Ms. Chubb is a therapist with the Suffolk Psychiatric Group, 2470 Pruden Boulevard, Suffolk, VA 23434. She can be reached at Maggie.Chubb@gmail.com
Thank you for the invitation to speak with you today. I have been a gender specialist in our therapeutic community for the past twenty years. In my work with people experiencing Gender Dysphoria, I am often asked why do I do this work. Partly it is the challenge of working with people who live a very different life. They live a life they know is not theirs every day. There is a deep pleasure helping folks discover their own authenticity. Therapy becomes a journey of self-discovery and emergence by “baby steps” of testing themselves and evaluating the outcome in preparation for the next step.
Mine is an empowerment model based on seminal work by Arlene Istar Lev in her book “Transgender Emergence.” The examples in this talk come from twenty years of my practice. I will start with a population description in terms of age, intelligence, work, spirituality and concurrent diagnoses. Then I will discuss treatment phases and issues of each phase. I will pause for questions as I speak.
People come to me from sixteen to over sixty years old. Men, women and intersex individuals cope in various ways with being different. They are people in context of families, both families of origin and current; friendship groups, spiritual communities and types of work environment. Depending on their age, each has more or less experience of a society, which does not understand them and often denigrates them.
They range in intelligence from mentally retarded to “rocket scientist.” Another challenge of this work is helping folks with very few resources find ways to express their authentic gender. This is not a cheap path and costs can range from a few thousand dollars for beard removal to many tens of thousands for extensive body modifications. Also, the insurance industry considers gender Dysphoria or other allied diagnoses as not medically justified and refuse to pay for various hormones or surgical treatments. Stringent saving, equity loans n homes and second jobs are all a part of being transgender and desiring physical changes. I use a secondary diagnosis such as depression or anxiety as a medically justified diagnosis for therapy.
Most of my clients work, although some are too young and some are disabled. They have a wide range of jobs. Some choose to enter the military and seek the most dangerous jobs as an attempt to “cure” their feelings and urges. Some marry and have children for the same reasons. Here in Tidewater, VA, they often seek therapy for change as they approach military retirement. Lately, I find many transgender people in the Internet technology field. The Internet has been wonderful for transgender people exploring their self-definition on web sites, chat rooms and blogs. Transgender presence on the web is a community where acceptance id given freely.
Spirituality is an aspect seldom referenced, but is important to explore. Many religious folks exit from their member churches before transition, knowing their changes will not be well received. There are several “welcoming congregations” in the Hampton Roads area such as the Metropolitan Community Church, the Unitarian Universalist Fellowship, Unity and some Episcopal Churches. I have hopes for future inclusion in more churches as transgender people meld into society more fully.
People come to therapy with all their “baggage.” Diagnoses can include dissociation, suicidality, sexual dysfunction, substance abuse, self-mutilation and even intense hostility toward other differently gendered people. Typical diagnoses are insomnia, isolation, dysthymia, anxiety, weight loss or gain and difficulties with work and school. I have seen these and more in the past twenty years. I ask you to think differently about these folks who are so different. In an empowerment model I look at most of these diagnoses as secondary to societal treatment and my clients’ survival modes. Arlene Istar Lev says, “Gender Dysphoria is a natural outcome of living within a culture that has an explicit gender system which associates certain appearances and behaviors with particular gender categories. The mental health field has labeled as pathological all deviations from this rigid system.”
Growing up different is tough and a thorough assessment needs to be made of how they grew up. Family dynamics, school bullying and/or coping, friendship and play modalities are all important. Trauma, as with most folks, determines treatment trajectory. Lev believes that PTSD is often an accurate diagnosis for growing up and living with gender Dysphoria. I talk with my clients around issues of isolation, anxiety, secret keeping, etc. as the Survival Syndrome and encourage them to challenge old dysfunctional beliefs about safety and acceptability.
Lev states three goals to work with transgender folks.
1. Accept that transgender is a normal presentation of human potentialities.
2. Place transgender in a larger societal context of family, friends, work, etc.
3. Focus on the process (baby steps) of transition and on the issues, not on just assessment and referral for surgery.
Those of us who work with Transgender issues belong to an international organization composed of therapists, surgeons, endocrinologists and other disciplines. Originally founded by Harry Benjamin, MD in the 1960’s Standards of Care for Transsexuals have evolved from a very medical model of understanding and treatment to a more client-centered approach over the course of six revisions. Most of the changes came as Transgender activists joined the group. It is now called World Professional Association for Transgender Health – WPATH.
