A Therapist's Manifesto
During the first stages of my transition, I saw three therapists. The first was clearly out of her depth, the second was mediocre but thought she was doing a good job, and the third understood pre-transition issues much better than the other two. She was a good match for me. None was trans. However, I don’t believe a therapist has to be trans in order to do good work with clients who are questioning their gender identity, or who are beginning the process of transition. In the years since, I have become a therapist myself and now have a clearer understanding of what the first two did wrong, and how the third therapist served me well.
The first therapist I saw worked in a now-defunct agency (Phoenix Rising) dedicated to providing mental health services to the GLBT communities of Portland, Oregon. When I first came to see her, I did not yet realize I was trans, but was aware of being in the midst of an existential life crisis of monumental proportions. After I’d seen her two or three times, I had an epiphany between sessions, realizing I was trans and not the lesbian I’d thought I was. Of course I brought this into my next therapy session, as I recognized this as the core of my life crisis. The therapist asked me how long I’d been conscious of feeling this way. Because I could not say I’d had a lifelong conscious awareness of discomfort with my birth gender assignment, she immediately discounted my conclusion and tried to convince me I was a maladjusted lesbian. (We had been doing some cognitive behavioral work which led directly to my epiphany – too bad she dismissed my conclusions!)
At the time, I was vulnerable to this sort of feedback, as I felt no certainty about my identity. My therapist’s interpretation caused me to doubt my own intuition and process. I had never been in therapy before, so had no way of realizing I was seeing an inexperienced therapist, or that she was counterproductive to my process – again, I was not able to trust my own intuition. I probably would have stayed with her, to my detriment, had she not violated confidentiality. I told a friend of the incident of violated confidentiality, because I wasn’t sure whether my feelings of betrayal were valid, and he was outraged on my behalf. Only then did I feel justified in switching therapists.
The second therapist I saw (at the same agency) tried to play devil’s advocate, challenging my conclusions about my identity. She, too, was suspicious of my new self-understanding, also because I had not had conscious knowledge of my “trans-ness” until I was nearly 40 years (which I now know is fairly common among FTMs). She saw her role as one of trying to pick holes in my conclusion, trying to test it as if it were a scientific hypothesis. She occasionally got angry with me when I stuck to my guns. I left when I realized I wasn’t getting anything out of our sessions. Since my friend had validated my feelings about my first therapist, I had a bit more trust in my own intuitive process at this point, and left the second therapist on my own.
The third therapist I saw charged a great deal more than either of my first two therapists, as she was in private practice. However, I ended up spending less money than I had for the first two therapists as I only saw her for three hours. That’s all the time it took for her to give me some concrete tools of self-knowledge, and see me further along my path of transition. It was she who wrote my referral letter for hormones and chest surgery, both of which I obtained in 1997.
The crucial difference between the first two therapists I saw and the other two is this: The first two saw their role as one of determining whether I was right in my interpretation of my gender identity (basing their conclusions on the DSM “symptoms” of Gender Identity Disorder), while the third saw her role as one of guiding me in a process of self-knowledge. I was not served well by my first two therapists because they saw my gender identity as an issue for them to diagnose. The third therapist saw my gender identity as an issue that needed clarification, so I could then decide how to live my life.
The following guidelines can help a therapist develop an appropriate case conceptualization for a client whose presenting issue is gender identity:
• Gender is an issue of core identity, not an issue of psychological pathology, and the client is the only one who can make decisions about their core identity. It is not up to the therapist to determine whether or not the client is trans, any more than it is up to the therapist to determine what the client’s sexual orientation is;
• The purpose of the therapy is not to change the client’s mind, play devil’s advocate, or provide some sort of “cure,” but to help the client understand and perhaps modify the natural defenses they developed over the years to cope with living in a narrow-minded culture. Such defenses, necessary while the client was growing up, are probably affecting current relationships in ways that don’t serve the client well. These defenses often inhibit the client’s ability to interpret (or even feel) their own emotions;
• The ultimate goal of the therapy is to give the client a deeper understanding of themselves – what their gender identity and sexual orientation are; how their behavior patterns affect their relationships; how gender has affected their lives; what they hope for the future; etc. This goal is much more easily achieved if the client has become aware of their own emotional process (see bullet point #2);
• In light of all this self-knowledge, the client will be best able to make informed decisions about transition – hormones, or not? Surgery, or not? Which surgical procedures? “Informed” in this case means not only informed about the effects of hormones, surgical options, etc., but more importantly, informed about who they are.
Though it is not the therapist's job to determine identity, it is the therapist's job to determine levels of ego strength and social support, both of which are necessary for a client to transition in this most-unsupportive culture. I believe the greatest predictor of post-transition suicide is lack of social support and isolation. Motivation and extreme unhappiness with their birth gender assignment are not enough - the client must also be stable emotionally, able to “roll with the punches” and handle negative reactions without being completely derailed. For more-fragile clients, establishing a strong therapeutic alliance may be enough for them to proceed with transition. At this point, the therapist will be a pivotal source of support as the client cautiously moves forward into unexplored territory. This is somewhat of a chicken-and-egg situation, as the emotional fragility of such clients is often deeply tied into having been socialized along an inappropriate gender vector, thus gaining ego strength and greater stability is dependent on moving forward with transition.
Regardless of theoretical orientation or methodological expertise, the primary goal in working with a trans client is to facilitate a process of self-knowledge. Because it is not the therapist’s job to determine whether or not a client is trans, this task obviously falls to the client. Because the decisions involved are life transforming and irreversible, deep self-knowledge is the key to the client’s ability to make the best decisions for their future happiness and fulfillment.
The first two therapists I saw believed their job was to determine to their satisfaction if I was really trans or not. What a burden it would be, if that was indeed their task! Making that kind of determination for another person is not a job I would want. The third therapist I saw was much more at ease with me, and more relaxed. Of course she was – she saw the task of determining my gender to be mine alone. She helped me acquire self-knowledge, and when she saw I had that, sent me on my journey.
Had my third therapist not been satisfied with my level of self-knowledge, that would have been a different story. Surgeons experienced in performing trans procedures generally require letters of referral from mental health care providers (one for chest surgery, two for lower surgeries), and I would only write such a letter if I were satisfied a client had deep self-knowledge.
If I find myself hesitant about a client’s process, the question I am asking myself is not, “Is this client really trans?” Rather, I ask myself, “Is this client trying to be more fully who they are – or are they trying to become someone else?” The latter is a client fleeing their past in a manner reminiscent of someone who has DID (Dissociative Identity Disorder, which used to be called Multiple Personality Disorder), and the client in this predicament is going to “feel” significantly different in the room than the client who is seeking self-actualization. If the therapist feels something of this nature may be going on, it may be time to seek consultation with a colleague who has some experience in DID work. I have not encountered (to date) a client who I felt had DID and might not be trans at all, though some of my colleagues have told me about a few clients they have had in that situation.
However, this situation is far from common, and most clients presenting with some degree of gender dissonance are going to be exactly what they seem – trans, perhaps unsure whether to transition or not, and seeking guidance. It is up to the therapist to provide guidance along the journey, without trying to determine what direction the journey takes.
©1998, Reid Vanderburgh, MA, LMFT