Don't repeat the mistake on page 847 of The Prayer Book .  Here is what God really requires from the chosen people:

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A series of essays towards General Convention in 2003

Not Even An Afterthought: Counseling for the Transgendered

Transgender Counseling:


Beyond Afterthoughts and Into the Margins


Ann Carlson

September 2002



Sue and Sue (1999) include as a final chapter in their textbook “four other groups who have experienced systematic marginalization and oppression by the dominant culture” who are included “because they have received the most interest from the American Psychological Association and the American Counseling Association.” (p. 304).  Even though they state that “the inclusion of these groups in a single chapter in no way implies that we view them as ‘less important,’ but rather that we have a greater familiarity with issues related to persons of color” (p. ix), one cannot help but interpret that these groups are something of an afterthought to the multicultural discussion.  However, there is one culturally different minority that does not appear, even as an afterthought, in Sue and Sue.   This equally marginalized, and often invisible, group comprises somewhere between 3% - 10% of the United States population.  (Ettner, 1999).  They are the transgendered – persons whose gender identity and/or biological sex in some way transgresses the societal norm.

What is it about gender that keeps us from knowing and serving the transgendered, that makes even the discussion of gender nonconformity in our society so difficult?  Who are the transgendered among us?  Can they be considered both culturally distinct and a marginalized and oppressed group?  What are their special needs and issues, and those of their family and friends, when interacting with the mental health system?  And, what are the added complications of gender variance and a minority ethnicity?  These are the questions I will attempt to address in this paper. 

I am also the partner of a transgendered person (John/Jan) who is in the process of male to female (M2F) transition.  Throughout this paper, when I feel that our experiences serve to illustrate a point, I will include parts of our personal story.  I will set these apart in italicized paragraphs to distinguish between my research and my personal feelings and experiences.


What is “Transgender”?

The relative invisibility of the transgendered in our society is directly related to our strict adherence to a binary understanding of sex and gender.  “Western culture is deeply committed to the idea that there are only two sexes.  Even language refuses other possibilities.”  (Fausto-Sterling, 1993, p. 20).  We see “male” and “female” and, for most of us, any exceptions to those categories seem so profoundly “other” that they actually serve to reinforce the binary system.  As Kate Bornstein (1995) says, “The choice between two of something is not a choice at all, but rather the opportunity to subscribe to the value system which holds the two presented choices as mutually exclusive alternatives.  Once we choose one or the other, we’ve bought into the system that perpetuates the binary.” (p. 101).  Thus, if we are not going to buy into the binary, if we want to see the transgendered for whom they really are, we need to understand the extent of the diversity around us.

Even without adding the more ambiguous layer of “gender” to the discussion, the question of physical sex leads to an amazing diversity.  According to scholar Steven Whittle (as cited by Mollenkott, 2001), “Currently medicine recognizes over 70 different inersex syndromes, and one in every 200 children will be born with some sort of intersex matrix.” (p. 45).  The actual number of intersexed individuals is difficult to determine, since the tendency, historically, has been to hide such a condition.  Kirk and Rothblatt (1995) appear to be in the minority when they state “Inter-sexual problems such as pseudohermaphroditism or Kleinfeler’s syndrome are very uncommon as well and will generally be diagnosed quite early in life.” (p. 10).  In her seminal 1993 essay, Fausto-Sterling stated that about 4% of human births are intersexual.  Mollenkott (2001) cites Rothblatt as another source of the 4% figure.  (Perhaps Rothblatt’s opinion has changed since the 1995 book, as 4% doesn’t sound “very uncommon” to me.)  Between 1993 and her 2000 revisit, Fausto-Sterling led at Brown University the first systematic investigation of the available data and concluded that 1.7% is a more accurate estimate.  1.7% or 4% or somewhere in-between, this is not an insignificant population.  Why do so many of us not know they exist?

In 1993 I was an infant in the complex gender world.  I had discovered a few years earlier that one of my best friends was gay, and had started to investigate the realities of that world and to transform my homophobic tendencies.  I was only vaguely aware of my husband’s cross-dressing, and it was not yet a subject that we could discuss.  But one spring day our issue of The Sciences arrived with the tantalizing cover article “The Five Sexes.”(Fausto-Sterling, 1993).  I read it, re-read it, put it away for a few weeks and thought about it, got it out again, copied it, and sent it around to several people for comments.  It was a revelation, but my main response was a feeling of betrayal.  If as many as 1 in 25 people are not by nature either male or female, why had I never been told?  Where was the discussion in my biology class?  In health?   In psychology?  Who are these people?  Surely I must know a few.  Why the conspiracy of silence?

I tucked copies of the article away in several of my files, afraid to lose track of it, afraid of forgetting this tenuous introduction to an entirely new reality.  I didn’t know why the article affected me so much, but I knew it was a beginning…

The concepts of gender, gender assignment, gender identity, gender expression, and gender attribution add considerable complexity to the discussion.  Gender is a socially determined construct – the association of particular qualities of behavior and societal roles with biological sex.  Gender assignment is a medical/legal determination: it’s the male or female designation on your birth certificate, the legal determination of whom you are allowed to marry, whether or not you are required to register for the draft.  Because of physical appearance at birth, or occasionally because of genetic testing, a person is assigned a legal status that allows only male or female, and nothing in-between.  Gender identity is the association of self with maleness or femaleness, or in the case of trans-gender, with something not entirely one or the other.  According to Fausto-Sterling (2000), “Gender identity presumably emerges from all of those corporeal aspects [sex at cellular, hormonal and anatomical levels] via some poorly understood interaction with environment and experience.”  (p. 22).  Ettner (1999) concludes from research done by T.G. White in 1997 that gender identity is a process that begins in utero and is consolidated by three years of age.  Gender expression is the outward expression of gender roles to society; the “performance of gender.”  Gender expression normally determines the gender attribution assigned to us by society.  In the words of psychologist Suzanne Kessler (as quoted in Fausto-Sterling, 2000), “In the everyday world gender attributions are made without access to genital inspection. … What has primacy in everyday life is the gender that is performed, regardless of the flesh’s configuration under the clothes.” (p. 22).

Final layers of complexity are sexuality and sexual orientation, encompassing a wide range of possibilities for anyone at any point on the gender spectrum.   “The matter of sexual orientation represents an ongoing concern for transgender individuals and those providing specialized support care, party because the terms sex, sexual orientation and gender identity are interchanged erroneously.”  (Israel & Tarver, 1997, p. 43).  “Some transgender individuals may not have crystallized a sexual orientation during puberty, and may feel uncertainty or reexplore their sexual orientation simultaneously with exploring gender-identity issues.”  (p. 45).  It can even be difficult to draw a line between “gay/lesbian/bisexual” and “transgender.”  “Since binary gender insists that ‘real men’ desire only women and ‘real women’ desire only men, homosexuals and bisexuals really do ‘trans’ or cross over the gender boundary by loving people of their own gender.”  (Mollenkott, 2001, p. 72).  As Erhardt (2002) says, “Human reality, however, resists being forced into neat little either/or boxes.  The existence of intersexuals belies the biological male/female dichotomy.  Some people are asexual, bisexual or omnisexual, so I wish society, even queer society, which you would expect to be a bit less sexually rigid, would quit trying to force us into hetero/homosexual boxes.  I see both gender identity and erotic orientation existing on a spectrum as well.”

According to Fausto-Sterling (2000), “The medical and scientific communities have yet to adopt a language that is capable of describing such diversity.” (p. 22).  The umbrella of “transgender” is often used, as I will use it here, to describe the full range of people who transgress the bipolar gender system.  According to Mollenkott (2001), “the term has been extended to include intersexuals, transsexuals, cross-dressers, drag queens and kings, androgynes, and anyone else who feels ‘othewise’ from society’s gender assumptions.” (p. 40).   Mollenkott introduces the term ‘omnigendered’ and Miller (1996) ‘polygendered’ into the mix to indicate individuals whose gender identity is either too expansive or too fluid to fit into the any of other categories.  Importantly, Mollenkott along with Israel and Tarver (1997) remind us that not all who would fit these definitions would agree on the use of the terms.

Most of these terms are in common enough usage that their definition in this paper is not necessary (see Mollenkott (2001), Ettner (1999), Israel & Tarver (1997), or Miller (1996) for more discussion).  I will, however, discuss the use of “transsexual” and “transgenderist.”  Ordinarily, transsexual is used to refer to people who have undergone, or plan to undergo full sex reassignment, including genital reassignment surgery.  Transgenderist, and occasionally simply “transgender,” can be used to refer to those whose core identity is transgender.  According to Mollenkott, they are those who live in role part-time or full-time as members of the “opposite” gender, “sometimes using hormones and cosmetic surgery, even castration, but they do not seek gender reassignment surgery.  Occasionally they self-identify as bi-gender.” (p. 64).  I will use the term “transgenderist” in this sense, to distinguish from my broader use of “transgender.”  Interestingly, the attempts to distinguish between “transsexual” and “transgender” become less clear as social acceptance grows and options increase.  Consider the ambiguity and overlap in the following definitions:

Transsexuality is a function of the binary gender construct, because when only two alternatives exist, a person is forced to choose one and then do whatever is necessary to present herself or himself in a way that is culturally appropriate.  (Mollenkott, 2001, p. 51)

Transsexualism, in fact, is one distinctly twentieth-century manifestation of cross-dressing and the anxieties of binarity, an identifiable site, inscribed on the body, of the question of the constructedness of gender.  (Garber, 1992, p. 15)

The term ‘transexual’ is used to describe persons who are either ‘pre-op’ or ‘post-op’ … Transsexualism is not a surgical product but a social, cultural and psychological zone.  (Garber, 1992, p. 106)

Transsexuals, people who have an emotional gender at odds with their physical sex, once described themselves in terms of dimorphic absolutes – males trapped in female bodies, or vice versa.  As such, they sought psychological relief through surgery.  Although many still do, some so-called transgendered people today are content to inhabit a more ambiguous zone.  (Fausto-Sterling, 2000, p. 22)

[The transgendered are] people who are challenging the obligatory two-gender system by blending public features of maleness and femaleness, or by accepting bits and pieces of the surgical options without “going all the way,” or by doing both.  People who are transgender disrupt gender in two ways:  They refuse to provide the cues that would permit them to be regarded as either male or female.  And they treat biological signs of gender (including genitals) as bodily ornaments – neither more nor less elective than a face-lift.  (Kessler, 1993)

The DSM-IV term for all of the above is “gender dysphoria,” which I address last and somewhat reluctantly because many feel the inclusions of “gender identity disorders” in the DSM-IV serves only to stigmatize individuals.  “The DSM-IV-TR (text revision, August, 2000), like its predecessors, may too easily be interpreted to deny the existence of healthy, well adjusted gender variant people and to provide a justification for discrimination against them.”  (GIDreform, 2002).  For transgender advocacy groups, “it is time for diagnostic criteria that serve a clear therapeutic purpose, are appropriately inclusive, and define disorder on the basis of distress or impairment and not upon social nonconformity.” (GIDreform).   As Bornstein (1995) says, “I was gender dysphoric for my whole life before, and for sometime after my gender change – blindly buying into the gender system.  As soon as I came to some understanding about the constructed nature of gender, and my relationship to that system, I ceased being gender dysphoric.”  (p. 119).

