Beyond Gatekeeping: Truth and Trust in Therapy with Transsexuals
Maureen Osborne, Ph. D.
IFGE Conference 3-20-03
Philadelphia, PA

In this presentation, I’d like to share some of the things I’ve learned during many hundreds of hours in therapeutic dialogue with transgendered folks and their loved ones. It has been a revelation and a privilege over the years to bear witness to the struggles and triumphs of these individuals, and I am grateful to them for the insights their life stories have given me into the nature of gender identity and the human condition

As a contextual therapist, my work is based, among other principles, on the idea that any interaction between people takes into account the particular context that the relating parties bring with them. I will begin, as I often do, with some pertinent facts about my own context, as it intersects with my work as a therapist, and I will later explain some of the principles of contextual therapy that inform my approach in working with clients. I am a middle-aged clinical psychologist, trained in the late 1970s, married 22 years, and the mother of two teenagers. I like the self-description: “straight, but not narrow”. With the exception of a notorious annual neighborhood Halloween karaoke party at which my husband and I have performed cross-dressed along with friends, neither I, nor any member of my immediate family has ever to my knowledge experienced any ambivalence or confusion about gender identity. Although I would characterize myself as a feminist, I can also say without hesitation that I “enjoy being a girl”. I say this with the pained knowledge that my gender comfort is a gift not available to everybody. And it has only been in the past eleven years that I have come to understand that the assumptions about the gender binary that most people take for granted are, in fact, far less clear-cut than I ever imagined.

So, you might ask, how does an average soccer mom like me end up spending a good portion of her professional life working with the transgendered? I don’t know how it’s been for other clinicians in this field, and I doubt that I can give a fully satisfying answer. I can only say that I have held a lifelong concern for justice issues in human relations, whether at the level of global politics, or in the microcosm of family dynamics. As the famous psychologist Harry Stack Sullivan said of his work with schizophrenics, “We are all more simply human than otherwise.” As an adolescent, I grew to question dogma and the status quo, especially when it did not conform to my own lived experience, or when people suffered as a consequence. Growing up in a large working class family, I often felt the sting of judgment from my more affluent classmates, and I saw the pecking order reproduced in my own family’s biased attitudes toward racial minorities. In my spiritual development, I abandoned my childhood Catholic religion and found a home in the Unitarian Universalist faith, whose principles and purposes affirm “the inherent worth and dignity of every person.”

These are some of the facts of my own context that were in place in early 1992 when a 50 year old married father of two entered my private practice therapy office, stating that he believed himself to be a transsexual. Apart from the usual media exposure and the seminars in human sexuality that were a part of my clinical psychology training, I possessed no special knowledge of the field in which I am now considered an “expert”. What I hope to convey to you today is a sampling of the rich and varied meanings that I’ve acquired over the last decade as a contextual therapist with a specialty in transgender issues.
First, I must digress briefly to explain a few of the basic principles of Contextual Therapy, to allow a better understanding of my therapeutic approach as well as the way in which I have organized this presentation. The theory underpinning contextual therapy emerged in the late 1950s with the work of psychiatrist and pioneer family therapist Ivan Boszormenyi-Nagy. Contextual therapy has evolved into a richly textured merging of individual and family or systems approaches, with an added crucial dimension, that of justice dynamics or merited trust. The ethical dimension bridges the gap between self-interest and fair consideration for others by assuming a shared human need for trustworthy relationships. Experiences with trust, fairness, and shared accountability in our families of origin affect our ability to develop satisfying adult intimate relationships and to function adequately as parents to our own children.

As a contextual therapist honoring the justice dimension, I hold up the claim of fairness for all parties in family or close relationships, regardless of whether they are present in the therapy room (and as many gender therapists have experienced, it is sometimes hard to advocate for those individuals who vow never to set foot in your office, and claim that you are putting destructive ideas into the heads of their loved ones, Svengali-style). Therapy boycotts notwithstanding, I assume that everyone has a side that deserves to be heard and considered, regardless of the current relational emergency. In contextual language, this stance is called multidirected partiality. It is neither so-called therapeutic neutrality, nor is it a unilateral advocacy. Rather, the contextual therapist recognizes that all relationships consist of at least two sides carrying different legacies, which require a balancing of needs and entitlements over time.

