URNotAlone

The Role of Psychotherapy in Meeting the Needs of the Transgender Community

July 24th, 2007 7:08 pm MDT

AGA Newsletter; Volume 2, Issue 1  Author - James T. Clarke, MSW, LCSW, Gender Specialist A frequent question posed by some individuals who are pursuing transition from biological gender characteristics to desired gender presentation is why do I need psychotherapy? The question is valid. After all, being transgender is not, in and of itself, a psychological deficiency that requires intervention, and unlike more recognized therapeutic interventions, there is no need to intervene to change the individual’s core beliefs. Being transgender is something that needs to be embraced, appreciated and validated.  However, the process of realigning gender presentation, whether this realignment is desired on a full time or periodic basis or includes hormonal or surgical intervention, is a process that should not be undertaken without assistance. The road to transition goes through each individual’s social and eco-systems and involves internal and external reactions to the decision. The best interests of the transgender client can only be achieved by assisting the individual to identify and achieve their desired outcome with minimum psychological trauma or interpersonal relationship disruption. That is why any therapeutic intervention with a transgender client should include an understanding and utilization of the Harry Benjamin Standard’s of Care for Gender Identity Disorder. The stated goal of the Standards of Care (SOC) is to assist the individual to achieve lasting personal comfort and maximize overall psychological well-being and self- fulfillment. It is imperative that this become the primary goal of the therapeutic intervention.  For many individuals seeking to change gender presentation, the psychotherapist and other members of the healthcare field are seen as gatekeepers, unfairly given the power to make decisions that affect the individual instead of respecting the right of the individual to determine what is in their best interest. These are legitimate concerns; however, these beliefs can be reframed if the therapist communicates with the client that they are not a gatekeeper, but rather an experienced guide who can assist the client to finally open the gates to gender freedom and be fully prepared for what is on the other side-- both the positive and potentially negative. Preparation, knowledge, understanding and an honest presentation of the realities of the transition process are imperative.  To this end, the essential goal of the psychotherapist is to establish a supportive alliance based on the client’s right to self determination and to assist the client to set goals, access resources and engage in productive dialogue that will assist in problem identification and resolution. All transgender clients share commonalities and yet, each client is a unique individual with unique problems. The assessment process of the therapeutic intervention is an integral part of establishing the unique needs of the individual.  A persistent argument among those who seek to unjustly pathologize transgender clients centers on whether Gender Identity Disorder (GID), is biologically or environmentally based. In other words, the old argument over nature verses nurture. Unfortunately, many ill informed healthcare providers would prefer to believe that the condition is based solely on environmental factors and can, therefore, be reversed. In reality, it is both biological and environmental. Even though much is left to be done in terms of research in this area, most current studies support the idea that being transgender is a biologically based condition related to a brain anomaly. Specific studies have demonstrated that the hypothalamus in a transgender individual is similar in size and consistent with that of a biological member of the individual’s desired gender as opposed to the birth gender inappropriately assigned based on existing sexual anatomy. So there exists support for the argument that being transgender is biologically based. Clearly there is an urgent need for more research, and the utilization of MRIs could be an ideal method of finally providing convincing data to substantiate the biological origins of the transgender condition. However, you cannot dismiss the role of the environment on the emotional or psychological development of the transgender client. Strong family and societal pressures, too often tragically negative, are exerted on the developing child and continue through adolescence and adulthood. It is these pressures that can produce co-occurring emotional reactions that eventually become the primary focus of psychotherapy. Of all these emotions, the most debilitating is shame. Until informed otherwise, the transgender client has no shame or guilt about the condition, but when shame is introduced within the family system, usually by parents or by school systems and/or peer pressure, the resulting internal conflict can result in depression, separation or generalized anxiety disorder, obsessive compulsive disorder, chronic stress disorder and in certain cases, the development of personality disorders including but not limited to borderline and avoidant personality disorders. Additional reactions to overt or covert shame and external pressure to conform include isolation; distress; problematic relationship issues; an inability to function in social, educational and employment situations; avoidant behaviors that include substance abuse, sexual addiction, self- injurious behaviors; and in far too many cases, suicide ideation that can lead to attempts and completion. In addition, being forced to deny one’s true gender identity can lead to medically related conditions, specifically but not limited to ulcers, hypertension and heart conditions. Shame and attempts at denial can have other detrimental effects. Biological males who are transgender can engage in what is referred to as the flight to masculinity which can include entering into ill-advised marriages and pursuing dangerous occupational choices as a means of preventing unwanted disclosure of their transgender status. Transgender, biological females who are faced with shame are forced to abandon their innate or natural sense of masculinity and instead retreat into the psychologically traumatic and painful socially-sanctioned role of femininity, and may turn to eating disorders or self-injurious behaviors such as cutting as a means to maintain the perception of control over their bodies. In other cases they are forced to accept the undesired role of being a lesbian as opposed to embracing their true gender and moving towards self-actualization.  The process of psychotherapy is, therefore, a process of support, validation, exploration, assessment of ego strength and the identification of co-existing mood disorders, destructive emotions, distorted self concepts and avoidant behaviors. It is in essence an orchestrated movement towards being genuine and a chance to put the puppet of undesired gender conformity away. As the process continues, therapy also focuses on family and other social system pressures including barriers to progress and resolving these conflicts. Psychotherapy with the transgender client is multifaceted, but in the end, it is about assisting clients to simply become themselves. It is imperative that a psychotherapist working with a transgender client be a trained gender specialist. A gender specialist is able to assess, explore and identify differential diagnoses where applicable and coordinate a treatment plan that meets the client’s needs. Of equal importance, a particular problem can arise when an individual meets with a therapist not trained to understand the needs of the community, specifically the issues related to countertransference. This occurs when the therapist projects his or her beliefs, misconceptions, biases or ignorance of the condition into the therapy session. Countertransference will prevent the creation of an effective therapeutic alliance and invalidate the client’s sense of self. It can also create hesitancy in the client to trust other therapists and seek to continue with transition on his/her own. A therapist that assists transgender clients must be completely non-judgmental and have the ability to understand the needs of the client from the client’s perspective if they are to see the woman or man within and be able to help that person to emerge. You cannot, nor should any therapist seek to cure a transgender client, primarily because the client does not want to or more importantly need to be cured. The essential goals of psychotherapy are, therefore, to increase internal self-validation, support self-determination and eliminate individual and societal barriers to gender congruity by creating a therapeutic environment that stresses the right of the client to achieve self-fulfillment while providing the tools through therapeutic interventions that empower the client on his/her individual journey.  This is the first in a series of articles about Psychotherapeutic Interventions with the Transgender Community. You can provide comments, feedback or seek additional information by contacting the author directly at \n jclarke@Transworldtherapy.com