Lastly, how many transgendered are out there?  We have already seen that somewhere around 2-4% of the population are intersexual.  According to Ettner (1999), a “conservative estimate is that 3-5% of the United States population has some degree of gender dysphoria.  Others claim that 8-10% is more precise.” (p. 28).  Israel and Tarver (1997) give a more conservative estimate of 3% of the general population.  Most sources claim approximately equal numbers of male to female (M2F) and female to male (F2M) transgendered or transsexual individuals, although several indicate that M2F individuals in our society are more visible, making true estimates of the numbers difficult.  Fewer F2M’s seek sex reassignment surgery, where the complexity, cost and success rates are not equal to M2F surgery.

Considering that many transgendered individuals do not completely come to understand themselves as such until well into their adult lives, and that intersexuals often never know about their condition or discover it only when they attend a fertility treatment clinic later in life (Steven Whittle as cited in Mollenkott, 2001), I agree with Mollenkott when she concludes: 

That means that anybody among the vast majority of us could conceivably be atypical and therefore intersexual and transgender without even knowing it – a marvelous reason for relaxing our rigid gender expectations.  (p. 44).    


A Brief History

Understanding some of the history of society’s interaction with the transgendered is a necessary background for working with these individuals, their family, friends and co-workers.

Despite the strident assertions of some of society’s “gender defenders” (For example, see Stanfield (2001), who says “The causes of such imbalances are varied – from stress and the drugs prescribed to pregnant women to environmental pollution – but the essential point is that human interventions are disrupting the natural dimorphic brain patterning of male and female infants.”), intersexuals and the transgendered have been a part of society throughout history.  Transgendered expression dates back to the beginning of time and documentation of such practices at least to the Old Testament. (Ettner, 1999)  I will discuss other societies’ responses further in the section Transgender and Other Cultures, but will briefly discuss the Western European perspective here.

Western European society has been heavily invested in binary gender rigidity at least since the Middle Ages.  “In Europe, a pattern emerged by the end of the Middle Ages that, in a sense, has lasted to the present day:  hermaphrodites were compelled to choose an established gender role and stick with it.  The penalty for transgression was often death.”  (Fausto-Sterling, 1993, p. 23).  Transgendered persons were forced to hide and only acknowledge by society in rumors, derision, and sensationalized stories, although the penalties were generally more severe for women than for men.  For example; sensationalized (but unsubstantiated) rumors of a female Pope Joan who was killed when giving birth made it obvious that she was a woman, or the burning at the stake of Joan of Arc for masquerading as a man, vs. the general notoriety but acceptance of James I for his flamboyance and overt bisexuality, or the “sorrow” and “anger” with which his enemies pointed to the “poor judgment” of Lord Cornbury (Governor of New York and New Jersey from 1702-1708) for dressing as a woman.  (Garber, 1992).

The twentieth century has ushered in great change in how the transgendered cope in society, with huge advances in medical care and much interest from the psychiatric and psychological professions.  Unfortunately, until recently most attitudes have remained in the Middle Ages.   “Most of us have grown up in a land that looks upon cross dressers and transsexuals as psychiatric casualties.”  (Richard Docter, in foreword to Miller, 1996, p. xix). 

According to Garber (1992), "Transsexual surgery has been performed since 1922." (p. 15).  However, it was Dr. Harry Benjamin who brought both the medical and psychological treatment of the transgendered into the national consciousness.  Dr. Benjamin saw his first transgendered patient in 1948, and by 1965 had seen three hundred and seven transsexual patients.  (Ettner, 1999).  His most famous patient, Christine Jorgensen, made headlines in 1953.  (Garber, 1992).  He published a book, The Transsexual Phenomenon, in 1966 that broke the silence for thousands of transsexuals.  (Ettner).  Dr. Benjamin lent his name to the he Harry Benjamin International Gender Dysphoria Association (HBIGDA) and the associated Standards of Care (HBIGDA, 2001), which are internationally accepted standards that remain the primary reference for the medical and mental health treatment of gender identity disorders. 

Controversy over the transsexual phenomena exploded into the news with the publication and ensuing debate about Green and Money’s Transsexualism and Sex Reassignment in 1969.  Money, an influential Johns Hopkins university gender specialist “believed that gender identity is completely malleable for about eighteen months after birth.  Thus, he argued, when a treatment team is presented with an infant who has ambiguous genitalia, the team could make a gender assignment solely on the basis of what made the best surgical sense.”  (Fausto-Sterling, 2000, p. 20).  He approached gender dysphoria as a psychological pathology resulting from inadequate early gender identity development.  Money’s ideas came into question as more research, along with transgender activism, moved the prevailing attitude towards the belief that gender identity development has both biological and environmental components.  “The revelation of cases of failed reassignments and the emergence of intersex activism have led to an increasing number of pediatric endocrinologists, urologists and psychologists to reexamine the wisdom of early genital surgery.” (p. 21).

By the late 1970’s, society had Renée Richards, Jan Morris, and several other famous transsexuals to contemplate.  However, throughout the 1970’s and into the 80’s, “Many people who sought psychiatric help for their gender condition, and the inevitable depression that resulted, were involuntarily committed.”  (Ettner, 1999, p. 45).  There was still much controversy and individuals willing to “go public” were subject to extreme prejudice.  In the spring of 1979, Johns Hopkins Hospital stopped performing sex-reassignment surgery because research by Dr. Jon K. Meyer failed to show objective improvement in patients’ lives.  However, this conclusion was successfully challenged in 1980 because of multiple flaws in his research methodology and conclusions, and the value-laden nature of the investigations.  (For example, patients were assigned a quantitative score of (minus 1) if they cohabitated with a person of the “non gender appropriate sex.”)  (Ettner).

 After a considerable thought and several previous attempts to “try on” various women’s names, my partner selected Jan Renée as the name to use during transition and which she will eventually make her legal identity.  At the time, the notion wasn’t a conscious one, but we are both now delighted to think of the name as a nod to the courageous Jan Morris and Renée Richards, who allowed their very public stories to blaze the trail.

Not until the 1990’s did the general view of the transsexual change from the perspective that the condition was associated with an underlying or coexisting psychiatric disorder.  A landmark study was conducted by Cole, O’Boyle, Emory and Meyer in 1997 retrospectively of 435 gender dysphoric individuals and concluded that transsexualism “is usually an isolated diagnosis and not part of any general psychopathological disorder.”  (Study as referenced in Ettner, 1999).  “Some European laws have been changed to reflect this new recognition that transsexuals are born, not made, and as such deserve medical care and legal protection.  We in the United Sates have not followed suit, as yet.”  (Ettner, p. 57).

Currently, the subjects of cross-dressing, transgender, and transsexualism are very much in the public eye.  “Why have cultural observers today been so preoccupied with cross-dressing?  Why is it virtually impossible to pick up a newspaper or turn on the television or go to the movies without encountering, in some guise, the question of sartorial gender bending?  On American television, talk shows have had a field day with the topic."  (Garber, 1992, p. 5).  But, it is the transgender community itself that is taking up and shaping the discussion.  “Many nontranssexual professional academics are beginning to catch on to what we transsexuals have know for a long time:  Transsexuality encompasses a fascinating, complex set of phenomena that poses some radical questions about that way sexuality, gender, identity, and desire are instituted and maintained.”  (Susan Stryker, as quoted in Israel & Tarver, 1997, p. 241).  “We’re moving from perverts to experts in that venue [TV talk shows], those of us who are speaking out, telling our stories.”  (Bornstein, 1995, p. 241).  And they are calling for change:  “The disproportionate number of essays in this addendum that address the need to depart radically from the existing standards of care endorsed by HBIGDA underscores both the depth of feeling on this issue in the transsexual community as well as the seriousness of the situation.”  (Stryker in Israel & Tarver, p. 244).

Society would do well to listen to this voice from the margins.  As Miller (1996) reminds us, “the minority of any group or society is the growing edge of that society, its conscience, and its spiritual teacher.”  (p. 156).


Transgender, A Culture?

The subject of this Capella University course is counseling the culturally different.  Therefore, we must examine whether the transgender community can be considered a culturally different group.  My thesis is that they can, and I will attempt to demonstrate this by looking at two different criteria: society’s response to the transgendered, and transgender identity development.


Society’s Response:

Sue and Sue (1999), observe, “The sociopolitical dynamics related to the treatment of marginalized or oppressed groups in our society share many similarities.  Prejudice, stereotyping, and discrimination and their negative effects on these groups operate from a common foundation with frightening effects.”  (p. 304).  Therefore, they assert that other groups, such as gays and lesbians, the elderly, and women may be considered “culturally distinct” because of the attitudes, isolation and oppression that they may experience from society, and the ways they may band together to endure or fight this oppression.  The transgendered are another such group.  In addition, in looking at the “anatomy” of prejudice, Young-Breuhl (1996) says, “There is an elemental anxiety, an inability to tolerate difference, a threat to narcissism -- 'She (or he) is not like me.’”  This perception of difference is what gives rise to oppressed cultural groups in our society, and society’s perception of the transgendered as “different” is very strong.  In fact, the transgendered are “The only group it is still politically correct to mock, and the only group specifically excluded from the Americans With Disabilities Act.” (Ettner, 1999). 