Over the course of time I came to see a flow in this work. Clients negotiate stages that looked very familiar to me from my own period of coming out as a lesbian. The major difference is the changes made to the body as they transition from one gender to any point along a spectrum. Transgender folks are visible. In her book, Transgender Emergence, Lev delineates six stages of work:
2. Seeking information
3. Disclosure to others
4. Exploring identity
5. Body modifications
6. Integration and prideStage One: Awareness
Awareness occurs as young as three or four years old. Sometimes early activity can include playing with cross gender toys, stating preferences for another gender, etc. In some other folks, awareness first occurs during puberty. Cross dressing often occurs in secret during latency or latter in puberty. The issue of sexual arousal as an indicator of “true” transsexualism is no longer considered by transgender people as reliable or respectful to the individual definition of self.
For an adolescent coming aware of being transgender the process of self identification seems easier, more a part of their natural age-appropriate exploration of self. Also, the society of their peers is more flexible in their acceptance of trying on a different self. Parental acceptance is a major concern and occurs on a spectrum from abuse to practical help.
For older adults self-acceptance has a different flavor. There is a big difference between self-acceptance in a context of peer acceptance and the partially negative sense of self, which feels it must remain hidden. There will often be a history of buying and purging clothing that is related to shame cycles. This person relates to others in many of the same ways as anyone with a secret. They have qualities of being watchful and guard their speech. They rarely feel natural and at ease. They often have no close friends. The decision whether or not to come out is often affected by being caught dressing or by their perception that their truth would not be acceptable. Sometimes they are not acceptable to themselves and try to “cure” themselves by living their natal sex in an exaggeration of that gender role. In other words, a transgender female may volunteer for the extreme military or civilian jobs or a transgender male play the role of a “girly girl.”
Stage Two: Seeking information and reaching out
As a therapist to a transgender person you may be the first person they have told what they consider a shameful aspect of themselves. I am always honored by the trust given in the telling. These folks are fragile and, as a group, have a very high rate of suicide, usually before they tell. Some are in despair in situations where they can see no way out.
Now my job as a gender specialist begins. At this stage I have several tasks to perform. The first is validation by accepting the transgender is a normal expression of human potentiality. Another is as a resource provider of community contacts such as support groups and welcoming churches and to offer encouragement to surf the Internet, if they have not already done so. Typical homework for self-image is to make a style scrapbook and compile their own resources for laser and electrolysis treatments. Perhaps, the most important quality in this stage is patience and lack of expectation. Each situation is different and moves at its own pace. Try and keep the concept of “baby steps” in the fore.
For those of you who do not chose to be gender specialist, this is a good time to honestly tell your client that you would like to refer them to a gender specialist. This transition is hard enough for the client without you trying OJT – On the Job Training. Be willing to do the homework necessary to work with them in the process.
Stage Three: Disclosure to others
After a variable period of time, the client comes to the stage of disclosure to others. Most transgender folks fear that disclosure will result in rejection, abandonment and censure. With this in mind and working with the client to develop a desensitization ladder, one of the first “baby steps” is to simply leave the house and drive around awhile at night. The, when that is comfortable, I suggest they stop and buy something at a 7-11, preferably one that is outside of their neighborhood. Going to a support group dressed for the first time can feel like a debut into self-identification. Gradually and well planned, the client discloses to one or two close friends, close family members, most often siblings, parents, grandparents and extended family.
Parents are usually experienced as most fraught with danger of rejection. Your client will need emotional support and basic validation from you, the family they have already told and their peer support group. Telling parents can be intense. Sometimes it is another family member the client fears telling. One Female to Male – “FTM” client told his close family – parents and siblings, but feared the judgment of a grandmother’s sharp tongue. He plans to tell the whole extended family at a Thanksgiving reunion and count on avoiding grandma’s toxic messages. Transgender folks have my utmost respect for their courage!
As a gender specialist I believe that it is important to focus on my client in context. Around this time of disclosure I ask my clients to invite their significant other and/or parents to meet with us in session. Reactions to the invitation vary widely from the spouse who not only refused to meet, but blames me for her spouse’s actions to the parents who bring me their adolescent for help Remember, as with LGB clients, not only the client comes out. The spouse, parent and very close friends all come out as being related to the transgender person.
Sometimes there are issues that complicate the relationship. Many “FTM” folks live in a lesbian relationship when they come out. Then, sometimes, the spouse’s sexual identity becomes an important issue that often severs the relationship. Later when hormones are started, testosterone changes the client’s body smell to a much more masculine aroma. A similar dynamic occurs in heterosexual relationships when the natal man comes out as a transsexual. Many heterosexual natal women fear being seen as a lesbian with their transgender female spouse.
There are other issues common to many couples in change and conflict. Religious beliefs are very important during this stage. I remember a Latter Day Saint, Male to Female – “MTF” client who chose to use a session to come out to her parents. I advocated strongly for emotional values of love and family connection. Both parents sat stoically, occasionally repeating religious statements until I made a forecast that their family will be without their child. Mom cried. I have hope for them.