Although merited trust is an important component of any therapy contract in the contextual approach, it is only one of four important dimensions of relational reality. In this discussion of therapy dynamics in the transgender context, I will discuss themes arising with transgender clients in each of four dimensions. The first is that of objective facts. Included would be all pre-existing factors of a person’s life, including genetic factors, physical health and medical history, appearance, intelligence, temperamental traits, developmental factors, economic/social class and all other events occurring in an individual’s life cycle. The factual dimension encompasses the existing realities of an individual; as such, it is the starting point for any therapeutic dialogue. A thorough individual and family history covering at least two generations is an essential tool for beginning any therapy process.

What facts might have particular relevance to a client presenting with gender identity concerns? Chronological age is certainly important. Depending on the stage of life, gender issues have different meanings and present different types of challenges with respect to transition. In her excellent recent review of developmental factors associated with gender expression deprivation, Anne Vitale (2001) delineates the ways in which untreated anxiety is manifested, starting with childhood confusion and rebellion, through adolescent false hopes and disappointment, continuing into hesitant gender conformity in early adulthood, leading to middle-aged feelings of self-induced entrapment, and finally into depression and resignation with old age. In my own experience, middle age is the most common time for entering into therapy for gender issues. However, I have been present to gender struggles ranging from young childhood to old age, and each presents its own unique set of challenges.

For example, the parents of a 4-year-old boy who had been disputing his assigned gender since he was old enough to talk consulted me about how to respond to their son. “Didn’t you know when I was in your tummy that I was supposed to be a girl?” he appealed to his mother. The parents, both professionals with advanced degrees, were understandably disturbed and hesitant about how to respond to their child’s curious protests. Nonetheless, their love for their child and their willingness to listen to him and to consult a knowledgeable professional afforded them numerous resources for facing this issue in the future. After familiarizing themselves with current knowledge on gender disorders, these extraordinary parents were able to reassure their son that if he continued to feel this way as he grew older, they would be willing to do what was necessary to help him change his sex. The age at which a child becomes aware of gender confusion, his or her behavioral response to that awareness, and the reactions of significant caregivers, constitute important facts in determining later outcomes on the gender journey.

Many of my adult transgender clients express envy of those who confront the issue in their teenage years. It is true that these young people avoid some of the heartbreak and lost opportunities that characterize the choice of suppression and gender conformity in adulthood. However, there are powerful consequences that come with addressing gender issues in adolescence. For starters, teenagers need parents’ support to pursue transition. Not surprisingly, few parents are willing to commit financially and emotionally to a process that produces such drastic results, especially when the diagnosis is largely subjective. Moreover, there are still many skeptical professionals supporting parents’ denial by claiming that gender confusion is a state their child will most likely outgrow. Add to that the inevitable humiliation that public gender transition would contribute to the already awkward self-consciousness of adolescence, and you begin to see the unbelievable courage and self-confidence that is required to face this issue as an adolescent. Other factors contributing to the challenge of coming out at this stage are the potential loss of the capacity to bear or produce children, massive confusion about sexuality at a time when it is a dominant life force, and fears about the pain of surgery.

Unquestionably, the saddest event of my own professional life came with the news that a client whom I had assisted toward MtF gender transition at 16 had taken her own life at age 19 after a disappointment in a romantic relationship. Although her loving and supportive parents assured me that her years living as a girl had been among the happiest of an otherwise severely depressed life, I could not help but wonder what impact the stresses of gender transition had on an already fragile and immature ego.