What gives rise to this fear and societal oppression?  According to Mollenkott (2001), “To many observers, the trans-ing of gender seems like a wanton removal of all the old landmarks.  If crossing gender boundaries erases those boundaries, how will social order be maintained?”  (p. 166).  The gender nonconformist is seen as a threat to the framework of society, the comfortable rules and norms that make us secure and give us a sense of security and unity.  Garber (1992) calls it a “category crisis,” a dissolving of the borderline that permits “crossings from one (apparently distinct) category to another:  black/white, Jew/Christian, noble/bourgeois, master/servant, master/slave.”  For her, “The notion of 'category crisis,' I will contend, is not the exception but rather the ground of culture itself." (p. 16).  Any group perceived as allowing these border crossings receives the full brunt of the cultural backlash.

If they let us dance,

Me and my people,

If they let us dance,

Who would lead?  (Bornstein, 1995, p. 228)

Considering this cultural backlash, it is not surprising that “social and economic marginalization frequently accompanies the transgender experience.” (Israel & Tarver, 1997, p. 19).  Transgendered individuals face high rates of poverty and victimization.  “This situation exists because transgender individuals have little societal support or access to legal recourse, particularly where they are disenfranchised.”  (p. 37).  The transgendered are “kept in line” by the constant public humiliation and threat of violence.  “Those who came out of their closets were either studied under a microscope, ridiculed in the tabloids, or made exotic in the porn books, so it paid to hide.  It paid to lie.”  (Bornstein, 1995, p. 8).  Thus, Bornstein concludes, “Humiliation is the whip of the defenders of gender.”  (p. 88).

Having been rejected by the dominant culture, transgender and transsexual individuals have created safe spaces for themselves, support groups, social groups, even whole communities, and are engaging in social activism.  “Is there a role for the transgendered in this culture?  I don’t believe it’s up to the culture to create such a role.  I think it’s up to the transgendered to claim one for themselves.”  (Bornstein, 1996, p. 130).  “But now there’s a new generation of transsexuals who are assessing their journey not as either/or, but rather as an integration, a whole.  In bypassing the either/or construct of what has up to now been transsexualism, these new transsexuals are slipping out from under the control of the culture.  And a new sub-culture is being born.”  (Bornstein, p. 121).

The transgender culture is hard to define.  Certainly it varies all over the place.  Jan and I have been lucky to be in a location where the local gay/lesbian/bisexual groups are generally also friendly towards transgender folks.  Jan had her first several experiences of “going public” at parties given by gay friends.  The local transsexual support group is a bit of a different story.  Some are really messed up and maybe not the people we’d normally choose to socialize with, although there’s a bond because of being in the same cultural boat.  Besides, they are really down on cross-dressers, and that bothers us.  I guess they think cross-dressers are not quite “the real thing.”  I have never had any inclination to go to any of the support groups for spouses and family.  The ones that I’ve been told about seem characterized by much angst and tears, and I just can’t imagine getting anything useful out of sitting in a bunch of “Why me?” sessions.  I can’t, right at the moment, see myself as being helpful to someone else in that situation, either.  I wouldn’t have enough patience.

Jan was lucky to be exposed to a much different transgender community at Esprit 2002, a regional transgender conference she attended last spring.  She was lucky (and relieved, I think) to discover a world of fun, intelligent, successful, and not gender-obsessed transsexuals, transgenderists, and cross-dressers.  It has made a huge difference to find a community where she fits in, and is proud to do so.  She wants me to go with her next year, and I plan to.  Maybe the other partners and spouses will be of the kind who think this is all just one aspect of life, and not the most important.


Transgender Identity:

Sue and Sue (1999) propose the use of a Racial/Cultural Identity Development (R/CID) model:

To aid therapists in understanding their culturally different clients’ attitudes and behaviors.  The model defines five stages of development that oppressed people experience as they struggle to understand themselves in terms of their own culture, the dominant culture, and the oppressive relationship between the two cultures:  conformity, dissonance, resistance and immersion, introspection, and integrative awareness. (p. 128).

It is easy to see transgendered people in and moving through these stages with regards to transgender identity development.

In the conformity stage, “individuals are distinguished by their unequivocal preference for dominant cultural values over their own.” (Sue & Sue, 1999, p. 129).  Bornstein (1995) writes; “most of us assume that there is gender; that there are only two categories of gender, and that we are (have the identity of) one or the other.  We have a lot invested in this belief – it’s very difficult to imagine ourselves genderless.  It’s difficult to the degree that our identities are wrapped up in our gender assignments.  We need to differentiate between having and identity and being an identity.”  (p. 117).  In this stage, attitudes and beliefs towards self are self-deprecating, while the belief is that the dominant culture’s attitudes and social standards are superior.  This stage “has a profound negative impact upon minority groups.”  (p. 129).   Transgendered individuals, being raised in a culture that is overwhelmingly prejudiced against them, generally by parents, who are solidly within the dominant culture, have considerable difficulty breaking from the conformity stage.  According to Israel and Tarver (1997), “In many cases, negative stereotypes reinforce transgender individuals’ fears, and so their conditions commonly reach crisis proportions before they seek help.”  (p. 33).  Sue and Sue also state that attitudes and beliefs towards members of different minorities in this stage are generally discriminatory.  Bornstein, reflecting on the transgender experience of identity development, writes; “One trouble in having only a few of ‘us’ and a lot of ‘them,’ is that it’s easy to hit out at the wrong ‘them.’”  (p. 82).

I would also say that the conformity stage “has a profound negative impact” on everyone around the transgendered person.  During the first few years of our marriage, while John was hiding his transgender status from himself and everyone else, the struggle came out in confusing and painful ways; inability to communicate, secrecy, unwillingness to trust, and constant anxiety.  We nearly divorced at John’s instigation after just one year of marriage.  After three-four years, I was the one who was ready to throw in the towel.  But at about the time we started being honest with each other and together exploring John’s gender confusion.  What a difference our attempts at understanding, communication and trust have made!

Encountering “information or experiences inconsistent with beliefs, attitudes, and values held by the dominant culture” brings about the dissonance stage.  (Sue & Sue, 1999, p. 132).  There will be conflict between self-deprecating and self-appreciating attitudes and beliefs.  As Bornstein (1995) describes it for transgender experience; “if we can’t call the freaks names anymore because we realize we’re one of them, then we have to look back at our position as a former insider, and we begin to devalue that.  (p. 81).  This stage also encompasses growing suspicion and distrust of dominant group values.  Transgendered individuals will start asking questions, such as; “I am forced to wonder whether our culture’s concept of sexual normalcy, which defines the sex organs of as many as 4 percent of newborn infants as ‘defective,’ is not itself defective.”  (Chase, 1993).

In the resistance and immersion stage, the “individual tends to completely endorse minority-held views and to reject the dominant values of society and culture.”  (Sue & Sue, 1999, p. 133).  Consider the experience of John Stoltenber, who says; “If you look at all the variables in nature that are said to determine human 'sex,' you can't possibly find one that will unequivocally split the species into two. … 'We are … a multisexed species.'  I first read those words a little over ten years ago – and that liberating recognition saved my life."  (As quoted in Davies & Haney, 1991, p. 147).  There may be feelings of guilt and shame for having formerly endorsed the dominant culture, coupled with anger at past oppression.  Mollenkott, a self-proclaimed gender-transgressor, exhibits this type of anger when she writes; “The fixed concept of bi-gender complementarity, with all its freight of male primacy and female subordination, has begun to collapse because its stake is moving out from underneath.  And I for one will be glad to see the conclusion of the matter.”  (p. 36) Bornstein (1995) shows both the anger and possibility of shame in past participation when she writes, “The correct target for any successful transsexual rebellion would be the gender system itself.  But transsexuals won’t attack that system until they themselves are free of the need to participate in it.”  (p. 83).

In many ways, Jan has gotten beyond this stage, but the anger and defensiveness still creep in.  Sometimes it’s a sharp rejection of heterosexual “types,” such as when she points out to me, “See what you could have ended up with?  A football fan with a beer belly and a baseball cap on backwards!”  Sometimes it’s an inability to tolerate old friends’ discomfort, or to believe that they could ever change.  Today it was because an old friend was at a loss over what to tell her 12-year old daughter.  Jan told me, “I should have just told her, ‘Good-bye.  It was nice being friends for a few years, but I guess we won’t be friends anymore.’”  That hurts.  Doesn’t Jan remember that we too were confused and upset, and maybe even a little phobic, a few years ago?  It took some serious soul searching for us to change, so mightn’t our friends eventually change too?

During the introspection stage, “the individual begins to discover that this level of intensity of feelings … is psychologically draining and does not permit one to really devote more crucial energies to understanding.” (Sue & Sue, 1999, p. 135).  “A need for positive self-definition in a proactive sense emerges.”  The person may also feel discontent with the rigidity of the resistance and immersion stage.  For Mollenkott (2001), this involves becoming open to the full range of possibilities.  “However much gender-related consciousness raising has already occurred, it is far from enough.  If people are ever going to be free to embody and enact the precise gender-blend they sense themselves to be, they need to be aware of the range of human possibilities.”  (p. 6).  To Bornstein (1995), it is taking the opportunity to define one’s self.  “Gender identity is a form of self-definition:  something into which we can withdraw, from which we can glean a degree of privacy from time to time, and with which we can, to a limited degree, manipulate desire.”  (p. 40).

In the integrative awareness stage, “minority persons have developed an inner sense of security and can now own and appreciate unique aspects of their culture as well as those of U.S. culture.”  (Sue & Sue, 1999, p. 136).  There are attitudes and beliefs of appreciation for self, members of the same and other minority groups, and selective appreciation of the dominant culture.  Bornstein (1995) is comfortable with herself and playfully challenges the dominant culture when she says, “after thirty-seven years of trying to be male and over eight years of trying to be female, I’ve come to the conclusion that neither is really worth the trouble.  And that made me think.  A lot of people think it is worth the trouble.  And that made me think.  Why?  Why do people think it’s worth all that trouble to be a woman?  And hey, I’m not just talking about transsexuals here.  I’m talking about men and women, maybe like you.”  (p. 234).   She is ultimately able to play with the whole premise that creates her minority status.  ““I love the idea of being without an identity, it give me a lot of room to play around; but it makes me dizzy, having nowhere to hang my hat.  When I get too tired of not having an identity, I take one on:  it doesn’t really matter what identity I take on, as long as it’s recognizable.”  (p. 39).

