). WashingtonDC: American Psychiatric Association.

Most transsexual, transgendered and cross-dressing persons are mentally healthy. Others may bear the psychological marks of keeping their natures secret from the world for decades, or for having been institutionalized or physically or sexually abused because of gender-nonconforming behavior. Some transgendered clients have psychopathology which has come about because of the way they have been treated by an intolerant society (e.g. post-traumatic stress disorder). Of course, individuals may also have one or more mental illnesses which are quite unrelated to the gender identity issue.

A number of psychiatric conditions can result in symptoms which can be misdiagnosed as GID. These include schizophrenia, body image disorders, bipolar disorder (especially in its manic phase), obsessive-compulsive disorder, borderline personality disorder, ego-dystonic homosexuality, and (rarely) malingering. Obsessive crossdressing has been reported as a result of brain damage, especially in the temporal lobe area. It is necessary to screen for these and other conditions when a potentially transgendered client presents for treatment.

If there is a long history of transgender feelings or behaviors predating the onset of other diagnoses, one can be fairly certain that the gender identity issues exist independent of them. Because the other diagnoses may be exacerbating or masking the transgender issues, it is important to stabilize co-occurring conditions while continuing to evaluate the transgender concerns.




Transsexual, transgendered and cross-dressing persons present to mental health professionals with a variety of goals and needs. The transgender or transsexual client who consults a mental health professional may be asking for help in dealing with the frustration of living in the original role or the many stresses associated with a change of gender role; attempting to gain a better understanding of his or her transgender nature and life options; seeking authorization letters for hormonal therapy or sex reassignment surgery, as mandated by the Harry Benjamin Standards of Care; asking for help with a life issue totally unrelated to his or her transgender nature; or presenting with a mixture of issues. Most often, however, the individual will be seeking help to deal effectively with his or her gender identity issue. Looking into this issue may or may not eventually lead to a decision to change gender roles on a full-time basis, or to have surgery.

Several visits are often needed to complete a thorough assessment and clarify the expectations of both client and therapist. This section will discuss the initial assessment, the establishment of treatment goals and expectations, and the comprehensive evaluation.



The clinician must carefully evaluate the client in order to determine how best to proceed. Why has he or she presented at this time? What does he or she hope to gain from therapy? Is he or she in crisis? If so, then immediate action may be required to ensure the physical and psychological well-being of the client before a more comprehensive evaluation is undertaken. Most clients will of course not be in crisis, and will readily provide an introductory description of their reasons for seeking therapy.

It is important to evaluate the “whole client” and to avoid drawing premature conclusions, which can assign a diagnostic label which the client may find difficult to modify in the future. For example, a client may enter therapy as a self-identified transsexual, but discover that periodic crossdressing or nonsurgical crossliving is as far as he or she wants to go. If the therapist has already accepted the assumption of transsexuality, it may be hard for the client to retreat from it.

Transgendered and transsexual clients have often “grown up with a secret”, i.e. have of necessity hidden their gender variant self-identity since childhood or adolescence. This can result in feelings of intense rage, shame, or guilt, which are often contained until the individual becomes overwhelmed and seeks therapy. Consequently, even in individuals who seem calm, initial assessment must address the degree of risk for suicide and other precipitous action. It is critical to ask formal mental status questions, unless the preceding portion of the interview has clearly demonstrated that these are unnecessary. The client should be queried about his or her immediate concerns and asked,“Why did you decide to be seen NOW, instead of yesterday or next week?” The therapist should ask about the vegetative signs of depression and the common symptoms of anxiety, while concurrently attempting to create a reassuring milieu.

If the therapist anticipates a need for psychiatric consultation, he or she can request a psychiatric evaluation during a first appointment, or may require that the client see a psychiatrist as a condition for beginning treatment.


Establishing Treatment Goals, Expectations and Limits

The therapist should review the expectations for treatment, provide reassurance regarding confidentiality and discuss the therapeutic process, as a therapist would with any new client. If possible, the first appointment should be ended with a mutual understanding of the goals of the next two or three sessions. The first several sessions typically include exploring personal history and relationship patterns and constructing a gyno/ecogram. The client should be asked his or her reason(s) for entering treatment and his or her initial expectations and goals for treatment.

Perhaps unfortunately, the therapist letters required by the Harry Benjamin Standards of Care can become the major focus of treatment. Sometimes the client will demand a letter immediately. The therapist is then cast in the role of gatekeeper, withholding the letter until the client has complied with the waiting period and other requirements of the Standards of Care. This creates a dynamic which can be extremely damaging to the therapeutic relationship. Consequently, the letter must be negotiated. The letter should not be used as an incentive to force the client to conform to the therapist’s wishes, but neither should it be given indiscriminately. During the first session, the therapist should bring up the issue of the letter, if appropriate, and negotiate with the client. Upon successfully concluding an agreement, a verbal or written contract can be devised, and should be adhered to by both parties.


Comprehensive Evaluation

Once the initial assessment has been completed and the therapist and client have agreed to go forward with treatment, it is advisable to obtain a more extensive history. This may require another two or three sessions, but is time well-invested.

The geno/ecogram should include the extended family of both the individual and the spouse or partner(s), if the client is in a partnered relationship. It is often useful to ask for several adjectives to characterize each person and his or her relationship with the client. The therapist can ask about friends, neighbors and co-workers, and end by inquiring whether there are other people who are or were important in the client’s life.