Addressing gender issues in early to middle adulthood, usually after a period of suppression and gender conformity, presents its own set of problems. Although there is a higher level of maturity, there is also a longer period of time spent in role behaviors associated with the birth assigned gender. These patterns are both habitual and self-defeating with respect to the true self. At the extreme, an individual at this stage may have engaged in extremes of gender stereotyped behavior, which often complicates the process of revealing the true self to loved ones. A frequent objection of significant others is that “there is nothing whatsoever feminine about this person”, and they point to his gun collection, or weightlifting, or obsession with football. In fact, efforts to force the assigned gender to “take hold” are often what cause these individuals to marry and produce children, all in the hope of burying or even “curing” the transgender issue. Although many clients report that their spouses “knew” of their gender issues before the marriage, their so-called awareness is almost always limited, because the transgender partner is usually in at least partial denial of the problem in order to consider marriage under the circumstances. Therapy for gender issues in middle adulthood will often need to include couple and family work to look for resources addressing the loss of trust and the social consequences that accompany a potential gender transition
Among those who postpone facing gender issues until older age, there will certainly be accompanying depression and resignation, as Anne Vitale points out. When clients who have avoided this issue for decades find that they can no longer survive for the duration, they come in with a mix of feelings: joyful relief at breaking their silence and being heard, a sense of long-awaited, unapologetic entitlement, guilt about the burden and shock this creates in loved ones, shame about the lies they have lived, regrets about their now-limited opportunities to experience an authentic life, and overwhelming self-doubts regarding their own capacity to transition acceptably.

Consider Nathaniel, a 62 year old physician, penetrating thinker, prodigious linguist, and accomplished photographer: a true Renaissance Man, who, despite his many external achievements, suffers from chronic and incapacitating depression, social isolation, and suicidal thinking, much of it attributable to gender dysphoria. After finding my name on a web site, Nate sent a touching Email, outlining his self-diagnosed condition, but indicating little hope of finding solution to his dilemma at this stage of life. When I responded with an invitation that we meet to discuss his options, Nate seemed surprised and overwhelmed with gratitude.

Over the course of the next year, Nate wrestled bravely with his conflicting feelings and motivations as he approached the possibility of a more genuine life, one in which his long-buried feminine self might be given a chance to exist that was more real than theoretical. Complicating the picture was Gloria, Nate’s loyal yet bewildered and skeptical spouse, who felt that she could never quite please her husband nor penetrate his armor. The couple’s two successful and independent adult daughters were willing to advocate for their beloved father’s liberation, but also found themselves caught in a split loyalty to their mother, whose interest was certainly not going to be served by her husband’s gender transition at this stage of life. Surely this transgender nonsense was just another one of those crazy ideas that the long-suffering and practical helpmate of this brilliant, yet distant and unrealized man had to indulge lightly in order to coax him forward toward their well-deserved Golden Years!

As the waves of Nate’s suicidal thinking began to crash over him with frightening intensity, it became clear to both of us that his only truly reliable Guardian Angel was Amanda, his inner female Self, who had been watching over Nate with patient compassion, waiting for him to allow her a fuller expression. Once Nate admitted to himself Amanda’s central role in his survival all these years, he began to grant her increasing latitude, and proceeded to make changes in his life that acknowledged his inner truth. Although the practical dilemmas of family, career, and personal appearance continue to challenge Nate, his suicidal ideation and self-defeating behaviors have diminished, and he is beginning to show some optimism about the future. If his progress follows the path of other late-transitioning clients I’ve seen, Nate/Amanda’s courage and persistence will be rewarded by increased physical stamina, a revitalized sense of emotional energy and relatedness, and a never before experienced sense of inner peace. Once they have come to terms with themselves, older clients come to realize they have “paid their dues,” and are unlikely to be affected adversely by the judgments of any but the most significant of others.