Watching Jan move into this stage has been a delight.  Lately, she had taken to wearing her own hair, grown long, dyed, and fashionably cut, rather than a wig.  It’s thin on top, and sometimes people stare, but now she says, “This is me.  Take it or leave it.”  And when people stop and stare, or even laugh and point, she just says, “They must lead really dull lives to find me so interesting!”  It seems so much healthier than the days when we were both constantly afraid she wouldn’t “pass.”

Thus, people who are transgendered, because of societal prejudice and oppression and because of their similar experiences and banding together for strength, do constitute a cultural minority group within the United States.  And, the R/CID model is appropriate in describing their identity development and coincident beliefs and attitudes towards the dominant, their own, and other minority groups in our society.


Counseling for the Transgendered

According to Ettner (1999), “It is safe to predict that every mental health care provider will encounter at least one transgendered ‘client’ at some point in his or her professional life.  Even if they refer to a colleague more experienced in this area, it behooves professionals to understand the nature of gender conditions so that they can act fittingly and expediently.”  (p. 108).  If you add in “family, friends and co-workers,” it is likely the mental-health provider will find transgender issues a frequent subject of concern in her or his practice.  In this section, it is not my intent to delve into the arena of the “gender specialist.”  With Ettner, I urge mental health practitioners to understand that “therapists who lack experience but opt to work with transgendered clients bear the professional obligation of seeking consultation or supervision from a gender specialist.”  (p. 109).  However, the typical mental health counselor will have opportunities to work with transgendered individuals and/or their loved ones on a variety of issues.  I intend to address those things that I believe it is important for any mental health provider who chooses to work with this population to understand about transgender issues and how these issues affect the lives of their clients.


Counselor Preparation

“Effective psychotherapy with transgendered clients flies in the face of much of the conventional pedagogy intrinsic to counseling and psychotherapy.  It requires the clinician to shift paradigms.”  (Ettner, 1999, p. 110).  “Although it is a cherished canon in psychotherapy that the therapist allow the client to find his or her own solutions to problems, working with the transgendered often require violating this precept.  Advice-giving, anathema to traditional treatment, is often essential to helping the client live safely and comfortably.”  (p. 116).  “The role of the therapist in helping an individual with gender-identity disorder is to be very clear about the physiological and psychological ramifications of the disorder and to serve as a guide in aiding the individual through the morass of possibilities leading to his or her own resolution.”  (Anne Vitale, as quoted in Israel & Tarver, 1997, p. 254).  “A good therapist must not only be able to ease the client’s anxiety but also able to educate, support and provide a variety of professional referrals.” (p. 255).

Before working with any transgendered clients or counseling on transgender issues, the mental health practitioner should engage in some personal preparation.  At minimum, “any counselor, in particular one who is going to be dealing with gender issues with a client, should work through his or her own sex and gender issues first.”  (Miller, 1996, p. 53).  According to Ettner (1999), “one must be cognitively flexible to work with individuals who undergo physical change that runs counter to deeply ingrained, bedrock beliefs.  Such flexibility requires a goodly amount of personal plasticity on the part of the clinician.”  (p. 110).  She continues, “More successful will be those practitioners who are humanistically or existentially oriented in theory.  They will resonate with the transsexual’s movement toward self-definition.” (p. 111).  “Respect and empathy act in tandem to provide clients with permission to grow and learn while accommodating to their new gender role.  The therapist who displays such attitudes and incorporates them into the therapeutic process provides a counter-shaming experience for the client, so essential for successful life transition.”  (p. 112).

Clinicians need to understand the full range of the continuum of gender dysphoria, and help clients determine where they lie on the spectrum. They must also educate the client about the nature of the condition for which they are seeking treatment.  (Ettner, 1999).  However, Ettner warns about over-application of the medical model and diagnostic techniques.  And Miller (1996) reminds us, “Your responsibility, among others, is to teach them how to learn in this situation, not to tell them what they are about.”  (p. 22).  Most important is a general understanding and communication to the client of the full range of human possibility.  In the words of Bornstein (1995), “How sad for a person to be missing out on some expression of identity, just for not knowing there are options.” (p. 51).  According to GIDreform (2002), “It is time for culturally competent psychiatric policies that recognize the legitimacy of cross-gender identity and yet distinguish gender dysphoria as a serious condition, treatable with medical procedures.”  Above all, “scientific, medical, and mental health professionals are strongly discouraged from portraying transgender individuals or transgender-associated experiences, feelings or thoughts as pathologically diseased, mentally ill, deviant, or in any other manner that exacerbates marginalization of the transgender individual within social, medical, and mental health infrastructures.”  (Israel & Tarver, 1997, p. 20).

The HBIGDA (2001) Standards of Care are a good place to begin an education about gender issues.  Israel and Tarver (1997) provide another excellent resource.  They recommended (for the gender specialist, but I advocate also for anyone working with this population):

Curriculum for Gender Specialists should include:

·         Familiarity with suicide and crisis intervention

·         A basic ability to recognize mental health disorders requiring appropriate referral.

·         An ability to promote consumer awareness of critical gender-oriented consumer needs

·         Appropriate intervention and educational skills relating to “safer sex” and sexually transmitted disease

·        An understanding of basic gender- and sexual-identity concerns.  (p. 13).

Your client may also bring you numerous resources and insist that you prove adequate preparation (this population has good reason to be suspicious of the mental health profession – see section on History).  Jan went to her first session with a counselor armed with Miller (1996), Israel & Tarver (1997), and Ettner (1999), at a minimum, and quizzed the counselor about her preparation and previous experience with gender confused clients.  They continue to share resources and discuss current research and recommendations.  I wish more people undergoing mental health counseling were as active on their own behalf because, unfortunately, not all counselors are as well prepared and willing to learn.

The therapist must be able to distinguish between gender problems and other concerns, and understand the interaction between them.  Not all transgendered clients will be seeking counseling for gender problems, nor will everyone with gender concerns perceive them as the reason for seeking counseling.  “Gender problems are so central to formation, regulation, and defense of self that they should also be addressed and acknowledged at the very outset of treatment.”  (Ettner, 1999, p. 113).  Ettner goes on to cite examples of the error of working on gender problems last, after other issues, as the other issues are often related to or a result of the gender issue.  “Many other seemingly intractable problems the client faces (including some Axis I and Axis IV factors) ‘dissolve’ when the client confronts the gender issue with a trusted and supportive ally.”  (p. 113).  “Parallel issues commonly accompany and mask gender-identity concerns.”  (Israel & Tarver, 1997, p. 32).   On the other hand, “ Sometimes people think they’re coming to counseling for a gender problem when they actually have other dysfunctions that need attending to.  They procrastinate or they keep losing their jobs or they have no friends, and they blame it all on their gender issues.”  (Miller, 1996, p. 28).  Miller advocated the use of role-playing and dream work to help clarify the issues and understand their origins.

Finally, “Individuals experiencing concerns about their gender identity may suffer social isolation, emotional anguish, distorted self-image, and even misdiagnosis by health professionals.”  (Israel & Tarver, 1997, p. 21).  Having been abused at the hand of “the system,” the individual may require a more active advocate than conventional counseling methods dictate.  Both Ettner (1999) and Bornstein (1995) recommend that the client be advised to consider a range of strategies and options.  For Ettner, “The therapist is proactive in creating an alliance with the client and is willing to be an active, even nurturing participant in such a venture.”  (p. 112).


Barriers to Effective Counseling

Until recently, most transgender care was offered by university based gender clinics, a system that did not always result in the best care.  “Transsexuals correctly felt put upon by having the access to their medical care controlled by opinionated researchers.  Academic physicians and psychologists were often more interested in validating their own theories of the etiology of transsexualism than in helping transsexuals to live happier lives.  Transsexuals learned to alter their own life stories to better match the pathologic model favored by the institution to which they were applying for their medical care.”  (Joy Diane Shaffer in forward to Israel & Tarver, 1997, p. xi).  Clients learned to look upon their counselors as “gatekeepers,” controlling their access to needed medical therapies.  “The ‘gatekeeper’ function refers to the client’s need for referral letters from the therapist for hormone therapy and, eventually, Genital Reassignment Surgery.  Given their desire for these letters, the clients are ready, if need be, to take on the therapist in a battle of wits.” (Anne Vitale as quoted in Israel & Tarver, p. 251).  Although the practice is moving away from the adversarial approach, Israel & Tarver remind us, “As professional organizations move toward the depathologization of gender-identity issues, it is important that professionals and consumers be aware that these changes (as well as the acceptance of them) are not likely to be uniform.”  (p. 24-25).

Even the 1995 Kirk and Rothblatt guide assumes the counselor will use a somewhat adversarial approach.  “The mental health-care professional on the other hand, while posing as an obstructionist in order to search out and clarify, should in time add therapy and support as well as direction to the interchange between the two.  I know of counselors who continue to place one impediment after another even when the tests and examinations clearly indicate the client is on the correct path.”  (p. 3).  Although they say, “The professional is not your enemy, even when you fell that this might be so”  (p. 6), it is easy to see that the client may approach a new therapist with some trepidation.  Trust may be difficult to establish.

Prior negative experiences are also not uncommon.  For Israel and Tarver (1997), “at the heart of the issue of supporting transgender individuals is the premise that psychiatrists, psychotherapists, and mental health counselors diagnose and treat only that which is disordered or diseased.”  (p. 25).  But, often the “treatment” seems worse than the problem.  For Bornstein (1995), “Transsexuality is the only condition for which the therapy is to lie.”  “As a result of the medicalization of our condition, transsexuals must see therapists in order to receive the medical seal of approval required to proceed with any gender reassignment surgery.  Now, once we get to the doctor, we’re told we’ll be cured if we become members of one gender or another.  We’re told not to divulge our transsexual status, except in select cases requiring intimacy.  Isn’t that amazing?  Transsexuals presenting themselves for therapy in this culture are channeled through a system which labels them as having a disease (transsexuality) for which the therapy is to lie, hide, or otherwise remain silent.” (p. 62).  She has similar criticism for the treatment of intersexuals.  “It’s a fairly common experience being born with different or anomalous genitals, but we don’t allow hermaphrodites in modern Western medicine.  We ‘fix’ them.”  (p. 57).  

