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Article Excerpt
This study explored the therapeutic alliance and satisfaction between transgender clients and their therapists. The design was qualitative and heuristically based. Seven transgendered participants who had lived full-time as their non-natal gender for at least three months and who had spent at least the majority of a course of therapy discussing their current gender identity were recruited. Interviews were semi-structured, and each was transcribed verbatim. Three levels of coding were used)or analysis: seven individual depictions in narrative form, a single composite depiction bringing together similarities between the experiences of the participants, and a single exemplary depiction of critical themes. Results suggest that the participants did not experience many of the heterosexist, sexist, and pathologizing biases described in previous studies. Rather, they described supportive and affirming relationships with their therapists. Some participants had had negative experiences with previous therapists. Participants called for further training and education for therapists and other helping professionals. Implications for theory, research, practice, and policy are explored.
INTRODUCTION AND LITERATURE REVIEW
This article explores how both transgendered and transsexual persons perceive psychotherapy and the current roles and training of mental health professionals who may work with such clients. Transgender refers to "behavior, appearance, or identity of persons who cross, transcend, or do not conform to culturally defined norms for persons of their biological sex" (American Psychological Association [APA], 2008, p. 29). Transsexual refers to "anyone who lives socially as a member of the opposite sex, regardless of which, if any, medical interventions they have undergone or may desire in the future" (p. 29). It is recommended that those to whom the area is new read recent statements by professional organizations, such as the American Psychological Association's (2008) Report on the Task Force Report on Gender Identity and Gender Variance; the reports of the Gay, Lesbian and Straight Education Network (www.glsen.org); and the American Counseling Association's (2008) sponsored podcast on counseling queer youth by the president of the Association of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, Dr. Anneliese Singh. Other fundamental writings are Bockting and Coleman (1992); Brown and Rounsely (1996); Califia (1997); Ettner (1999); Gainor (2000); Lev (2004); Lothstein (1983); Pauly (1992); Schaefer and Wheeler (1995); and Seil (1996).
Working with transgender and transsexual clients calls for specialized knowledge. Multicultural counseling guidelines (e.g., APA, 2003) warn of the dangers of therapists not receiving proper training in working with clients who are different from them. According to many authors (Cole, Denny, Eyler, & Samons, 2000; Denny & Green, 1996; Ettner, 1999; Fassinger & Arseneau, 2007; Fontaine, 2002; Gainor, 2000; Perez, 2007; and Ramsey, 1996), graduate students are rarely trained in transgender issues. Lev (2004) notes that current training programs for therapists provide little to no education on gender variance, on the rationale that there are too few gender-variant individuals to justify such attention. If any education is provided at all, it is usually theoretical or tacked on to gay/lesbian/bisexual (GLB) issues. Because of the lack of formal specialized training, therapists wishing for specialized training often have to educate themselves about working with transgendered persons. Few receive the recommended levels of education and supervision for providing care to gender-variant people (Israel & Tarver, 1997; Korrell & Lorah, 2007).
One of the key roles clinicians play with transgender clients is as gatekeepers determining which clients are appropriate for sex reassignment surgery (SRS) or hormone treatment and which are not. Guidelines and recommendations for this decision, called the Standards of Care, were drafted in 1979 by the Harry Benjamin International Gender Dysphoria Association (now the World Professional Association of Transgender Health, WPATH). The current Standards of Care (Meyer et al., 2001) state that anyone desiring SRS or hormone treatment must acquire letters from at least two mental health professionals recommending the individual for the intervention. Previous versions of the Standards of Care specified a certain length of time that the client must be in therapy before the therapist writes the letter, but the most recent version states instead that the length of time is at the discretion of the mental health professionals, putting the onus of responsibility, and power, onto psychiatrists and therapists.
Another area where it is essential for therapists to have specific knowledge and training is diagnosis. Here two concerns are important: differential diagnoses other than gender identity disorder (GID; American Psychiatric Association, 2000), and common comorbid disorders often associated with GID. According to Brown and Rounsley (1996), there are many presenting problems similar to transsexualism for which surgery and hormones are not appropriate, among them confusion and conflict regarding sexual orientation, malingering, and gender dysphoria occurring exclusively during psychotic episodes or dissociative states. Bockting and Coleman (1992) noted other instances in which gender dysphoria is part of another presenting problem, such as psychological pain stemming from a history of abuse, depression, anxiety, or loneliness. Besides determining whether or not a client actually suffers from GID, it is also important to determine what other diagnoses deserve clinical attention. Most authors describe anxiety disorders and depression as being commonly comorbid with GID (Bockting & Coleman, 1992; Gainor, 2000; Israel & Tarver, 1997; Lev, 2004; Ramsey, 1996).
According to Denny and Green (1996), clients usually seek out therapists just before transition when they are having trouble functioning in school, work, or social situations; are confused about their sexual orientation; are depressed or experiencing substance abuse problems; or are engaging in fetishistic behaviors. All these difficulties can mask an underlying GID. It should also be noted that there is heated debate about whether or not a diagnostic label of GID is helpful to transgendered individuals (APA, 2008).
Perhaps linked to the diagnostic debates within the mental health field, as well as inaccurate assumptions and stereotypes among counseling and medical professionals, many transsexual persons have historically not felt comfortable trusting therapists (Cole et al., 2000; Gainor, 2000; Israel & Tarver, 1997; Korrell & Lorah, 2007). Transsexual persons have admitted to fabricating or exaggerating experiences so that they would not be denied surgery or to conform to what they believe their therapists' stereotypes might be (Bolin, 1988; Brown & Rounsley, 1996; Ramsey, 1996). In fact, some transgender and transsexual clients may consider their therapists to be adversaries due to the power differentials inherent in the therapist's gatekeeping role (Fontaine, 2002). Such assumptions may be barriers to an effective therapeutic relationship.
In contrast, Bolin (1988) found that not all transsexuals distrusted their therapists. Through communications networks transsexual persons learned which professionals were more likely to recommend them for surgery or which had less stringent criteria for evaluative resources, such as inventories measuring femininity. Bolin's participants also tended to trust clinicians with master's degrees or social workers more than those who had doctoral degrees in psychology or were psychiatrists. They preferred therapists who had no preconceived notions about transsexualism until they themselves began working with transsexual clients. Bolin's participants also trusted female clinicians more than males because they felt females were less likely to endorse stereotypical sexist definitions of femaleness and femininity. Seil (1996) also noted that many transsexual and transgendered clients prefer gay-identified therapists or those who specialize in treating gay, lesbian and bisexual clients. While a number of more current writers (Bockting, Knudson, & Goldberg, 2007; Israel, Gorcheva, Walther, Sulzner, & Cohen, 2008; Korrell & Lorah, 2007) speak to recommended approaches for counseling transgendered clients, the views of transsexual clients themselves are largely unpublished.
Given that heterosexist, sexist, and pathologizing biases have existed among clinicians even in the recent past, the present investigation sought to determine the therapy experiences of transgendered and transsexual individuals today. It has been at least five years since research on this topic has been conducted. Although in...
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