A mental health history should be taken. Has the client seen a mental health professional before? Were there any psychiatric hospitalizations? Suicide attempts? Why was treatment sought, and what was its outcome? What is the mental health history of family members? The therapist will need to decide if there is sufficient reason to obtain records from previous treatment. If so, it will be necessary to obtain a signed release of information from the client.

It is important to determine the client’s feelings about past interactions with mental health professionals. All too often, transsexuals, and other gender-variant persons report that prior attempts to obtain help for their gender identity issues were disillusioning and that therapists were actually obstacles to treatment. If there is such a negative history, the therapist will need to work to gain the trust of the client.

An individual and family health history should be obtained. Is the client healthy? Has he or she had a recent physical examination? Have their been any hospitalizations or surgeries? Does he or she have any diseases or complicating medical conditions? If so, are they being treated? Does the client take any medications? Is there a need for HIV testing, and has the client been tested?

If there are health concerns such as diabetes, heart disease, or HIV, they may make it difficult or impossible for the client to obtain desired medical treatments such as hormonal therapy or surgery. The therapist should discuss this possibility with the client and help the client work through his or her feelings about the impact of the health concern on transition. It may also be important to obtain medical consultation early in the therapeutic process.

A legal history should include juvenile problems and adult legal involvements, including divorce and custody issues. Were there any arrests or incarcerations? Is there a police record? Are there any indications of a substance abuse problem? Has the client been involved in any kind of illegal activity? If so, is it related to the client’s transgender status (i.e., has the client faced discrimination which has made it impossible to maintain employment and forced him or her into sex work?). If a transgendered person has been taken into police custody for any reason while crossdressed, it is important to pursue a trauma history in as gentle and supportive a manner as possible.

The client’s religious beliefs and background should be determined. Many transgendered clients experience tremendous internal conflict associated with religion, and often benefit from contact with a peer support group. In that setting, the client is likely to encounter other transgendered persons who share their religious struggle.

Substance abuse is always a risk in individuals who are highly stressed. Consequently, a substance use/abuse history should be obtained. Has the client been previously or currently engaged in the misuse of alcohol or other drugs? Has he or she ever been arrested for use of illegal drugs, or entered a treatment program? Do other family members have histories of substance abuse?

What is the client’s education, employment and military history? Does the client possess college degrees, professional licenses, or certifications? What type of discharge did the client receive from the military? How is the type of work which the client performs likely to affect the transition process? If the client is transsexual or pursuing full-time transgendered living, has she or he initiated the process of legal name change for these documents? Is he or she eligible for Veterans’ benefits?

What are the client’s hobbies and interests? What sort of social life does he or she have? What sort of support system does he or she possess? How will the support system be impacted by gender transition? Will the client lose friends, family, or a job? Will he or she be excluded from church, school, or social organizations? Does he or she have friends, a support group, or other sources of support in the new role?

It is also important to take a sexual history. Do other family members show atypical sex or gender behavior? Does the individual have a history of fetishistic arousal to crossdressing? Does this currently occur? How often does he or she masturbate, and with what fantasies? What is the client’s history of sexual activity? Has she or he ever been in a sexual relationship? Has he or she ever been partnered or married? Have sex partners been male, or female, or both? How does the client feel about his or her sexual life? Does he or she currently have a sexual partner? If so, what is the perception of the partner’s feelings about the client’s gender issue? And finally, what is the client’s sexual orientation? The therapist should keep in mind that a person unsure about his or her own gender identity may be unsure about which exactly IS the “opposite” sex. It can be determined, however, if the client is attracted to males, or females, or both, or neither. Many transgendered people find themselves attracted to other transgendered people.

The therapist should help the client construct a chronology of gender identity issues. When did he or she first become aware of a sense of difference in regard to gender? How did awareness evolve? What were the client’s fears, discoveries, reactions, punishments, beliefs, and feelings about the gender issue? How does the client perceive these issues currently? Has the client ever crossdressed in private? In public? Has the client thought about or actually undertaken body alteration with hormones, electrolysis, or surgery? When did the client become aware of the transgender community? Has there been prior contact with support groups? Is he or she currently attending a support group?

One useful tool which clients can employ to describe both current self-concept and its evolution over time is the Nine Point Gender Continuum (Eyler and Wright, 1997). This schema is based on the premise that, like sexual orientation, gender identity is also best understood as a continuum. As with the description of bisexuality on the Kinsey scale, individuals who consider themselves as being neither fully male nor fully female may describe themselves with a variety of distinct identifications. Furthermore, when discussing gender, it is important to accommodate both “non-traditional” (from a Western standpoint) gender identifications and the “gender agnostic”; that is, the individual who either regards gender as being a very fluid concept, or a notion which is irrelevant to the freely-expressive person. The Nine Point Gender Continuum can also be used by the “gender questioning” person to indicate self-concept at the beginning of therapy, and can be revisited at later times in the therapeutic process. This gender schema is presented in Table 2, and represented in Figure 1.

Table 2: The Nine Point Gender Continuum I

Table 2

The Nine Point Gender Continuum



I have always considered myself to be a woman (or girl).


Female with maleness

I currently consider myself to be a woman, but at times I have thought of myself as really more of a man (or boy).


Gender-blended female predominating

I consider myself (in some significant way) to be both a woman and a man, but somehow more of a woman.



I am neither a woman or a man, but a member of other gender.



I am neither a woman, a man, or a member of any other gender.



I consider myself bi-gendered because sometimes I feel (or act) more like a woman and other times more like a man, or sometimes like both a woman and a man.


Gender-blended male predominating

I consider myself gender-blended because I consider myself (in some significant way) to be both a man and a woman, but somehow more of a man.