Obviously, the therapist should encourage the client to talk about other experiences in therapy and their assumptions about the process, and should not be surprised if she or he has to earn the clients trust.

I knew for a time back in the late 80’s or very early 90’s a gender specialist who had a large number of transsexual clients.  One time he admitted to me, and a small group of friends, that he thought ALL of his transgender clients were crazy.  He said that he didn’t think it was possible for a transsexual to be well adjusted and mentally healthy.  I was appalled.  If the professionals that purport to be transgender advocates are contemptuous, to whom can the transgenderd go?  If John/Jan and I waited too long to go for counseling in our journey, I can only point to this experience.  Trust was a long time in coming.


Common Needs and Concerns of the Transgendered

“According to Israel and Tarver (1997), “The most common mental health issues transgender persons experience are depression as well as adjustment, anxiety, personality, and posttraumatic stress disorders.”  (p. 40).  While the transgender state itself is not any longer considered to be unhealthy, the stress of dealing with the confusion and society’s negative response can lead to numerous other problems.  One common tactic is denial.  Ettner urges that the therapist is responsible for “educating clients early on that denial is never a healthy option for living with the condition.” (p. 115).  Additionally, transgender persons are no more or less prone to disfunctionality in their relationships than the general population.  “Dysfunctional patterns learned in the family and other places are brought into the current situation and affect the way a person deals with the gender issue.  But they usually don’t have to do with the actual gender behavior itself.”  (Miller, 1996, p. 49).  “A big challenge for the counselor is to make sure that dysfunctionality issues are worked on and separated from the gender issues.”  (p. 99).

Guilt and shame may be problems.  As mentioned previously and stated so well by Bornstein (1995), “humiliation is the whip of the defenders of gender.” (p. 88).  Ettner (1999) stresses the devastating effect of shame on the development of a positive identity.  The lack of positive role models and sensationalized stories of cross-dressers and transsexuals on TV talk shows and in the news serve to reinforce the shame and raise the barriers to seeking counseling.  Guilt arises because many, if not most, transgendered persons inextricably involve others in their often-painful search for a positive approach to life: partners, parents, other family and friends.  “Guilt over ‘damage,’ or perceived damage, done to others is often expressed in therapeutic situations and thwarts realistic decision making.”  (Ettner, p. 104).  Researchers Schaefer and Wheeler (as cited in Ettner) identified guilt as underlying a host of psychological problems facing the gender-variant individual. 

Some people try amazing things to produce both guilt and shame in people who are different.  Our Episcopal church has, in general, been amazingly supportive of our journey.  But not everyone in it has agreed with the supportive approach.  First, there came the anonymous letters telling us how perverted we were and how sickening to others to have us around, telling us we needed to leave the church or there would be no church left.  When that didn’t scare us away, a few of the “dissenters” conducted a door to door campaign asking all the parents in the church if they weren’t frightened to send their children to a place that allowed a man to come to church in a dress.  The priest and vestry heard of this, tried to respond with education on transgender issues, and also responded with an announcement in the bulletin and church newsletter that all are welcome at our church and we have no dress code.  In a final attempt to humiliate, before leaving for a more conservative parish, one church member demonstrated his scorn by attending a baptism and confirmation service, at which the Bishop was presiding, in nothing but his swim shorts – so much did he hate the “no dress code” proclamation and object to what he could only see as “a man in a dress.”

An issue that is almost a given for transgenderd clients is coping with loss.  “This population of clients, more than most others, are faced with many possible losses in their lives.”  (Miller, 1996, p. 49).  Choosing to be openly gender variant, in particular the transition process for a transsexual, can result in the loss of family and friends who disapprove or don’t understand.  The loss can be particularly traumatic if, as is often the case, the disclosure or discovery of the person’s transgender status is unplanned.  “In many circumstances, being forced or even choosing to disclose without being fully prepared for what disclosure involves can have devastating consequences.” (Israel & Tarver, 1997, p. 49).  The loss of a job and place in the community are also very real possibilities.  Kirk and Rothblatt (1995) advise, “You should consider the very real possibility that you could lose your position.”  (p. 127).  Even for those people who successfully chose to keep their transgender status private, there is loss.  “Denied the opportunity to speak our stories, transsexuals are denied the joy of our histories.”  (Bornstein, 1995, p. 127).

I would say there is also a significant loss of social confidence and comfort.  Jan, as John, spent a decade as an active member of the local volunteer fire department and rescue squad.  As we drive by her old station house she often remarks, “I wouldn’t be able to do that now.  I can imagine how they would react to me.”  Sometimes she says, “It’s funny, I never used to think about watching the people around me, to see who might be a threat.  I didn’t worry about going where I wasn’t known.  I always felt confident about being able to handle myself.”  In part, she’s just learning what it’s like to be a woman in a man’s world, but she’s also learning what it’s like to be unacceptably different in this society.  She’s been stalked, threatened, and narrowly avoided being beaten for presuming to be openly transgendered.  Even though she passes most of the time, she’s learned to be always watching, always alert for the next “incident.”  Beyond the personal safety issues, there is the profound loss of unconscious belonging.  There’s no longer the general expectation of positive regard or the comfortable assurance of anonymity in a crowd. 

“The matter of sexual orientation represents an ongoing concern for transgender individuals and those providing specialized support care, partly because the terms sex, sexual orientation, and gender identity are interchanged erroneously.”  (Israel & Tarver, 1997, p. 43).  Ettner (1999) points out society’s inability to separate gender from sexuality.  The transsexual, raised in this confusion, may need to work out issues of sexuality.  Because questions of both sexuality and gender identity tend to peak at puberty, Israel and Tarver find, “Some transgender individuals may not have crystallized a sexual orientation during puberty, and may feel uncertainty or reexplore their sexual orientation simultaneously with exploring gender-identity issues.    He or she should be encouraged to explore these issues without preconceived expectations.” (p. 45).  Mollenkott (2001) reminds us, “Transsexuals are often presumed to be homosexual, but only about half of male-to-females end up as lesbians.  Among females to males, an increasing number identify as bisexual or gay.  But people cannot be sure where their change of gender may lead them because sexuality can be very fluid during the transitional time.”  (p. 54).

For the transsexual and transgenderist, the counselor should actively encourage exploration of expectations.  They are often not realistic.  It is a role of the counselor to make sure that the client doesn’t proceed too far down an often-irreversible path without adequate exploration of the consequences.  “The initial pre-transition evaluation will be a challenge on occasion and the impediments may be frequent.”  (Kirk & Rothblatt, 1995, p. 3).  Although the gender specialist will pay particular attention to this process, exploration of expectations is beneficial at every stage.  For example, “Often the M-F transsexual fantasizes a beautiful female figure and a lovely lilting feminine voice, both resulting from hormone use.  Be assured, neither will happen.”  (Kirk & Rothblatt, p. 23).  Thinking ahead to the transition process, the client should be encouraged to plan for the “real life experience” and all that it will entail.  Kirk and Robhblatt explain that this experience is “to live, in every sense of the word, in the role of the cross-gendered, to exchange and experience with all in his or her life with family, friends, workplace associates, store clerks, everyone – as a member of the opposite gender.    It is in my view, a must.”  (p. 5).  A year or more of real life experience will be required before medical intervention, particularly sex reassignment surgery, by nearly all gender specialists.  Initial real life experiments, such as cross-gendered experiences outside of work, or during a vacation, may be useful to help the client prepare and develop realistic expectations. 

The need for counseling, and for the counselor as advocate, does not disappear immediately after successful gender transition.  Ettner (1999) finds no validity in the common myth, popular with the media, of mutilating surgery that transsexuals often live to regret.  Instead, she finds that research shows post-operative results are consistent and point to high satisfaction levels.  However, she reminds us that many individuals experience psychosocial difficulties post-surgery and unexpected problems of acclimating to the new gender role.  They may also continue to deal with the aftermath of unrealistic expectations.  As gender specialists often do not do much long-term follow-up, this is an area where the general mental health counselor may be a particularly important part of the client’s support system. 

Until recently, post-transition transsexuals, or transgenderists living full time in the opposite gender from their biological sex, were encouraged to adopt the gender roles dictated by society.  Kirk and Rothblatt (1995), in their advice to post-operative transsexuals allow some place for androgyny, but say to the M2F,  “Genetic women in all of their lives have experienced things you will never know and, in fact, may not be aware. … At work, at a social event, in a variety of places and times, you may be quite outstanding if you have no contribution to make to those conversations.” (p. 85).  “Genetic females have a built-in capacity to relate easily and to connect effectively with others.    If you still present yourself with the typical masculine attitude and thought process, you will fail in virtually all of your social endeavors.  You should have been developing that mystical, feminine approach to all around you.”  (p. 89).   And to the F2M they say,  “There is no doubt that the masculine approach to life is what you want.  The aggressive, dominant attitude, the one-upmanship, all of this is important.”  (p. 93).  However, as transsexuals become more assertive and proactive in their own care, a different attitude and an acceptance for ambiguity are emerging.  Mollenkott (2001) notes that often transgendered people enjoy being neither woman or man and resent society’s attempts to push them into and either/or choice.  Bornstein (1995) is an eloquent advocate of this point of view, challenging us even in the title to her book, Gender Outlaw:  On Men, Women, and the Rest of Us.  She says, “Transsexuals and other transgendered people are finally sitting down, taking stock, comparing notes – and it’s the dominant culture that’s coming up short.  Some of us are beginning to actually like ourselves and each other for the blend we are.  Many of us are beginning to express our discontent with a culture that wants us silent.”  (p. 64).

Jan is showing the beginnings of becoming a “gender outlaw” herself.  After Esprit 2002 she came home with a bold new attitude.  It was exhilarating to see people comfortable with who they were, rather than always trying to adopt the outward signs, “perform the gender,” society dictates.  She told me that after seeing trans-women carrying themselves with dignity who had little or no hair, with her wig she began to feel “fake.”  Now, as far as she’s concerned, it’s ok to have a bald spot and receding hairline with hair that is cut, dyed and arranged in a nice, feminine style.  And, she doesn’t feel like she has to layer make-up on an inch thick to hide every possible trace of her remaining beard.  It’s nice to pass, fun to dress up to the hilt, ok to modify her voice to sound more feminine, but it’s no longer required.  She’s discovered that if people don’t react well to a very feminine person with a bald spot and deep voice, it’s really their problem, not hers.  I find it not only a healthier attitude, but also a lot easier on the companion!  It’s easier on both of us than the constant pressure of maintaining the fiction.  Referring again to Bornstein who complains, “Transsexuality is the only condition for which the therapy is to lie.”  (p. 62), Jan and I are finding that trying to live a lie is not emotionally healthy.