In taking the time to describe in detail the impact of just one of the countless number of facts of an individual’s context – that of chronological age - has on the course of therapy involving gender issues, I hope to convey an impression of the myriad and complex ways that the particulars of a person’s life story affect the direction of the gender journey. Other facts I’ve found relevant include, but are not limited to: intellectual level (those with higher cognitive intelligence tend to agonize and obsess more over decisions, and to have used their intelligence in the service of denial/avoidance), physical appearance (with those closest to the normative standards of the desired gender having the easiest time adjusting in terms of body image), career/financial level (with those in higher paying and more rewarding careers having more difficulty with choosing to risk transition, and those in lower paying jobs encountering difficulties with the costs of gender transition), family of origin issues (including degree of closeness vs. distance, ethnic background, birth order, gender of siblings, family losses, tolerance of differences, emotional and/or physical abuse, gender-stereotyped attitudes, and any number of other potentially important variables), current family context (such as number and ages of children, spouse’s attitude toward the gender issue, degree of emotional/financial interdependence of the partners, length of the marriage, existence of previous marriages, extrafamilial support systems), and so-called co-morbid psychiatric conditions, (that is, the existence of serious mental disorders either unrelated or only marginally related to the gender variance, such as psychosis, depression or bipolar disorder, anxiety conditions, personality disorders, and posttraumatic stress).

Although time will not permit a thorough treatment of all the factual elements to which I have alluded, I would like to share some thoughts with regard to the treatment of co-morbid conditions. In my work, I have found it a mistake to postpone a thorough examination of the client’s gender-related complaints in favor of treating a more obvious psychiatric or psychological issue. First, the client has risked hope and trust by revealing this highly conflictual and shame-bound issue to a professional, and it is my responsibility to honor that disclosure with careful and serious attention. Second, it often happens that the psychiatric or psychological issue becomes less pronounced and troublesome when the gender problem is being addressed.

On the other hand, I have also found that ongoing psychiatric conditions can be masked by the flurry of excitement and tasks that accompany active address of gender identity concerns. In one case, a 36-year-old married father of five children consulted me with a request to be considered for an SRS recommendation without ever intending to live as a woman. This individual had a history of serious Obsessive Compulsive Disorder, but presented as free of symptoms when I worked with him. I worked to help him become more accepting of the consequences of gender reassignment, and once on board, he moved full speed ahead with transition and eventual SRS. This client was, by all appearances, a model example of a successful reassignment, managing to retain her successful career, her marriage, and the relatively good adjustment of her children. One year later, almost to the day, this client began to experience agonizing regrets about the surgery, severe depression and suicidal ideation, and a wish to return to living as a male. To simplify a very complicated case history, this individual had been acting in part out of a compulsive need to satisfy what she thought was her spouse’s emergent same-sex preference, and when the spouse later expressed that she missed her partner’s male sex organ, the client became obsessive about the lost penis and frantic about what she feared the consequences to her marriage might be. The point is that this client’s psychiatric condition was effectively concealed by an energetic and compulsive focus on fulfilling the requirements of gender transition, and its subsequent flare-up led to an obsessive wish for reversal. At this point in time, I can cautiously report that this client has come to terms with her choices and is living as a man, but allowing herself periodic female expression.

The second dimension of relational reality in Contextual Therapy terms is Individual Psychology. Each of us is a product, not only of the objective facts of our life experience, but of the unique and subjective way in which we perceive, organize, and integrate those facts. The psychological dimension encompasses those processes and resulting traits and patterns of behavior that make up an individual’s unique personality. Such concepts as motivations, unconscious defense mechanisms, feelings, learned behaviors, and self-esteem would fit into this category. A detailed understanding of the ways in which individual psychology affects a client’s awareness of and response to gender variation can be a valuable tool for the therapist. In the following case example, I hope to illustrate the ways in which individual psychological dynamics can operate in therapy involving gender dissonance.