Male with femaleness

I currently consider myself to be a man, but at times I have thought of myself as really more of a woman (or girl).



I have always considered myself to be a man (or boy).

Figure 1: The Nine Point Gender Continuum II

Figure 1 

The Nine Point Gender Continuum


                    F          F/m                       GB/F O U B GB/m                       M/f M 

“Female-based” identities     “Non-traditional” identities       “Male-based” identities


How do you perceive your gender currently? (Place a mark at the most appropriate place.)

Have you understood your gender differently in the past?

Do you think that this perception may change with time? If so, in which direction may it evolve?

This may appear to be a daunting amount of material to gather, but a practiced therapist can obtain a reasonably thorough history in two or three sessions. If the client understands that the therapist is gathering an overview in order to identify areas to return to later for further exploration, this will be helpful, especially if the therapist raises a sensitive issue during the history-taking.

As the history is gathered, potential goals for therapy will evolve and become defined. At the conclusion of the comprehensive evaluation, the therapist and the client should be able to come to agreement about areas that warrant further exploration. Issues which are usually prominent during the “middle” stages of the therapeutic process include the transition itself and self-disclosure (“coming out”).


The Therapeutic Process: Gender Transition and Self-disclosure (“Coming Out”)


The Transition Process

Transition is the term used to describe the process of moving physically, psychologically and socially into the gender role with which the trans- person most closely identifies. Many trans clients will find enough satisfaction in lesser measures of cross gender expression to make transition unnecessary. Some may defer transition until a time when their life better supports such a move, such as after children have been raised or employment advancement achieved. However, some clients will be prepared to live full time in the chosen gender role, with or without surgery, and may well be prepared to make major sacrifices to do so.

The medical aspects of transition are discussed in a separate section of this chapter. However, even from the perspective of social interaction, transitioning from natal female to male (FTM) is quite different from transitioning from male to female (MTF). In addition, although there are probably about equal numbers of transgendered people of both natal sexes, (Signorile) currently more MTF transsexuals, transgenders and cross-dressers have publicly self-identified in Western countries.

Gender variant persons who are beginning therapy (and their therapists) should be made aware of the interaction between identified gender, personal valuation and social acceptance. In a society with a paternalistic heritage (such as contemporary Western culture) maleness is more highly valued than femaleness, in most contexts. FTMs often experience a rise in social status and income (without any change in credentials, only in sex), whereas, MTFs are more likely to experience the reverse. Associates and family members may also find the decision of “a man to turn female” harder to understand than an FTM “freeing himself” of the female role. However, the majority of persons who undertake gender transition will experience some degree of censure. For example, an FTM who has previously identified “herself” as a lesbian and developed “her” social outlets in the lesbian community may find the experience coming out as FTM to be a mixture of relief (at expressing his true self) and loss (of his lesbianism). One of the gifts of the transgender community to contemporary understanding of mental health and social context has been to increase social awareness regarding the spectrum of gender and to call cultural perceptions about sex and gender into question.

The impact of social position and earning power also impacts MTF and FTM transsexuals and transgenders at different times during the transition process. Despite recent progress, and the achievement of partial equal rights legislation, women in general have less earning power than their male counterparts. For an MTF, this can result in a lower standard of living, which may come as a shock to the individual. If income changes occur, they may negatively affect the ability of the MTF person to pay for facial electrolysis (which is usually needed in order to negate one of the strongest “male” appearance cues) and perineal electrolysis, which is needed prior to MTF sex reassignment surgery. In most cases, electrolysis represents a time-consuming, painful and expensive process which may require years to complete. Conversely, although FTM persons may begin at a lower income level, and may therefore experience difficulty in paying for therapy and hormonal services, improvement in income or insurance status will often be needed prior to sex reassignment surgery, which is more expensive than male-to-female surgical procedures.

Consistent participation in therapy is necessary prior to the decision to begin hormonal therapy or to seek surgical procedures, as well as when other significant events such as coming out or beginning the first sexual relationship in the true gender are in progress. Although the transition process can often be completed within two or three years, both FTM and MTF individuals in transition will often experience times during which further progress will be delayed, either due to financial limitations or to practical considerations (such as the need for facial electrolysis prior to coming out in the case of an MTF transgender or transsexual with extensive facial hair). This time can be well spent in discussing what it means to the person to be male or female (or some other identity), in identifying and addressing the obstacles which are likely to be encountered in the transition process, and in expanding the individual’s experience and confidence in contra-gender expression. Other, concurrent life issues may also benefit from further attention during these times.

When sufficient medical and cosmetic alterations have been obtained, the process of coming out to the larger society, rather than to the client’s closest friends and family, can begin. Coming out issues are discussed below.


Self-Disclosure (Coming Out)

The coming out process is the very essence of transition. It is truly a process rather than an event, as there are many steps and layers involved. Early in the transition process, the therapist should inquire about the degree to which the client’s transgender behavior is a secret: Who knows (or suspects)? Exactly what do they know? How long have they known? How did they learn about your identity (or behavior)? What is their attitude toward your transgender issues?

The therapist should also attempt to determine the risk for the person precipitously “outing” him- or herself– to, for instance, a supervisor or parent– without carefully weighing the consequences. The therapist may wish to advise the client to defer this step until self-disclosure can be planned for in a way that will maximize the chances of a successful outcome. Concurrently, it is crucial that the therapist avoid giving the impression that transgender status should remain hidden as a shameful secret.