The collective voice that transgender activists are beginning to develop emphasizes the need for a feeling of community – that knowledge that others share your particular viewpoint and experience similar joys, challenges and concerns.  Most transgendered individuals benefit from a support group or from group counseling.  Cross-dressers, in particular, are often closeted from family and feel isolated and alone.  “Many cross-dressers feel bad about their cross-dressing; consequently, the International Foundation for Gender Education (IFGE) urges them to join one of the support groups available all over the United States.  According to the IFGE, the urge to cross-dress ‘may be hard-wired into the brain.  It will not go away.  Unless you face your feelings, denial will cause frustration, anger, and depression.’” (Mollenkott, 2001, p. 60).  Most areas have transgender support groups.  In many urban areas, there are separate support groups for the cross-dresser, the transsexual, for partners, and for a number of other related but specific populations.  However, some people won’t feel at home in a support group, and shouldn’t be required to participate if they find no benefit.  The novel Trans-sister radio (Bohjalian, 2000) gives a very realistic presentation of a transsexual going through the process of transition, and in this case presents a person who feels completely out of place in the only support group available.  If support groups don’t work, other support networks should be explored.  The transgendered individual should be encouraged to seek out trans-friendly businesses and individuals in their community or workplace who can provide that needed psychological boost and assistance in negotiating the minefield of daily life.  They do exist, in every community.  Find one, and others come out of the woodwork.  But, never let your client think that it’s possible to “go it alone.”

Ultimately, the counselor should encourage in the client the skills of self-help and self-understanding.  The transgendered will face a life-long challenge of being “different,” and of having to cope with an ever-varying array of challenges.  They need to become confident with their ability to assess situations and make decisions.  For Bornstein (1995), this meant asking a lot of questions and making sure she got the answers.  “Before going through with my surgery, before creating myself in Third, I asked questions, as many as possible, as many as I could think of.  And I wrote down all the questions that people asked me.  Before creating a Third space, it might be a good idea to make sure that all the questions that need asking actually get asked, as many as possible.”  (p. 98).


Common Issues and Challenges Facing the Transgendered

Besides the emotional needs and common concerns of the transgendered, there are a number of specific issues in society that this population will likely face.  The counselor should be aware of these issues and prepared to help the client with these challenges.

The all-encompassing issue is simply that society is not friendly to transgressors of binary gender.  Ettner (1999) warns against ignoring the social pathology that emerges.  Gender conditions arouse intense societal response and real oppression.  Bornstein (1995) describes this pathology in terms of the imperative of “passing.”  “Most passing is undertaken in response to the cultural imperative to be one gender or the other.  In this case, passing becomes the outward manifestation of shame and capitulation.”  (p. 125).  “There is most certainly a privilege to having a gender.  Just ask someone who doesn’t have a gender, or who can’t pass, or who doesn’t pass.  When you have a gender, or when you are perceived as having a gender, you don’t get laughed at in the street.  You don’t get beat up.  You know which public bathroom to use, and when you use it, people don’t stare at you or worse.    Passing by choice can be fantastic fun.  Enforced passing is a joyless activity.”  (p. 127).  “The fear of being read as transsexual weighs so heavily on an individual that it focuses even more attention on ‘passing.’” (p. 128).  Mollenkott (2001) reminds us, “Even people with a transgender core identity have been socialized to prefer binaries and to fear difference – so they must combat not only society’s violent repudiation of themselves, but the own terror of one another.” (p. 66).

A direct result of society’s gender pathology is the issue of safety for the transgendered.  Many are not aware or adequately prepared.  Quite possibly the most useful thing a counselor can do for a transgendered clients is help them become educated about safety risks and urge that they learn techniques for self-preservation and self-defense.  No other counseling or coping technique will have any validity if the client does not live to try it out.  “The intersexual or transgendered person who projects a social gender – what  Kessler calls ‘cultural genitals' – that  conflicts with his or her physical genitals still may die for the transgression."  (Fausto-Sterling, 2000, p. 23).  Israel and Tarver (1997) state that rape is a common problem.  “One characteristic that places MTF transgender individuals at a high risk of victimization is that they typically have not been conditioned to guard against misogynistic sexual violence from an early age.” (p. 37).  We need only to look at the paper regularly or watch the news to know that this is true.

Two transgender teenagers, best friends who were biologically male but dressed and lived as women, were shot and killed early yesterday in Southeast Washington -- a crime that police said was unusually violent and has left them with few leads.  (Fahrenthold, 2002)

Jan went alone one Halloween night to a bar that was having a costume party.  While “reading” her for a guy, it became obvious to some young and macho customers that she was too “good” to be simply in Halloween costume.  Shortly after returning from the men’s room, another customer at the bar, with his wife, struck up a conversation with Jan.  After initial pleasantries, they indicated that when she was ready to leave for the evening they would like to escort her to her car.  Jan assured them that it wasn’t necessary and that she didn’t want to inconvenience them.  They told her it was indeed necessary.  The man had just overheard that group of young thugs in the men’s room making plans to “follow that cross-dresser out to the parking lot and teach him a lesson he wouldn’t forget.” 

Jan is surprised I even remember this incident, but it’s not the kind of thing I’m likely to forget.  Neither the fear of violence nor enduring its aftermath is limited to the transgendered individual.  I don’t want to lose her.

Beyond safety, another direct result of society’s gender pathology is abuse.  While abuse isn’t limited to intersexuals, they are particularly prone to abuse as children through being denied any choice in the major decisions made about their future.  “Surgical and hormonal treatment allows parents and physicians to imagine that they have eliminated the child’s intersexuality.  Unfortunately, the surgery is immensely destructive of sexual sensation as well as one’s sense of bodily integrity.  Because the cosmetic result may be good, parents and physicians complacently ignore the child’s emotional pain in being forced into a socially acceptable gender.  The child’s body, once violated by the surgery, is again and again subjected to frequent genital examinations.  Many ‘graduates’ of medical intersex corrective programs are chronically depressed, wishing vainly for the return of body parts.  Suicides are not uncommon.  Some former intersexuals become transsexual, rejecting their imposed sex.  Follow-up studies of adults to ascertain the long-term outcome of intervention are conspicuously absent.”  (Chase, 1993).

Transsexuals and transgenderists who take hormones need to be aware of the emotional and psychological effects of the medical treatment they receive.  “Individuals who are initiating hormone administration frequently are poorly prepared for the emotional changes that go with it.”  (Israel & Tarver, 1997, p. 43).  Israel & Tarver also point out that, because of the considerable expense and refusal of most insurance companies to provide coverage, they are frequently exposed to hormones of questionable quality, and with no medical supervision, via the black market.  They may be also vulnerable prey for irresponsible practitioners.  Gender identity clinics can help clients negotiate some of the medical/psychological issues.  Kirk and Rothblatt (1995) believe they pose an advantage for the client because all the team will be there, in one place, able to consult with each other.  But, Israel & Tarver and others applaud the closing of most gender identity clinics.  They feel they perpetuate old myths of psychopathology, and tend to treat clients from that particular clinic’s thesis about the origin of transgender phenomena rather than stressing what’s best for the client.  Medical issues are not limited to hormones and surgery.  Ettner (1999) reminds us that many gender-variant clients will have attendant depression, which may require pharmacological management.  Consulting with a physician who is comfortable with gender variant clients is important.

Workplace issues and other legal issues are major concerns.  Counselors may be asked to, or should in some cases volunteer to, consult with employers and co-workers to help explain gender issues or the process of transition.   “When you transition on the job, it’s wise to consider the possible need of a conference between your mental health-care professional and your employer.”  (Kirk & Rothblatt, 1995, p. 128).  The client may have to negotiate employer requests for a transfer in association with transition, or may wish to request a transfer, assuming that the client doesn’t outright loose his/her job over being openly transgendered.  Or, the client will have to work with supervisors and company equal employment officers over conditions for transition on the job.  Beyond the workplace, the client may have to negotiate the multivariate world of legal documents.  Drivers license, birth certificate, passport, and many others all require listing gender or sex as a defining characteristic of the individual.  Rules vary about when and whether a person can petition to have that designation changed.  States vary in laws about name changes.  Beyond dealing with the many legal entities that control the process, the client may need help dealing with disappointment, which can be profound, when he or she encounters an immovable roadblock.

“Being originally from Ohio, …” was the way John began an introductory letter to a new friend many years ago.  It seemed, at the time, a clever way to start a discussion about background and family origin.  Little did we know how significant “being originally from Ohio” would turn out to be.  Ohio is one of the few states that will not permit, even after a complete sex reassignment, the modification of the birth certificate to reflect the new gender.  Without the birth certificate, it becomes almost impossible to change the passport.  Even changing the driver’s license, the most common form of identification, can be problematic.   Since we frequently travel internationally, and it’s becoming more and more difficult for Jan to “masquerade” as a man, this is going to be a problem for us for a long, long time.  And the laws change so slowly…

“Perhaps the most significant mental health and social support issue faced by transgender individuals revolves around the disclosure of one’s transgender status and needs to others.” (Israel & Tarver, 1997, p. 48).  The individual must decide who to tell and how to tell, and may need work on communication skills in general or specifically tailored to disclosing his or her transgender status.  “Most non-intimate acquaintances such as coworkers or neighbors do not have a need to know about the individual’s transgender status.” (p. 51).  However, “Most knowledgeable Gender Specialists are quick to recognize that this secretive process is burdensome and isolating.”  (p. 50).  As we have already noted, unplanned or forced disclosure can have devastating consequences, so the individual should be encouraged to plan disclosure to all who are likely to need to know or who are likely to discover through the course of regular interactions.  Israel & Tarver suggest the following basic disclosure tools:

-        Reflect on the consequences

-        Contemplate how the disclosure will affect others

-        Prepare for communicating

-        Make an appointment

-        Validate the relationship

-        Relieve stress by revealing

-        Share the facts

-        Affirm and respect the other person

-        Seal the communication

-        Reflect inward

The best way to jeopardize a relationship is to be coy.  Jan really hates to pin herself down.  If she’s unsure of the outcome, she will often give hints or play mysterious.  Once she said to an associate at work (where she has yet to transition), “You’ve noticed that I’ve been looking different lately?  [Meaning painted nails, shaped eyebrows, disappearing facial hair, androgynous to somewhat feminine clothes.]  Well, if we go out socially, I’ll be like this – only more so.”  The poor man looked quizzically at her, then blushed, stammered, and quickly switched the subject.  I’m still not sure exactly what he thought, but he hasn’t been interested in getting back together with us.  I had a talk with Jan later about disclosure and trying to understand things from another’s point of view.  Yes, it’s a temptation to protect one’s self from outright rejection by being vague, but it can be very confusing and even a little cruel. 