Mike, a 42 year old highly successful bond portfolio manager and married father of two young children, consulted me in the hope of “getting rid of all these obsessions,” his summation of a lifelong gender identity conflict. He had found some relief a few years earlier when he entered therapy on the heels of a self-described “breakdown” involving risky and self-destructive behavior, but the gender issue was not discussed. On the surface, Mike’s life had been phenomenally successful – he was highly intelligent, tall and handsome, well educated, challenged and happy in a well-paid career, and married to a beautiful woman who was every bit his equal. However, gender dissonance had come to dominate Mike’s inner experience, and it threatened to overwhelm his exhausted defense mechanisms. He could fool everybody but his wife, who had long sensed his estrangement, and exhorted him to “live life.”
In the years prior to this crossroad in Mike’s life, he had relied upon numerous defense mechanisms to distract him from the gender dysphoria. On the positive side, he had developed his intellectual capacities to earn advanced degrees in the fields of economics and business, and was now functioning at the peak of his game, career-wise. His considerable athletic talent afforded him a sense of achievement in sports, as well as a “cover” for the inner dissonance. Although Mike backed away from team sports that would evoke too much anxiety, he showed an amazing ability to build his body into a well-honed masculine machine, and this activity helped to stave off the gender longings as well. On the negative side, he had also developed more self-destructive defenses, including the abuse of alcohol and drugs and, prior to marriage, a tendency to seek the temporary comfort of random sexual liaisons.

Mike described his family of origin as “highly dysfunctional.” Dad was distant, womanizing, and financially reckless, himself fatherless after his father died when he was 11. Mother expressed her fury and disappointment with Dad by frequent criticism. Although neither parent was seriously neglectful or abusive, Mike often felt like a low priority in his parents’ conflictual lives. He adopted the parentified child role in his family, where he looked out for everybody and tried not to make too many demands. The only adult figure with whom Mike felt any closeness in childhood was a grandfather who died when he was 8 years old. Unfortunately, this loving and caring role model was also a “man’s man,” which probably added to Mike’s’s internal ambivalence about his gender variance. An additional complicating factor was Mike’s conservative Catholic upbringing, in which he continued to find solace, but which also condemned his transgender self. He often remarked that his Catholic roots were characterized more by “hellfire and damnation” than “Jesus loves you.”

It was indisputably true that nobody judged Mike more harshly or demanded higher standards than he set for himself. An insight that came early in the therapy was his perfectionism – a defense that both fended off his fear of being an irresponsible failure like his father, and proved to his mother that she was not a failure as a parent. Additionally, this defense served Mike’s need to conceal his inner gender feelings by presenting a well-honed and believable male identity. Unfortunately, Mike’s perfectionism also made it difficult to imagine a reasonable chance for a normal life as a woman, because there were simply too many things about gender transition that were beyond his control. Mike had done a terrific job at creating an admirable life as a man, and he clung to the self-esteem he had acquired from this persona, despite a painful awareness of the fundamental dishonesty required to sustain this picture. The contradiction between the two aspects of Mike’s being drove him into repetitive downward spirals. Despite his decision to honor his own and his spouse’s integrity by moving into a separate residence, and the relief he’d achieved from psychotherapy, hormone therapy and antidepressant medication, Mike felt no closer to a solution to his dilemma.

A detailed analysis of my 2+ years work with this remarkable person is beyond the scope of this paper. I can report that Mike finally moved to accept and embrace his female self, Melinda. Having hit a very deep and dark bottom one night was partly responsible, as was the gracious circumstance that brought him together with a very special nun who works with transgendered Catholics seeking spiritual solace within their religious tradition. Melinda also credits the many wonderful kindred spirits who have become close friends to her on this journey, as well as our work together in the therapy office. What I have seen is an individual who always came back to her own integrity as a guide, regardless of the difficulties that created for her. She knew that she would have to turn over every stone in seeking a path to follow, and she did so with tremendous honesty, humor, and consideration for those she loved, a subject to which I will return in discussing the justice dimension.

The third dimension of relational reality in Contextual terms is that of Transactions. The notion that people’s behavior involves not only individual psychological processes, but systemic patterns of behavior comes from the field of family therapy, where it was observed that people in closely relating systems tend to form certain patterns of behavior, especially with regard to boundaries, communications and power dynamics. In my assessment, I pay attention to these variables as they reveal themselves in the transgendered individual’s current family, the family of origin, and in the spouse’s family of origin. An understanding of these patterns can suggest creative resources for addressing broken trust and creating new options for healing movement. For example, a communication pattern that fostered distance, silence and secrecy in either partner’s family system might be carried forward by one or both, creating an implicit “don’t ask, don’t tell” rule. If I can guide a client or spouse to become aware of this unseen legacy, it can help assuage the guilt or anger created when concealing the gender problem is a logical outcome of this communication pattern.