In most cases, it is optimal that the client’s transgender status eventually be disclosed to select individuals; however, the therapist must allow the individual to make his or her own decision, after the ramifications of coming out have been thoroughly explored. The therapist may also assist the client in assessing the risks associated with going out in public in particular settings. For example, a client who goes to a restaurant or mall where he or she is well known, or who ventures into a setting which poses a risk of physical attack or public ridicule, may be exposing him- or herself to a higher degree of consequence than was anticipated.

The lack of childhood and adolescent gender congruent socialization may pose additional, practical difficulties for persons who are just beginning the process of expressing their true selves in public. Male-to-female “novice” crossdressers often lack skill with make-up and style of dress and may not have objective perceptions regarding how they appear to others. The client should be advised to proceed cautiously in order to reduce risk, while concurrently exploring ways of gaining skill and poise through therapy, support groups, speech therapy, etc. The client may be fearful about making contact with transgender social or support groups. If so, this fear can be used to increase self-awareness and to reinforce the realization that the she or he may not be ready for other, even more public steps.

If there is imminent risk of discovery of gender-variant dressing or behavior by a specific individual, the advisability of “pre-emptive” self-disclosure should be explored. Otherwise, it is generally advisable to begin with the person who is most likely to be accepting and to keep this confidence These two factors are critical in selecting whom to tell first. Supportive friends and family are critical in developing a support system. However, support is of limited value if the person cannot maintain confidentiality.

One initial step is often for the client to reveal his or her true gender to a parent or sibling. This revelation will raise its own questions: When will your mother allow you to show her a picture of you “the other way”? When will she meet the you in person as a member of your true gender? When will your father be seen with you in public? How will he adjust to the new pronouns? Even in very supportive family relationships, parents often experience their own grieving process at the loss of the adult child they “always thought they knew”, at the loss of the name they chose at birth. This will be followed by their own coming out, as they tell friends and neighbors and acknowledge the transition with extended family members.

During the coming out process, the client may need to be counseled not to announce intent to “go further” in transition than it is certain that she or he will proceed, or to make promises that he or she may not be able to keep (or that will give away control of their life to another person). For example, a client who is pressured by his mother to promise not to reveal his true self to his father, who is struggling with a chronic illness, may crave acceptance sufficiently that he will promise. But it would be less problematic for the client to say, “I can only promise to take your feelings into consideration, but I will have to make my own decision based on my relationship with Dad.” This will prevent the promise from becoming an additional obstacle in the coming out process.

In a majority of cases, coming out at work is a last step, after the client has taken hormones for an extended period of time, lived most of his or her life outside of work in the gender to which they are moving, and is ready for a legal name change, which would necessitate use of the new name for social security purposes. By then, the individual will have dealt with numerous other transition related issues. If the person was married, they may (but are not required by law to) have gotten a divorce, or redefined the relationship. When other issues have been cleared up first, the client is more free and better equipped to address work issues.

Clients may use the therapy setting as a source of both “reality testing” regarding gender expression decisions, and support during the sequential layers of the coming out process. One additional principle which should be emphasized to the client is that, if hormonal therapy is begun prior to coming out, it must be kept at a level at which the physical changes are not so noticeable that they will force premature disclosure.

Hormonal therapy effects different people differently. Some people react very slowly and gradually. Others blossom out in breasts or beard so quickly that it may force a more rapid outing of the true self. Therefore, the client should be close enough to this step that the physical changes will not precipitate a crisis. Some clients will benefit from low doses of hormones that do not precipitate rapid physical changes, but this varies considerably from one individual to the next. A physician who is experienced in transgender medicine should be able to offer a range of possible approaches to hormonal transition. Throughout the transition process, consultation between the therapist, client, and physician is advisable.

After the desired physical changes have been obtained and the coming out process is reasonably complete, the transgendered or transsexual person will eventually desire termination of the therapy process. This is discussed in the following section.


Terminating Therapy

Readiness to terminate therapy will depend upon the needs of the individual client and the treatment goals (which may have evolved during the therapy process). The extent and ease of the client’s gender journey will also be major determinants in this regard. For clients who have undertaken full gender transition, practical considerations (e.g. whether and how to begin using the restroom of the other sex) may have been addressed along with intrapsychic and interpersonal issues earlier in treatment. Before the termination of therapy, socialization into the new gender role, including employment stability, should be reasonably complete. Further, if the client has chosen full transition with genital reconstructive surgery, issues which have been previously addressed may require further attention post-operatively, and additional material may need to be brought to the therapy sessions before termination is achieved.

The adjustment process for persons who undertake full gender transition is in some ways analogous to a period of adolescence (although fortunately with the benefit of greater life experience prior to its onset). Varying the frequency of therapy sessions can be a useful technique as the client passes through different “stages” of the transition process, sometimes achieving a “plateau” and at other times contemplating major life change. Alternation between regular and less frequent sessions may be arranged several times before the therapy process is complete, and the continuing availability of the therapist for follow-up visits once or twice annually may be useful during the years immediately following the completion of transition. Nevertheless, the sense of closure is important. The client and therapist have shared a remarkable journey together, and can arrive together at the best plan for closure of this relationship.


The preceding portion of this chapter has described many of the issues involved with individual transgender clients. It is also useful for mental health professionals to be familiar with the couple and family dynamics which often provide a context for the self-disclosure of transgender. These are discussed in the following section.




One of the most important aspects of the transgender journey is “coming out” to family members, partners and close friends. This step almost always precedes the decision to inform employers and co-workers, and may predate the real life experience by months or years. Transsexual, transgendered and cross-dressing persons who are not in a partnered relationship and do not have children will nonetheless usually need to come out to their family of origin: siblings, parents and other close relatives. For persons who are married, partnered or parenting, this process may become even more complex. This section addresses issues which are frequently encountered in intimate partnerships, with or without children, in which one partner discloses to the other the fact of his or her true gender identity.