Religion, for a client who professes any religion at all, is likely to be a major issue.  Mollenkott (2001), herself a Presbyterian minister, asserts, “Christians (and religious people generally) offer almost no safe faith-oriented space anywhere for transgender, gay, lesbian, or bisexual youth to sort themselves out.”  (p. 67).  Transsexuals and other openly transgendered people often face outright repudiation of their stories, and have their nature questioned as a deliberate choice or even outright defiance.  The assertion that this is deliberate social defiance is at odds with most current research.  Studies cited by Ettner (1999), Miller (1996) and others point to a combination of biological, prenatal and environmental influences.  But, rather than accept contemporary research results, many religious activists propose more research, targeted towards substantiating pre-determined conclusions based on their particular convictions.

The Evangelical Alliance [of England] has published the first official evangelical Christian study and response to the issue of transsexuality, which calls for a more holistic response to the treatment of the ‘condition’ without recourse to unnecessary surgery and falsely raised hopes. The Alliance also calls for a full independent inquiry into the causes of transsexuality by the Chief Medical Officer. … But we do maintain that a publicly promoted, determined transsexual lifestyle is not compatible with Christian profession. (Evangelical Alliance Voice, 2002). 

Mollenkott (2001) urges the religious to take a softer approach.  “To religious people and perhaps certain other readers, my list of transgender categories may seem to mix that which people cannot help (such as being intersexual) and voluntarily chosen behaviors which could be interpreted as deliberate defiance (such as cross-dressing).  But as Israel writes in a sample disclosure letter, cross-dressing is often ‘necessary to [an] individual’s self-integration process.  Therefore it should not be misconstrued as an attempt to impersonate the opposite gender or perpetrate wrong-doing.’”  (p. 41).  However, most religious transgendered individuals, Christian, Jewish, Muslim or otherwise, can expect somewhere between a negative reception and outright rejection from their church.

Dear Paul,

We will pray for your conversion to the Lord, and a return to manhood.  Until a full return is made to your masculinity, we consider you to have severed your relationships with all of us.   (Letter to a M2F client from her family, as quoted in Ettner, 1999, p. 115).

Finally, a situation that is guaranteed to cause distress and confusion for your transgendered client – the public bathroom.  In what must surely be a contender for the understatement of the decade, Kirk and Rothblatt (1995) warn, “Agreeable solutions are often hard to come by.”  (p. 136).  It must seem utterly implausible to our European colleagues, but Americans have a collective paranoia about what Jacques Lacan (as cited in Garber, 1992) calls “urinary segregation.”  There are no Federal laws dictating the rules for use of public bathrooms, and few state or local laws exist, but self-appointed “bathroom police” make simply relieving one’s self a traumatic experience for all but the few who manage to “pass” in every situation.  Recommendations, even from gender professionals, vary concerning the appropriate room to use.  Men’s restrooms can be more physically dangerous for the transgendered, but women seem much more likely to report the “pervert” to the manager or to the police.  So, there is no acceptable choice.  And, when a transsexual is known, that person is often forbidden to use either the women’s or the men’s room.  “I suppose he [the building manager] felt I would terrorize the women in their bathroom, and lie in waiting for the men in their bathroom.  Finally, a solution was reached:  even though I worked on the 11th floor of a large office building, I would use a bathroom on the seventh floor.  The seventh floor had been under construction, but for the lack of funds they simply stopped construction; no one worked on that floor.  Piles of plaster and wiring littered the floor and pools of water lay everywhere.  But there was a working bathroom in the very back of that floor, and that’s where they sent me.  No one ever cleaned it, no one kept it stocked.  It was poorly lit and scary.”  (Bornstein, 1995, p. 84).

I still find it amazing how much energy “the bathroom question” takes from our lives.  There have been many evenings out at restaurants when Jan sat counting and timing the women going into the women’s restroom (or men going into the men’s room, depending on which room she felt she should use that night), waiting for the right moment to scoot in and have a reasonable chance of not encountering anyone.  One night, she thought she had calculated it right.  She almost made it.  But, as she was washing her hands in the men’s room, an elderly gentleman walked in and nearly had a heart attack.  In some ways it was humorous, but we both watched anxiously for him to come out – wanting to know that he was alright.  As much as possible, Jan tries to avoid drinking anything when she knows she’s going to be out, so she won’t have to use a public restroom.  Not only is that not always possible, it’s not healthy!  However, since many of the potential situations border more on the dangerous than on the humorous side, it’s not “healthy” to have to take the chance more often than absolutely necessary.


Special Populations

There are several distinct groups that require special consideration, beginning with partners, family, friends and co-workers of the transgendered.  Disclosure to the partner and close family is a critical issue.  According to Erhardt and Swenson (1999), accidental disclosure or disclosure by a third party is likely to seriously jeopardize the family relationship.  Yet, this can be the most difficult disclosure for the transgendered person, because the risk of loss is so great.  Thus, it is not surprising that “often the clients arrive with a confused or angry spouse in tow.”  (Ettner, 1999, p. 70).  Miller (1996) recommends, “In counseling a ‘T’ who is in a significant relationship it is very important for you to see that other person as well.”  (p. 15).  “One of your jobs as the counselor is to help these two people to be willing to takes the risks involved in honest communicating.”  (p. 123).  Although until recently marriages rarely survived the decision to transition, she warns,  “Beware of deciding how it will come out.  Just support each person and the couple in deciding what is right for them.”  (p. 130).  Erhardt and Swenson (1999) describe four typical stages that close family or partners go through after disclosure:  1) Initial anger, pain and confusion; 2) a stage of denial, and urging the transgendered individual to change or find a cure; 3) a feeling of being left out, unimportant, that everything is now about gender; and, 4) for the partner, a questioning of one’s own sexual identity.  (If my husband is really a woman inside, does that mean I’m a lesbian?)  Concerning co-workers, and equally applicable to more casual acquaintances, Kirk and Rothblatt (1995) have the following suggestions, “Be prepared for the fact that acceptance of your coworkers will be at different levels and will take variable lengths of time from one to another.  They may also be ambivalent.”  (p. 127).  “Expect surprise, expect reluctance to accept, even rigidity and worse, even recrimination.”  (p. 130).

It’s frustrating for us that so few transsexual people have spouses that stayed with them throughout the process.  We plan to stay together, but we don’t know what to expect.  Erhardt (as quoted in Vitale, 2002) is in the process of writing a book about spouses of M2F transsexuals who do stay with their partner.  She says, “I have been at a loss because of the lack of resources to offer partners that might answer their question, ‘how do others feel and how have they dealt with this?’"  However, one aspect of this relationship is sheer fun.  When confronted with overly zealous defenders of heterosexuals-only marriage – the “Take Back Vermont” people come to mind (When I first saw the signs I thought, naively, that it was a Native American slogan.  It wasn’t.) –  it’s comforting to know that we will be a legally wed lesbian couple!

Another group that requires special consideration are androgynes, simply because they are often assumed to be transvestites or transsexuals and are not.  “Androgynes simultaneously adopt the characteristics of both males and females or else attempt to wear gender-neutral clothing in order to be identifiable as neither male nor female.”  (Mollenkott, 2001, p. 69).  “Androgynes should not be expected to conform to transvestite or transsexual models and should not be urged to seek gender reassignment.” (p. 70).  Echoing Mollenkott’s point, Israel and Tarver (1997) assert, “Neither transgenderist nor androgyne individuals should be required to conform to transvestite, transsexual, or other stereotypes or support models.  The end result could be misdirected focus on Genital Reassignment Surgery rather than integrating their actual gender-identity needs.” (p. 16).  

There are also specific drag performing and cross-dressing populations who have their own needs and issues, and should not be treated as transgenderists or transsexuals.  They are transgendered in the broad sense, because they blend gender lines and cross social gender boundaries, but they rarely have any desire to live full time in the gender roles they occasionally adopt.  According to Mollenkott (2001), drag kings and queens are men and women, generally gay and lesbian, who impersonate the other sex for largely for entertainment purposes, and who often enjoy flamboyant challenges to sexual stereotypes.  Cross-dressers are generally heterosexual men.  They ordinarily have a male gender identity but experience the occasional need to express the feminine side of themselves by dressing as women.  Often, but not always, the cross-dressing is associated with sexual arousal.  For some, cross-dressing is an initial step toward discovering a repressed transsexual identity, but this is not generally the case.  (It’s difficult to conceive of female cross-dressers, in the sense of defying social gender roles.  Women wearing men’s clothes is, for the most part, socially acceptable and would not bring into question a woman’s gender identity.  Additionally, women who wear men’s clothes rarely do so for sexual stimulation.) 

Intersexuals may or may not have the same needs and issues as other transgendered people.  But, one unique issue that they may face is their attitude toward living in a binary gendered world, and feelings about having been assigned one of those genders without being consulted.  Mollenkott (2001) refers to the videotape, Hermaphrodites Speak! Produced in 1996 and made available from the Intersex Society of America, which explores the feelings of Intersexuals towards the attempts by the medical and psychological establishment to fit them into societies binary gender expectations.  “All [on the tape] agree that they would have preferred to have been left alone, ‘not helped so much.’” (p. 49).  She writes, “Both surgeries and social institutions are utilized to maintain that binary.  The surgeries amount to intersex genital mutilation, and it seems to me fully as horrible as the female genital mutilation that occurs in many cultures.” (p. 42).  Mollenkott, Fausto-Sterling (2000), Chase (1993) and others recommend only those medical interventions necessary to save the life or preserve the health of intersexual infants, and that further intervention be left until such time as the intersexed individual can be consulted about preference.