A kind of boundary issue that I have seen repeatedly involves an enmeshed or codependent relationship between spouses. In these cases, there is typically some overt or covert knowledge of the gender issue, but little or no attempt to negotiate its expression. When the gender condition intensifies to the point where transition is seriously considered, the threat to the viability of the relationship becomes intolerable to one or both partners, and catastrophic reactions can quickly ensue. It becomes vitally important for the therapist to anticipate and work with both spouses, both together and separately, when the assessment reveals an enmeshed relational pattern.

An example of a case with enmeshed marital boundaries will illustrate this pattern. Sheila, 48, whose male name was Lloyd, consulted me after having seen a different therapist and taken female hormones for more than a year. Her external presentation was entirely female. Despite the fact that Sheila’s wife of 30 years, Darlene, accompanied her to our first few sessions, it became clear that she had not been a participant in the therapy process, and appeared uncomfortable in her husband’s female presence. In a separate session with me, she disclosed her doubts and objections to the whole process, and expressed considerable resentment toward Lloyd for subjecting her to embarrassing and unwelcome life changes. Darlene had known about Lloyd’s gender identity problem for most of their married life. She had also weathered his periods of suicidal depression, and was intelligent enough to see the connection between Lloyd’s demons and his gender conflict. Darlene had basically indulged Lloyd’s cross-dressing and hormone therapy in the hope that it would keep those demons at bay. For his part, Lloyd had downplayed his growing conviction that he would progress to transition and sex reassignment.

When Darlene told me in no uncertain terms that she would not remain married to Lloyd if he became a woman, I focused my therapeutic efforts on assisting this couple to disentangle a highly interdependent relationship. In particular, I worked toward helping Sheila to see the validity and the reality of her wife’s position, rather than feeling betrayed and abandoned by her. In that vein, I told Sheila that she should start driving to her therapy sessions by herself, rather than relying on her wife to bring her. This small, but symbolic intervention brought into focus for Sheila a reality consequence of her intention to transition, and allowed her to weigh the resulting impact.

Over the next year, Sheila and Darlene eventually managed an amicable separation, although not without a few serious recurrences of Sheila’s depression and suicidality. Both spouses fought to salvage the marriage, but could not do so within the context of gender transition. Sheila managed a successful transition on the job, and completed her surgery a few months ago. The former partners have made tentative progress in reworking their relationship within the new context. Sheila reports great satisfaction with her gender correction, but continues to struggle with loneliness and social isolation in the absence of her marriage relationship
Power dynamics fall within the transactional dimension, and represent another important part of a relational assessment in therapy where a member of the system has a gender conflict. Consider the case where one spouse earns considerably more money than the other, and uses that fact to act unilaterally in the relationship. It is well known that the treatment of gender conflict can be costly, and an unbalanced power dynamic in this area can enable one spouse to blackmail or ignore the rights of the other partner in a committed relationship. This kind of power maneuver should be exposed and confronted by a therapist interested in assisting, not only the transgender client, but the entire system affected by the decisions made on this journey.

In my work, I have repeatedly witnessed the importance of multilateral interventions in the overall address and resolution of gender conflict. In cases where one partner uses a power manipulation to either prevent or carry forth a gender agenda, it has been useful to imagine the underlying positive intentions of the actor. For example, some partners of transgendered spouses will bring forth all sorts of “heavy artillery” in an attempt to sabotage transition, from vowing to take away the couple’s children, to emotional abuse (“you will never be anything but an ugly woman”) to threats of widespread premature disclosure. When this happens, it almost always seems that the underlying motivation is the spouse “fighting for the marriage,” and being willing to do whatever seems necessary.