Couples and families will often present to a therapist in the wake of the disclosure or discovery of gender variance within the partnered relationship. Even if a prior therapeutic relationship exists with the transgendered partner, attention must to be directed at this time to the partners and families whose own concerns may seem to be eclipsed by the presence of transgender in the relationship or family. The context of the discovery is also a crucial therapeutic consideration. When, how and from whom the significant other or family learns that transgender is a part of their lives is fundamentally important. The partner may be dramatically influenced by these factors in her ability to grasp information, understand this change, then respond and integrate the presence and reality of transgender uniqueness into her own life and that of the family. For many, grappling with this new information can be stressful. Initial responses can resemble post traumatic stress in those individuals who struggle with the discovery.


Female Partners and the Discovery of Transgender

Psychotherapeutic experience with the male partners of female-to-male (FTM) or male-to-female (MTF) transgenders is currently very limited. One of the authors (SSC) has conducted retreats and discussion groups for partners of transgendered persons for sixteen years. Therefore, this section will report her experience with female partners of MTF and FTM individuals, with or without children.

The female partner of an MTF husband, in a “traditional” marriage, may feel challenged and conflicted in her multiple roles in the relationship and family as wife, lover, mother, and helpmate. She also may have her own career or employment responsibilities, community and religious activities and responsibilities. It is generally observed that she will now, also, assume the larger responsibility of the necessity of “keeping the secret,” as her confidence in her husband’s judgment about discretion may be eroded, particularly if he is choosing public behaviors which risk being identified or discovered. She will often recognize, and may live in fear of, the unforgiving attitude and punitive behavior of society toward people it considers variant or deviant (Goffman, 1963).

When the wife or lover learns of the partner’s transgender identity is a crucial factor in the adjustment process. When transgender identity is known in the initial development of the relationship, whether heterosexual or lesbian, the couple can more satisfactorily integrate and develop their bond together. Discovery of transgender after the relationship has been established is considerably more complex (Talamini, 1982). Factored into the couple’s therapeutic process must be an understanding of how long the relationship has been established; whether or not children are present in the family; their ages, as well as the situation in which discovery took place and how she emotionally experienced learning of the transgender aspect of her partner. Discovery of transgender after the dyad has had years of shared experiences can result in her predictable experience of emotional trauma, most specifically initial feelings of betrayal, revulsion, anxiety, paranoia, and intense competition.

How and from whom she learns will also influence her response. If he initiates the process of disclosure, and reveals his transgenderism in an honest and truthful way, many couples will work toward resolution over time, often with strong indications that the couple will stay together long-term (Brown, 1998). If the female partner discovers the clues or actual evidence herself, she may experience more intense feelings of betrayal, humiliation, shame, and revulsion. She may experience the desire to flee, or may actually abandon the relationship, or, in her fear, rage and betrayal, she may “out” her partner deliberately as retaliation. This reaction is potentially harmful to the entire family system, as once the “secret”is out, there is no recovery, and the couple and the family may be placed in a compromising and defensive social position, especially if the “outing” has occurred in particularly negative circumstances. More usually, the wife will fear exposure, social retaliation, and loss of her sense of, and will therefore work to maintain the feared and deeply resented secret of transgender.


Coming Out (Or Not) In Families With Children

The coming out process is often more complex in families with children, especially if transgender is still a secret from certain members of the family or others in the community (such as may be the case when the husband/father cross-dresses but is not actively involved in pursuing “public” gender transition or sex-reassignment surgery.) Couples often seek professional assistance in grappling with these decisions. The choices about coming out must be made individually by each couple; considerations for the dyad (and therapist) include previous and current family construct, values, and styles of communication (Docter, 1988; Zuger, 1988, 1989). The ages of the children, communication patterns between parents and towards the children, prejudices, biases, social awareness, honesty and truth-telling are other key assessment issues. In general, adolescents and pubescent youth are considered to be more vulnerable to negative emotional responses than either younger children or older teenagers, as they themselves are personally experiencing enormous physical, hormonal and emotional changes and challenges to their bodies, feelings, gender identity and sexual orientation.

Many families choose to wait until their children are older (e.g. late teens or twenties); some families decide to be open and to develop a sense of understanding and coping skills together; and some choose not to involve the children or other parts of the family at all, or as long as they can manage such privacy.


Responses to Transgender: Emotional Evolution Over Time

Female partners of MTF or FTM persons may respond to the disclosure or discovery that their partner is transgendered with any of a variety of emotional responses and behaviors. These include feelings which may be described as a deep sense of betrayal, violation of trust, fear, competition with this “new” female (if the disclosing partner is MTF), shame, curiosity, anxiety, repulsion, embarrassment, isolation, challenge, sexual arousal, eroticism, desire to be supportive, sexual dysfunction, aversion, increased self-imposed responsibility to the family, cooperative determination and feelings of abandonment. There is an enormous potential for wide array of feelings and behavior which may vacillate time, depending on the circumstances and life situation.

