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Checking in With Osbo’s Bridge Club: Who Needs Therapy?

| Nov 10, 2008
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Doctor Maureen OsborneSpeaking from the perspective of a therapy client as well as a practitioner with almost 30 years of experience, my knee jerk response is to say that everybody needs therapy – that an unexamined life is, well, hardly worth living. However, I have come to see over time that not everybody shares my biases (duh!). Some people are simply unwilling, unready, or uninterested in psychological introspection. Although there is the rare and lucky individual who can lead a full and satisfying life by intuition and presence rather than self-examination, the rest of us will face times when therapy with a competent clinician can be a very helpful way to navigate through the tough patches.

When it comes to transgendered folks, life can often seem like one continuous tough patch. Whether the precise nature of the discomfort is identified from an early age, or is deeply repressed, the transgender Self is always screaming to be heard, silently or otherwise. Although I may risk the scorn of some intelligent and thoughtful members of the T* community in stating this position, my conclusion based on years of listening to transgender stories is that there is always some degree of psychological mayhem that results from growing up gender variant in a society that is staunchly committed to the gender binary. For this reason, I do strongly recommend some involvement in therapy for those considering gender transition. If a competent and experienced gender therapist can see that the individual is relatively healthy psychologically, he or she can serve as a consultant and support person, with sessions limited to a minimum number and frequency. Other clients may require and/or desire a more intensive and lengthy therapeutic engagement in order to come to satisfactory agreement about the nature of his or her true self and what path to follow in order to find comfort and wholeness. For part-timers who have no interest in transitioning but who want to negotiate time and space for their transgender persona with significant others, a trans knowledgeable therapist can be an important resource.

What are the areas in which therapy can be useful for the trans person? The ones that have been most salient in my own practice can be summarized as follows: diagnosis, direction, dialogue, education, and support. I will touch on each of these functions. First is the question of diagnosis. I know full well that a lot of people are prickly about the whole area of diagnosis, and I will postpone the topic of the validity of the GID diagnosis for another column. In my experience, many people arrive at their first appointment with an admirably thorough knowledge of TG issues (thanks in large part to the Internet). Many also present with a pretty accurate estimate of where they stand on the TG continuum, from occasional crossdresser to high intensity, body dysmorphic transsexual. However, they often express both a need for and a fear of a professional validation of their self-diagnosis. It can be a delicate therapeutic matter to affirm a person’s inner gender identity without making them feel that they are heading into the path of a runaway train. On the other hand, there are some people whose gender malaise is more amorphous and variable, and it can take some time to sort out the meanings of this type of presentation before moving into any type of an action plan.

A potentially complicating factor is the presence of so-called comorbid diagnoses, a fancy term for the presence of other complicating psychiatric conditions which need clinical attention and might in fact supercede or call into question the GID diagnosis. Although I have found that it is always therapeutic to validate and begin to explore options for the gender issue, the possibility that other serious psychiatric disturbances exist should not be overlooked. Among common comorbid diagnoses are mild to moderate depression, substance abuse, mood disorders, and personality disorders.

Once a person’s position on the transgender continuum is clarified, therapy can be useful in determining the direction an individual might take to achieve some relief from gender dysphoria. A knowledgeable gender therapist can be a valuable consultant regarding the client’s options, providing education, clinical experience, knowledge of medical, legal, and social resources, and professional referrals for treatments such as contrahormone therapy, electrolysis, voice therapy, and surgical interventions.

I make it clear to my clients that my role is to walk beside them on this journey, with no personal investment in what options they might choose to achieve gender comfort/congruity, or at what pace they choose to move. My main concern is that their choices are ones that will enhance their health and well-being without risking unsustainable personal losses. From the unique perspective of having seen hundreds of others grapple with this dilemma, I’m able to provide feedback about the potential repercussions of their choices. At times, a client’s joy in having his/her inner self acknowledged and the excitement at the prospect of finding relief for lifelong suffering can lead to lapses in judgment which might be avoided with a therapist’s guidance. However, it is also often the case that the client imagines consequences far more devastating than those s/he is likely to encounter in reality, and these folks can benefit from the long range perspective and calm encouragement of an experienced gender therapist.

Dialogue is an important skill for any client to learn to master in therapy, but it can be particularly useful for transgender clients as they try to articulate their inner experience to family, friends, and coworkers. In my approach, dialogue begins in the relationship between therapist and client. My job is to challenge and encourage the client to listen to the “still, small voice within” and to examine his/her own feelings and experiences in depth, with all their possible meanings arising in the context of their roles in family and society. Self-knowledge and a growing self-acceptance allow the client to gain the entitlement to express their side to others who initially might not be understanding or tolerant.

The invitation to dialogue calls for a respectful airing of painful truths among all parties in a relationship. This is no small task when so many of the facts of a transgender person’s inner world have been suppressed or denied or distorted or minimized over many years. One of the important tasks that I undertake as a gender therapist is to invite family members into the therapy office to ask questions, express their own sides, and engage in direct address of one another, with the help of my mediation. I try to set an example by encouraging direct address while deflecting overt hostility. A dialogic approach acknowledges that everybody has suffered and has a story that deserves to be heard.

Education is a valuable function of the experienced and knowledgeable gender therapist. There is an appalling amount of ignorance and bias about gender identity issues among the public and professionals alike, and the internet is awash in misinformation as well. In addition to my clinical experience, I feel that it is my responsibility to keep up with the research literature in this area, to participate in as many professional conferences as possible, and to familiarize myself with trans friendly medical, legal, cosmetic, and community resources.

Lastly, I see the therapist as potentially providing support to the transgender client, both personally, and as a resource for persons in the client’s familial, social, vocational, and religious support systems. I make every effort to be available to speak to or meet with members of the client’s social networks in order to help explain and validate aspects of the transgender experience, particularly where gender transition is part of the therapy. Often I provide a document on my professional letterhead explaining that the client is under my care and engaging in a medically supervised transition, in the event that they run into trouble with legal authorities. Or I might speak with or write a letter to school personnel when the client is a school age child and needs special consideration. I have met with clergy in a transitioning client’s church, and I have also recommended particular churches and/or members of the clergy who I know to be welcoming to trans individuals. I consider all of these activities as part of the working repertoire of the gender therapist, although they might be considered outside the boundaries of a generic therapist.

One final word of warning for the transgender individual seeking professional help is to ask the prospective therapist if they have worked with other transgender clients, and if so how many, and whether they are familiar with the WPATH and the Standards of Care (whether you believe in the SoC or not, this is a good question to weed out people who pretend to know something about treating transgender issues ). I have been surprised by how many clients come to me after spending significant periods of time in therapy with clinicians who have little experience or knowledge of transgender theory and research, and who hold themselves out as competent to treat a transgender person in a generic therapeutic capacity. They may be seasoned, intuitive and highly trained, but without specific knowledge and experience in this area, you may spend more time educating your therapist than receiving the benefit of their expertise. Worse yet, they may believe that their job is to teach you to “accept” your birth-assigned gender, or to overcome your “sexual compulsion”, or some other misinformed but well-meaning mission.

In next month’s column, I will discuss the psychiatric diagnoses associated with transgender phenomena, including Gender Identity Disorder and Transvestic Fetishism, and will consider the controversial question of whether it is at all appropriate to include these in the DSM-IV. I invite your questions and comments.


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