Spouses who have resorted to power maneuvers often blame the gender specialist for their unhappy predicament and may withdraw from further therapy sessions. Obviously, the therapist should resist the temptation to take these projections personally. It is important to continue raising the side of the wounded loved one while helping the transgendered spouse to resist capitulating in the face of destructive power displays. I have known several wives who still harbor enormous grudges toward me, but have moved forward productively in their own lives, maintaining reasonably friendly and cooperative relationships with their former partners.

It can be especially discouraging when parents use their emotional or financial power to block a minor child from exploring or pursuing relief from gender dissonance. The therapist must move with extra care to balance the young person’s request for resources and options with competing needs for parental acceptance and support. Parents need accurate information and empathic listening as well, especially in cases where they present as highly suspicious and oppositional. In my experience, it can be a wise investment to move slowly and patiently with parents, allying with their protectiveness toward the child while at the same time educating them with the most current thinking about the nature and course of gender identity disorder. In the occasional case where a young person consults me without the knowledge or financial support of parents, I will not refuse to speak to him or her, but will do so with the clear indication that parental involvement is a mainstay of a successful gender therapy.

The fourth dimension in contextual therapy, Justice Dynamics, also called Relational Ethics, defines the foundation and methodology of the contextual approach. The assumption is that, beyond the objective facts, individual psychological processes, and transactional patterns of relating persons, there is an ethical plane, which includes concepts such as merited trust, constructive entitlement, fairness, commitment, accountability, and the balance of give and take. I rely heavily on this dimension in all my work as a therapist, and have found it especially helpful in working with the crises presented by an individual addressing gender issues. Of particular relevance in this work are questions central to relational ethics.

“How do I balance my need for genuine self-expression against the fair consideration owed to loved ones sharing my life?”

“To what extent have I been openly accountable to others for the loss of trust created by my failure to disclose the full extent of my lifelong gender conflict?”

“How do I find the courage and entitlement to embrace my authentic Self, in the face of all the real and imagined consequences”?

“What am I willing to give in my effort to repair damaged trust without sacrificing my claim to wholeness and integrity?”

“How, despite my personal suffering and that potentially inflicted on others as a result of my gender conflict, do I measure the worth of the positive contributions I have made to my family, friends and colleagues?”

“If I do move forward with gender transition, what changes are necessary for me to fulfill my ongoing commitment to children and others who have relied on me”?

The vast majority of people who enter my office to discuss gender identity issues have reached a crisis point in their ability to further manage or contain the dysphoria that has been a familiar demon since childhood. Some have made repeated efforts at address of the problem, followed by cycles of purging and self-loathing. Others have never breathed a word of their inner secret to a living soul. They may have approached the assigned gender role with determined energy and attention to detail, or lurked on the shadowy edge of life for fear of detection. Common to all is an almost constant and nagging awareness of a discordant part of themselves that was somehow more real than the one they were presenting, and which now threatens to upset whatever balance they have achieved in life. They come to a gender therapist in hope and trepidation, determination and terror. Whatever the expectations, that first contact is always a holy moment, and I do my best to honor it through crediting their suffering, normalizing their ambivalence, and pointing to the admirable courage it has taken to turn and face this dilemma. Once I have acknowledged the client’s courage and suffering and assured them that options do exist, I introduce my belief that any journey toward wholeness must consider one’s important relational connections, without allowing the needs of others to overshadow one’s own. Thus, the importance of a balance of give and take is a bias I share from the outset of therapy.

Justice issues are prominent in therapy for gender conflict. The most effective treatment we now have to offer usually involves some degree of cross-gender expression or transformation. Although there can be great relief in the prospect of living as one’s authentic self, it is typically accompanied by a great upsurge in fear, guilt and shame with regard to public exposure. In the process, all of the original reasons for concealing the gender conflict begin to resurface, in magnified form. Added to the self-generated conflict might also be the external complaints, judgments, accusations and threats of significant others fighting to block this unwanted challenge to their own belief systems and life plan. In the midst of this tangled mess of feelings and conflicting motivations, the gender variant individual is likely to experience renewed doubts about fairness and entitlement to claim the True Self, which are nonetheless countered by the immediate internal pressures that brought the person to the therapy office in the first place.