In addition, the female partner of a transgendered individual may experience further challenges to her own gender identity and sexual orientation. Most female partners of MTF persons identify themselves as heterosexual without a self-concept of being partnered with a woman. Indeed, most MTF individuals are attracted to women after transition as well, and some continue to refer to themselves as heterosexual, despite the fact that they are now women partnered with women. Similarly, the majority of partners of FTM are female with a lesbian self-identity and do not have a self-concept of being partnered with a male. Whereas the partner of an MTF may experience feelings of betrayal of the couple’s commitment to each other, or to a “traditional” marriage, the partner of an FTM may experience rejection from her lesbian community and may actively grieve her perceived loss of lesbianism which is her own true identity (Devor, 1998). In some cases, she may be pressured by her FTM partner to tell others that she is heterosexual, so that he can be regarded as a “real man”.

Some female partners may be attracted to such challenges and explore the flexibility of their own gender identity, expanding their own self-concept of masculinity/femininity. Some bisexual women may enjoy the “mix” of developing gender characteristics within the same partner. However, many women respond to their partner’s gender transition (or exploration) more negatively, or with stoicism. (Having a transgendered partner, is not, after all, the basis on which their relationship was initiated.) Most partners of transgendered individuals will express concern about how far the transgender journey will go. Will it include taking hormones and eventual surgery, including genital surgery? Will I be able to allow myself to stay in the relationship if these events occur? (It should be noted that, although some couples do not stay together during the gender transition process, the widespread belief that sex reassignment surgery will invalidate a legal marriage is, in the United States, false. Marriages end if the participants wish to terminate them, and can not be ended by the state due to gender transition.)


Sexual Intimacy in Transgender Relationships

If the transgendered partner has been open with his/her female partner since the early stages of the relationship, then the gender journey may be experienced as a desired component of the sexual partnership, “freely chosen” and erotically embraced. However, when women enter romantic or committed relationships on the assumption that gender variance is not present, only to discover this reality at a later time, psychological stress and sexual dysfunction may occur.

Female partners of MTF transgendered individuals may experience a decrease in sexual desire, usually as a result of concerns and anxieties about the relationship. During the times of disclosure and transition, she may inadvertently neglect her own health, including sexual health. The most common informally self-reported sexual dysfunction of women after discovery of transgender is secondary anorgasmia. In the beginning, she may not be able to tolerate feminine expression by her male partner during intimacy, especially when the MTF partner refers to herself as a lesbian, experiences feminine feelings, and wants to be made love to as a woman. Other partners may be sexually aroused by the sexual opportunities presented by challenging traditional gender norms (Docter, 1988; Brown, 1998; Cole, 1998).

For the female partner of an FTM individual, the sexual issues may be quite different. She has been sexually active with her female partner in a lesbian relationship and may not be prepared to have familiar intimacy activities suddenly considered “off limits” such as sex play involving her FTM partner’s breasts and female genitalia. It should also be noted that persons who are experiencing gender transition are not homogenous in their own sexual responses. Some FTM and MTF individuals “divorce” their genitals, and consider them “off limits” for sexual pleasuring until after sex reassignment surgery. Others are accepting of, or erotically enthusiastic about their genital “incongruence”, especially if surgery is not desired or is far in the future.

In relationships in which the partner’s transgender identity is unexpected or undesired, other more serious sexual and psychological sequelae may result. Women may become so distracted by the new changes in their relationships that they neglect their own medical health (pap smears, breast exams, and general well-care). They may present symptoms of depression and post-traumatic stress disorder, especially when feeling enormous responsibility to “guard the secret” from the family, friends, employers, church and community. Serious consideration must also be given to the female partner’s own previous sexual history and life experiences. These may influence her ability to accept and learn about her partner’s true gender identity, particularly if she has previously experienced betrayal in childhood or adolescence through family alcoholism, divorce, incest, sexual exploitation, or rape (Cole, 1998). If she has experienced any of these issues in her youth, her reaction to the discovery that her husband or partner is transgendered may resemble compounded post traumatic stress syndrome.


Response from the Mental Health Professions

For all of these issues, partners and couples often benefit from counseling or psychotherapy with mental health providers who have training and experience with transgender issues, and who are knowledgeable about the impact which non-traditional gender identities may have on partners, families, employment and community (Cole, 1998). Therapists and physicians who are experienced in transgender healthcare are currently not available in many areas, although the Harry Benjamin International Gender Dysphoria Association (HBIGDA) and other organizations have provided increased professional cohesion in recent years. In the future, additional outreach efforts to network with other members of the professional community will promote medical and mental health well-care for transgendered individuals and their partners and families.

Partners frequently benefit from participation in partner /significant other support and social groups which can offer empathy, advice, problem solving opportunities and personal sharing of feelings and concerns. The opportunity to talk about feelings about transgender in a nonjudgmental environment can be extremely important, and is usually not available to the partner among her own personal confidants and friends (Weinberg & Bullough, 1998).


Other Issues in Transgender Therapy

North American families have usually been created around the dominant Western cultural paradigm in which gender is viewed as a dichotomy (women and men) which corresponds to the two sexes (female and male). When families learn that a transgendered person exists within their own family system, the response is often predictable, and reflective of the social values of the culture in which they live (Rosenfeld & Emerson, 1998). Hence, the struggle to learn more about their transgendered family member may include elements of behaviors such as denial and grief.

Although families tend to move through recognizable stages as they learn to accommodate these changes, the course of adaptation does not usually follow the theories of grief, death and dying of Kubler-Ross (Kubler-Ross, 1969) in a linear fashion. Progression through the stages of denial, anger, bargaining, depression and acceptance is rarely direct and linear. Instead, the movement more closely resembles a kaleidoscopic journey in which individuals react and respond independent of one another, and in different stages, depending on the circumstances. The emotional journeys of families are highly individual; individual members will have different experiences in each stage, and will not necessarily experience these transitions at a similar pace.