I believe in marriage – heterosexual or gay – and work hard to help the couple through their issues, concerns and choices. The manner in which the non-transitioning partner learned of the transitioning spouses wishes and behavior carries great weight. Teaching negotiating skills is important at this stage.
Another issue of disclosure is feelings of betrayal on many levels. “Why didn’t or couldn’t you tell me?” The transitioning spouse has a whole life they have never been in or know about. Their anger can be impressive and needs to vent. It is usually better for the prognosis if the non-transitioning spouse agrees to vent their emotions with you, their gender specialist. Separate therapists can muddy the waters. I have helped negotiate marriages, which have lasted, and separations with a minimum loss for both spouses. Child custody and children having the attention and love of both parents can be at risk. All of us have had clients we feel we failed even though we had no control over the outcome. One client lost contact with their child. They had been very close, but the spouse’s mother’s family used the court system to deny my client contact with their child. This client holds hope and counts the years until their child is eighteen.
Toward the end of this stage is a referral for hormones. As you can see from my examples, some folks may need a longer time than others. I talk with the client about the whole process and help them find their own readiness to begin hormones. Gender specialists are often called gatekeepers or “risk managers” because it is their responsibility as a specialist to write referrals for Sexual Reassignment Surgery – SRS. Using a client centered empowerment model has resulted in only one angry email from someone who has never been my client.
Stage Four: Exploring Identity
My clients are exploring body language, speech patterns and harmonies and new clothes all in the context of others. Many clients could be labeled “paranoid” at this stage. I often suggest to a client to sit in a mall to watch people for a variety of gender presentations. Also, I tell them that most people do not care unless someone’s body language alerts them. Nothing alerts danger more effectively than someone who is covertly watching them for their reaction. Many of my clients who are new to their target gender benefit from group outings for supper or shopping.
Hormones are very powerful in their effect on emotions and cognitive processing, as well as physical changes. Part of the exploration of identity is recognizing changes as they occur. Increased emotional lability varies from one client who cries often to one who may benefit from just recognizing feelings beyond anger or sadness. This is usually a joyous time, so I ask them how they celebrate their changes.
There is also a timing issue with hormones. As a rough guesstimate, I remind people that hormones change the physical and that after six months changes are hard to hide in the workplace. Planning for transition becomes part of identity change along with name change to reflect their new gender.
Stage Five: Body Modifications
Transition begins with a minimal one year “Real Life Test” where one dresses and acts in the world as one’s target gender. Please be aware that the goals in this process belong to the client. Some may not wish hormones or cannot use them for health reasons. Some may only wish low dose hormones to manage gender conflict as a heterosexual cross dresser. Some adolescent male to females may start on an androgen blocker only until the age of eighteen or with parental consent, thus delaying the development of unwanted secondary sexual characteristics.
Transition brings many concrete changes. The client is “out” to family and friends and living “24/7” in their target gender. Very often name change and transition in the work place signal the beginning of this stage. My clients are transitioning at a time in history when a great deal of publicity ranging from television daytime talk shows to more respectful articles in newspapers and magazines inform the public. If your client works for the federal government there is a protocol for transition in the workplace. Many major corporations are comfortable with the process. One notable company assigned an E.A.P. counselor to facilitate the process for one of their employees. It was a wonderful experience for all of us!
During or just before transition my clients often explore body modification beyond beard removal. Those male to females who can afford it may choose facial feminization surgery, body hair removal, tracheal shave to lessen the Adam’s apple and breast implants. However, I encourage folks to have at least a year on hormones before breast implants to allow for maximum growth. Female to Male clients usually have their breast removed and chest contoured which is often their only surgical body modification. Hormones trigger secondary sexual characteristics such as beard growth and, for some, hair loss. There are a number of plastic surgeons who do this work, some of whom are transgender themselves.
The year or more of transition is a special time for the transsexual client as they take their place in the world as what they perceive to be their true self. They “grow into themselves” and often shed depression and increase confidence and assertiveness. My pride in them is huge, as is my respect for their courage.
Stage Six: Integration and Pride
At this point, they are ready to choose a surgeon for sexual reassignment surgery. Since the state of the art is still very poor for Female to Males, many elect either no genital surgery or an operation, which frees the clitoris and creates a small penis still capable of sexual sensation. For Male to Females the choice of surgeon is fairly good in this country and overseas.
Most transgender people leave therapy when their goals are met. For some that can be during the second stage of validation and seeking information. A gender specialist works with the whole spectrum from closeted cross dresser to fully integrated transsexual. Unless there is a major Axis I diagnosis requiring further supportive therapy, they have used their gender specialist well and no longer require service.
Thank you for your time.