Within the unforgiving terrain between a rock and a hard place, a therapist grounded in justice dynamics can offer potential resources for addressing the gender dilemma, always keeping in mind the goal of achieving a balance of fairness between the claims of all parties. Ideally, therapy sessions including significant others should take place periodically. In the rare cases where family members refuse to attend, I consider it the therapist’s responsibility to include and raise their side even in their absence. For the transgendered client, the process of therapy typically comprises a sequence of external validation through confirming the diagnosis, patiently supporting the client as he or she struggles through doubt, fear and ambivalence, and then guiding the process of gender transition and post-operative adjustment. The diagnostic stage is the shortest, relying on relatively objective and empirical criteria. The ambivalent stage and the transition itself can involve a considerably longer time, and it is during these periods that an ongoing therapeutic dialogue can be of crucial importance.

During the ambivalent, fear-dominated phase of therapy, the experienced gender therapist can offer useful observations on how other clients have overcome their own doubts. A group therapy context such as the monthly one I have facilitated for several years can be an ideal place to test one’s fears and entitlement issues. It is also important to notice and point out the factual experiences, psychological processes, and transactional patterns that may fuel the client’s ambivalence, while at the same time reassuring them that their doubts and fears are quite understandable and may require substantial work to overcome. Among the points of fact that I find particularly pertinent and emphasize repeatedly are the client’s years of personal suffering, their heroic efforts to live a life that considered the comfort of others over their own, their fundamental right to claim their brain’s gender identity, and the cumulative nature of gender dysphoria over time.

Once the client has reached a modicum of self-acceptance, the objective in therapy is to suggest options for decreasing gender dissonance, being careful to evaluate whether progress is either prematurely fast or too hesitant within the client’s particular context. My assessment and recommendations regarding pacing rely on my accrued knowledge of gender issues and experience with the process of transition, combined with an ongoing effort through dialogue to be aware of the relevant issues in the client’s particular relational, vocational, legal, economic and spiritual worlds. Not infrequently, my role will include direct or indirect interface with individuals representing any or all of these aspects of the client’s life context.

There are many, many aspects of therapy with transgendered clients that I have not mentioned in this discussion, and I invite each of you to contribute your ideas to a dialogue at the conclusion of this paper. In closing, I will quote from some ideas put forth by a former client, Dr. Christine McGinn now living happily as a woman after sex correction surgery and who gave her blessing to my use of her personal reflections on the topic of “selfishness” in our monthly therapy group
“…We spend our whole lives feeling awful about who we are…feeling a need to apologize to humanity for breaking the most basic social norm. Then when it comes time to empower ourselves and rise above every social teaching that has metastasized from society to our consciousness, we feel a great ache in our solar plexus – guilt. And ironically enough, the people who want to block us realize this better than we do, and they dig in for battle, throwing back at us our greatest fear…”How can you be so selfish???!!!” I say, how can we be so SELF-LESS!! We have spent a whole life trying to ease the sense of comfort in others by sacrificing our entire identity. If you don’t believe you are justified in being yourself, why should anyone else?”

“The pitfall…is that the selfishness/self-esteem balance tends to be a floodgate instead of a rheostat. In the past, I had built up tremendous resentment toward the world over not being able to be myself. The funny part is that the world had no idea that I was not being myself…the joke was on me. I created 30 years of negative energy…this was my own baggage that wasn’t going to fit into my overhead compartment on my new journey. The party was over…the pity party. I did this awkwardly, as I think many of us do. In order to mount the courage to overthrow this wave of guilt, it is easy for us to call upon the natural power of this negative energy…resentment and anger…which gives birth to self-entitlement, i.e., not me, not me…becomes me, me, me. I think we are truly entitled to a period of me, me, me as we go through transition…with one very important caveat…intent has to be in the right place. To fine tune that balance is the key to finding grace in gaining the respect of others in your transition…solving a problem requires different thinking than the mind set that created it. So keep your minds open, trust your intuition, and the rest will fall into place.”

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