When disclosure within the family is not managed in a constructive manner, threats and unrealistic boundaries may be imposed on the newly identified transgendered family member. Spouses and families may threaten rejection or force the transgendered person to leave. Partners may threaten to leave or may actually flee. Family mental health therapy made available to such partnerships or family systems may help manage feelings of loss and anger, prevent unnecessary family trauma, and mitigate long term guilt, shame and grief for all parties concerned. Family therapy can also help the family attain a level of stability which will allow all members of the family to function normally and can assist the family unit in learning necessary problem solving skills.

From a therapeutic standpoint, it is crucial for the partner and family to finally be able to abandon the desire to change the transgendered individual and accept the reality of the situation. This does not mean that approval always accompanies acceptance, but it does allow the family and partners to move on in their lives. Brown notes that, with regard to a women with “closeted” transgender or cross-dressing partners, “The overall trend observed was for greater acceptance over time, assuming that the woman obtained accurate information and access to other women living in similar circumstances” (Brown, 1998; p.364).

Family therapists can positively influence the family struggle and journey as it grapples with possible disruption of the unit, new knowledge which is often uncomfortable and anxiety-producing, and an abiding concern about what others will think in its attempt to integrate information which was previously incomprehensible and unknown (Cole, 1998). In addition, many families report gratitude and high satisfaction from association with peer support groups, which offer the opportunity to discuss, learn and process with others who are also experiencing the journey of transgender.

Participation in support groups is particularly relevant for families of children and youth who exhibit non-conforming gender behaviors, or who may be emerging as transgendered. Transgendered young people who are facing the pressures and confusion of gender-specific roles which may be contrary to their self-identity need love, support and education. Family support is extremely important, but may be difficult for parents and siblings to provide as they themselves struggle with a complex and unfamiliar situation. Parents may experience isolation, disbelief, shock, anger and shame. Groups such as PFLAG (Parents, Families, and Friends of Lesbians and Gays) often include transgendered members and services for families of transgendered youth. Networking with other parents may be highly effective in helping the family to gain comfort, understanding, confidence and practice in effective coping strategies while striving to learn, accept, accommodate, and embrace their transgendered youth (Xavier, et al., 1998). Therapists working with transgendered adolescents can facilitate the process of family acceptance and functional normalization through referral to supportive community groups. Participation in groups can also complement concurrent family therapy, the goal of which is to enhance the family efforts to facilitate its own journey toward understanding and resolution, while supporting and respecting the transgendered child’s unique personal journey.


Conclusion and Future Directions

An awareness of the variety of human gender expression and knowledge of the individual, dyadic, and family dynamics which accompany the transgender journey can provide the mental health professional with a foundation from which to assist transgendered persons and their loved ones. Due to the societal complexities which currently surround gender variance, it is essential to consult with colleagues who are experienced in this area of practice.

This chapter focuses on female partners only because clinical experience with male partners of MTF transgenders is very limited, and experience with husbands and male partners of FTM persons is nearly non-existent. This should not be understood to imply that other transgender dyads do not exist, but only that they are well-studied. Non-transgendered partners reflect the entire continuum of gender identity themselves. Some partnerships consist of two transgendered persons (MTF and FTM, MTF and MTF; FTM and FTM); the previously described MTF and female; FTM and female; FTM and gay male; MTF and gay male, MTF and heterosexual male, and FTM and heterosexual male. In addition, many FTM persons have children from previous long-term heterosexual or lesbian relationships. Furthermore, although cross-dressing was once defined as strictly an MTF phenomenon, it is clear that some women also cross-dress to express gender variance or for erotic enjoyment. As the field of transgender studies matures, it will behoove mental health professionals to stay informed with respect to emerging issues for individuals, partners and families.




Many therapists who provide services to transsexual, transgendered and cross-dressing clients do so as solo practitioners, making referrals, as appropriate, to medical colleagues for hormonal or surgical therapies. An alternative approach, introduced by Richard Green and John Money in 1969, is practice within a multi-specialty transgender healthcare team.

In the 1970s, there were approximately 40 university-based “gender programs” in the United States (Denny, 1992). Subsequently, transsexual medical care shifted largely to the private sector, with most providers offering either mental health or surgical services exclusively. Until recently, these programs neglected transgenderists—that is, people who crosslive full-time without seeking sex reassignment surgery. Cross-dressers have also experienced difficulties in obtaining needed medical services in a welcoming environment.

The pattern most commonly seen today is for independent practitioners to offer specific services such as counseling, electrolysis, hormonal therapy, sex reassignment surgery, breast augmentation or reduction and to refer their transsexual and transgendered clients for other medical or mental health services. Transsexuals, transgenderists and serious cross-dressers have learned to shop “a la carte,” selecting service providers based on price, reputation, services offered, and location.

The chief advantage to this a la carte approach is that the individual becomes his or her own case manager. He or she can choose from a menu of services and service providers, shopping for price or competence in much the same way that he or she might purchase a new car. This is also the chief disadvantage, for many transsexuals are not emotionally or intellectually prepared to undertake the difficult task of coordinating their transition. In addition, accurate medical knowledge regarding the safe use of contra-gender hormones has not been widely available, and many transgendered persons, seeking a rapid transition, have suffered medical complications from taking hormonal preparations inappropriately, or from multiple simultaneous prescriptions.