Ettner (1995) as well as Kirk and Rothblatt (1995) offer some comments about how F2M transsexuals may differ from M2F transsexuals.  Kirk and Rothblatt say, “The new male seems to make a wonderful adaptation to his new existence.  Adjustments to family, loved ones, friends and the workplace seem to be far easier and much more firmly established than is often the case for the M-F.”  (p. 89).  For Ettner, F2M’s respond in significantly different ways from M2F’s.  She says they are generally psychologically better adjusted and better integrated socially.  However, for very young F2M’s, she finds that puberty, particularly the onset of menses, may create a crisis.  Attempts to remain androgynous may result in being labeled “lesbian.”  She recommends that therapists need to be sensitive to the developmental and societal forces that collude in keeping F2M identities hidden.

Children who experience gender confusion are especially vulnerable.  “Because gender identity conflicts are still perceived as a mental health disorder by uninformed care providers, today’s transgendered youth still are at risk of being treated in the same manner gays and lesbians encountered years ago.” (Israel & Tarver, 1997, p. 135).  Ettner (1999) finds that not all children with gender identity disorders will grown into transgendered adults.  Therefore, she finds it imperative that counselors be able to distinguish gender non-conformity from gender dysphoria.  They should be trained in developmental psychopathology and generally competent in treatment of children and adolescents.  Family therapy and follow-up is crucial.  Parents must be warned to exercise extreme caution in seeking aversion therapies or radical, unproven methods.  She encourages the use of support groups for families of children experiencing gender identity conflicts.  Mollenkott (2001) suggests that androgyny be considered as an option for youths experiencing gender conflict, to give them freedom to explore without committing to a presentation in either gender role.  Israel and Tarver offer advice on determining whether a child’s gender-identity questions and exploration are “just a phase” or indicative of special gender issues and needs.  “If there is a ‘cure’ for children or youth with gender-identity issues, it can be found in the key words acceptance, androgyny, compromise, and communication.” (p.137).


Transgender and Other Cultures

The final issue I would like to address concerns the transgendered in other cultures.  I will explore first how issues of gender nonconformity have historically been dealt with in non-western cultures, and will then address some of the particular issues facing transgendered people of minority ethnicity in the U.S. 

All societies have gender roles, but the gender roles are not all the same.  Varying greatly are not only the roles played by men or women, but even the perception of which attributes are masculine and which are feminine.  Mollenkott (2001) shows in detailed analysis that no one attribute that we think of as “masculine” or “feminine” is universally ascribed to that gender, not even “masculine aggression.”  Bornstein (1995) concludes from this, “The possibility missed by most of the texts prior to the last few years, and by virtually all the various popular media, is this:  culture may not simply be creating roles for naturally-gendered people, the culture may in fact be creating the gendered people.  In other words, the culture may be creating gender.”  (p.12).  Into the mix, societies vary in their acceptance of, and in the accepted place for, intersexuals and transgendered people.  The following are a few examples:

·        “Hijras in India, for example, call themselves ‘neither men nor women.’  Their role in Indian culture is a spiritual one, presiding over marriages and births.”  (Bornstein, 1995, p. 131).  “Classified as neither men not women, the hijras are castrated males who dress in female clothing, wear their hair long, and pluck out facial hair to make their skin as smooth as a woman’s.”  (Mollenkott, 2001, p 145). 

·        “In Burma    the acault are well known for their cross-gender behavior.”  (Mollenkott, p. 142). 

·        “In north and central Thailand, Buddhist myths or origin refer to three basic sexes – male, female and hermaphrodite (called kathoey, an independently existing third sex).  Only in the twentieth century did kathoey come to mean a ‘deficient’ male.” (Mollenkott, p. 143).

·        Williams (1986) discusses the concept of the Berdache in Native American cultures – a male who generally takes on the feminine role in society and possibly also in sexuality.     He finds, “the mediator between the polarities of woman and man, in the American Indian religious explanation, is a being that combines the elements of both genders.  This might be a combination in a physical sense, as in the case of hermaphrodites.  Many Native American religions accept this phenomenon in the same way that they accept other variations from the norm.  But more important is their acceptance of the idea that gender can be combined in ways other than physical hermaphroditism.”  (p. 21). 

·        “The Hawaiian language contains no female or male adjectives or articles, and even proper names are androgynous.  This reflects the Polynesian emphasis on integration and balance of the male and female gods.  The notion of gendered polarity – of opposite sexes – is foreign to Hawaiian thought.”  (Ettner, 1999, p. 6).

·        Leslie Feinberg, as quoted in Mollenkott, mentions African spiritual beliefs in intersexual deities and sex/gender transformation among followers.  Mollenkott gives as an example, “Among the four Bantu-speaking societies, Transgenderism is closely associated with religious authority, prophet-status, and spiritual healing.  He-Shes or men-women are perceived to be especially powerful because they combine masculine and feminine powers just like the original creative deity.”  (p. 137).

·        Even for Islamic countries, Mollenkott points out that “during Islam’s first century, for a period of several generations, a group of male musicians called mukhannathun (‘effeminates’) held a social position of exceptional prestige and visibility.” (p. 149), and that in Oman, “xaniths or khanith perform a function similar to that of the hijras of India, although the xaniths are not castrated.” (p. 150). 

Unfortunately, a history of acceptance in representative cultures worldwide has not, in general, created a modern, tolerant society.  Negative attitudes towards the transgendered have either been absorbed from the western culture, or in some cases adopted in reaction to western tolerance.  Mollenkott (2001) reports that between 1920 and 1950, Gandhi and Nehru did everything they could to eradicate from Hindu and Indian culture all positive references to transgenderism and same-sex desire.  Gandhi even sent his devotees to 11th century Hindu temples to destroy carvings of same-sex coupling, in an attempt to convince people that any queerness in India was entirely the result of European or Western influence. She also refutes, and cites the damage done by, frequent modern-day assertions that gender-variant behavior was unknown outside of Africa until introduced by westerners.  And again, in the Islamic world, “The oppression of homosexuals and transgendered people was increased exponentially after the rise of Islamic fundamentalism during the late 1970s.” (p. 148).

In the U.S., “the odds are badly stacked against those who are easily identifiable as members of ‘dual minorities.’” (Israel & Tarver, 1997, p.125).  Gender-specific roles may be more pronounced in ethnic minorities.  Sue and Sue (1999) assert that Asian families may be more hierarchical and have strict gender-specific roles (p. 262), and tell us that Hispanic families often experience conflict over traditional sex-roles.  (p. 293).  Tolerance for gender confusion may be less in such cultures.  An individual may be accused of betraying her or his ethnicity as well as of transgressing the norms of the broader culture.  That same individual may encounter racism in the transgender community.  “Just as there is certain to be transphobia among individuals of any race, it is essential to recognize that racism exists within the transgender community.” (Israel & Tarver, p.129).  Rather than finding solidarity within one minority group, the individual may be doubly on the margins.  “The displacement of prejudicial commentary from one embattled minority onto another, the desire to scapegoat another vulnerable group so as to assuage one's own pain and vulnerability, is a familiar and dismaying move; it is also, self-evidently, a sign of what we have been calling 'category crisis' at its rawest and most disturbing." (Garber, 1992, p. 270).

Israel and Tarver remind us, “Culture and race must be viewed as having equal importance to an individual’s identity and presentation.” (p. 128).  Just as it’s important that the counselor be educated about transgender issues and knowledgeable about needs and life experiences, so is it important for the counselor to be culturally competent.  “The greater the difference between the degrees of acculturation of the care giver and the consumer, the greater the need to inquire about and negotiate cultural differences.” (p. 126).  Ideally, the client would benefit from a counselor of the same ethnicity.   

While it’s frequently not possible to convene a sizeable group of transgendered individuals from a specific minority ethnicity, it seems very helpful when it does happen.  At Esprit 2002, Jan became an honorary member of the informal “Asian T-girls” group.  (Jan speaks Japanese and is a student of Japanese culture and tradition.)  The importance of having other Asians to confide in about transgender issues seemed enough that several individuals put in many extra hours of effort and, even when they could ill afford it, extra dollars to make it possible for a “critical mass” of Asians to gather.  Immediately after the 2002 conference, they began work on retention and recruiting of Asian T-girls for next year. It seemed the sense of doubly belonging, after years of being doubly in the minority, was critically important.


Final Thoughts

Traveling through “Genderland” with my partner not been easy, but has been an enlightening and freeing experience.  I did not choose this path, but, nevertheless, I am the spiritual and emotional benefactor of Jan’s “huge desire” for honesty and integrity. Thank you, Jan, for showing me a world of amazing diversity, unique beauty, strong survivors, and generosity in the face of overwhelming obstacles.

Writing this paper has also given me the pleasure of reading the words of some remarkably gracious, knowledgeable, kind, and above all, hopeful people.  I’d like to close with a few of their words – words that helped me hope too.

“I predict that eventually those with the ‘huge desires’ to be authentic will emerge as the sanest people in a world that has become obsessed with gender conformity.” (Mollenkot, 2001, p. 165).


"Sometimes people suggest to me, with not a little horror, that I am arguing for a pastel world in which androgyny reigns and men and women are boringly the same.  In my vision, however, strong colors coexist with pastels.  There are and will continue to be highly masculine people out there; it's just that some of them are women.  And some of the most feminine people I know happen be men."  (Fausto-Sterling, 2000, p. 23).


"Hope.  It was not that I expected it to alter radically the nature of my living, but rather that it put me actively into a context that felt like progress."   (Audre Lord, as quoted by Davies & Haney, 1991).




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Vitale, A.  (2002, August 11).  Call for Participants:  Head Over Heels: Women Who Stay With Their Transgendered Partners.  Vitale Letter #229, a free online news service of


Williams, W.L.  (1986).  The spirit and the flesh: Sexual diversity in American Indian culture. Boston: Beacon Press.


Young-Bruehl, E.  (1996).  The Anatomy of Prejudices.  Cambridge, MA:  Harvard University Press.

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