Another disadvantage of the a la carte approach is that the various professionals who treat the client rarely have a chance to interact with one another. There is therefore insufficient opportunity to fully coordinate care, and care providers will of necessity make treatment decisions with less than full knowledge of the clientís situation. Furthermore, significant health concerns may be overlooked or go unaddressed. Often, services are delivered far from the client’s home, in another state or even out of the country, making follow-up difficult. This is of especial concern with regard to surgery, which can be followed by a variety of complications. If treatment-related health problems or complications develop, the treating physician may be unfamiliar with clientís history or the procedures used, and it may prove difficult to consult with a previous physician who practices in a distant time zone.

A third problem with the a la carte approach is that treatment of gender identity issues is a highly specialized field which requires particular competence. Some providers have only limited experience with gender identity issues. They may draw from personal experience, extrapolating about all transgendered people from contact with a very small number of individuals, or consulting textbooks which contain obsolete or harmful information. Countertransference is common among health providers (Franzini, & Casinelli, 1986; Green, 1969), and it is not uncommon for transgendered people to find themselves in the care of providers who try to “cure” them of their transgender feelings or who do not treat them with respect and recognition of their personal autonomy.

Under the a la carte approach, general health care is often overlooked both by transgendered people and by their care providers. The focus is often on crossliving, hormones and surgery, to the exclusion of cancer prevention, cardiovascular risk-reduction, and health maintenance services. Many transgendered persons go years without medical checkups, or avoid treatment of serious health problems because their genitals are not consistent with their gender presentation, or because they fear being questioned about an incongruous appearance when undressed in the examining room. Cross-dressers also may avoid care due to conflict regarding being asked to explain societally non-conforming patterns such as body hair removal (or non-removal) or “contra-gender” tattoos.

There are a number of advantages to the provision of services by an interdisciplinary team. The most important is that all services are provided at a single institution. The client can come to one location for preventive care, treatment of chronic illnesses, mental health services, speech (voice) therapy, electrolysis, facial plastic surgery, breast augmentation or reduction, sex reassignment surgery, and vocational counseling, all of which can be coordinated by a case manager or the primary care physician. Services are less likely to be duplicated, as they might be with the a la carte approach, and a wider range of health needs can be addressed in an integrated fashion.

Currently, such services are provided in the university sector by the University of Michigan Medical Center Comprehensive Gender Services Program in Ann Arbor. A number of other centers provide a variety of services, but do not yet offer comprehensive health care to their transsexual and transgendered clients.

A historical disadvantage to gender programs has been compromise of the autonomy of the transsexual client. Actions into which transsexual persons have historically been coerced by gender programs as a condition for receiving services have included divorce, participation in research projects, conformance to stereotypic (e.g.”Barbie and Ken”) gender presentations, heterosexual post-transition sexual orientation, making firm commitments to alter their bodies with sex reassignment surgery, and leaving successful careers to take “gender appropriate” jobs. Unfortunately, a recent survey (Petersen & Dickey, 1995) showed that throughout the world transsexuals continue to be coerced into specific outcomes by gender programs. Petersen & Dickey’s survey also revealed that some centers routinely exclude transsexuals they feel are too old, too young, too ugly, and those they feel will not “pass” well as members of the new gender. Unfortunately, some programs also still require their transsexual clients to cross-live full time as a condition for initiating hormone therapy. This practice is disruptive of the lives of transsexuals and places them at considerable danger for hate crimes because without the masculinizing or feminizing effect of a period on hormones, they tend to be noticeably crossdressed in public. Since 1991, the American Educational Gender Information Service (AEGIS) has condemned the practice of enforced crossliving, and recently released a position paper stating that the practice of requiring crossliving as a condition for hormones is unethical.

Several centers in the United States have broken with the unfortunate and unethical traditions of their predecessors, and unfortunately, some of their contemporaries. The University of Michigan Comprehensive Gender Services Program and the Program in Human Sexuality at the University of Minnesota allow and encourage their clients to come to their own decisions about whether to modify their bodies and take great pains to ensure their clients are treated in an ethical fashion. Other North American programs have modified their requirements and procedures over the years, bringing them into line with current common practice.

Mental health practitioners who care for transsexual, transgendered and cross-dressing persons should be alert for abuses of their clients’ personal autonomy, and should check to be sure all medical needs are met. Discussion of the client’s previous experiences in the medical sphere should be routinely addressed in therapy, and the treating physician should communicate with previous physicians or the previous program case manager, when this is desired by the client.


Further Options

Therapists who do not engage in team practice will be best served by maintaining professional contact with other professionals who treat transgendered clients and their families. The American Association of Sex Educators, Counselors and Therapists, and the Harry Benjamin International Gender Dysphoria Association are two professional organizations through which such networking, support, and continuing education can occur.



Transsexual persons, transgenders, persons who claim non-Western gender identities, and who cross-dress are visible in larger numbers than has previously been true in North America since the time of European settlement. Transgender behavior has existed since prehistoric times, and is not evidence of mental illness; nonetheless, transgendered persons remain stigmatized in contemporary society. Furthermore, the current process whereby transsexual and transgendered persons obtain hormones mandates the involvement of the mental health professions. Until such time as gender variant persons are allowed to develop naturally during childhood and adolescence and to live autonomously and without fear during adulthood, the skills of psychologists, psychiatrists and social workers will be needed in service to this population.



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1 Given the diversity of personal expression and self-perception within the transgender community, historical terminology and categorization are currently being questioned. For the purposes of this chapter, the term “transgender” will be used to describe an individual who lives (full- or part-time) as a member of a gender which is incongruent with his or her anatomic sex, usually with hormonal support. “Transsexual” will be reserved for persons who also seek sex reassignment surgery.